MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

This is a somewhat unusual post.

I do not normally dwell on personal anecdotes or experiences – but this one might be relevant, and it is absolutely true.

About 7 or 8 years ago (we had just published our book Trick or Treatment), I was invited to a meeting of health insurers. Not just any old meeting, but a top-notch conference where many of the world’s most influential executives of large insurance companies were gathered. It took place in one of the most luxurious hotels of Istanbul. The most prominent speaker was the brother of France’s president Sarkozy (who flew in by helicopter and came with two body-guards). He began his lecture by stating “You of course all know me because I have a famous sister in law.”

I did not have such a witty opening phrase for my talk. My task was to review the evidence for and against the major alternative therapies (at the time, I did such lectures regularly). My audience of about 300 people listened politely to what I had to say and, during, question time, they made some relevant comments. Altogether, it was a good and well-received lecture.

But the interesting bit came later.

Over coffee, I was surrounded by people who came to me and said something like this: “We know the evidence, of course, and we know how flimsy it is, particularly for homeopathy. But we still pay for it, because the competition does it too. We cannot be seen to offer less than they do. This is purely a commercial decision about being seen to be competitive.”

Such honesty came as a surprise to me. I had expected that they were well-informed about the evidence; after all, they were in charge of huge companies selling health insurances. Not knowing about the evidence would have been negligent. But I had not expected they would volunteer their motives quite so openly. I got the impression that they were trying to justify their nonsensical actions without seeming irrational. In a way, they seemed to say: ‘Such treatments might not work for the patient, but they do work for us’.

I remember suggesting to some of these executives that they could even be more competitive, progressive and ethical by telling their customers that they took better care of their money that the competition by NOT paying for ineffective treatments. Such remarks  resulted in blank faces or vague smiles. I felt my audience had not really understood the opportunity. Being honest, transparent and evidence-based was evidently not understood as a viable marketing tool.

As I said, this was almost a decade ago

… lots has happened since.

I wonder whether the message might be more attractive today.

146 Responses to Why do insurance companies pay for ineffective treatments?

  • Ernst,

    Since you’ve been self-quarantined primarily within the field of academia, I am not surprised you didn’t understand why you were the victim of “blank stares and vague smiles” from the insurance company executives. In private, they were most likely laughing out loud at your lack of business sense.

    Medicine is a profession. Health care is a business.

    Insurance companies’ risk for homeopaths is negligible compared to that for conventional medical practitioners. One UK insurance company advertises coverage for homeopaths at just £17.99 per month. Their web site notes that they also insure practitioners of acupuncture & acupressure, massage, reflexology, aroma therapy and Reiki …all the natural approaches to health care that worshipers of big pharma love to hate.

    • Oh Sandra!
      How you always manage to misunderstand even the plainest of post.
      I did suggest that (because healthcare is a competitive business) they use NOT paying for nonsense like homeopathy as a competitive advantage.

      • Oh Ernst!

        My comment addressed your lack of business sense….the reason you were the victim of “blank stares and vague smiles” by insurance company executives.

      • Oh Edzard!

        The insurance executives obviously thought little of your “business” idea. That was my point. Profits count. Your rationale to change a marketing approach that has been successful for them was indeed laughable. A 1M potency of Arnica would have eased your (amazingly still) bruised ego.

        • Sandra Courtney, it’s you!!! You’ve been spreading the silly all over the internet for more years than I can remember. Full marks for persistence, but you still make about as much sense as a bag of hammers. I am delighted to share with you that my insurance company is finally offering customised plans for supplementary benefits. Soon I’ll no longer be covered for naturopathy, chiropractic and homeopathy. I’ll have more money in my pocket and the wonderful knowledge that my premiums are not contributing to quackery.

    • … and CAM is a particularly odious business.

  • Homeopathy is cheap–if the patient never gets around to getting real treatment, the insurance company wins.

    If the patient delays treatment, the insurance company might lose, but only if the condition worsens to the point where more costly treatments are called for.

    Overall insurance companies love this sort of thing.

  • Of course companies can offer insurance against anything they wish – effectively a bet that the premia they charge will be greater than the cost off settling claims.

    I dare say insurance can be obtained for injuries sustained by slipping on unicorn dung.

    To insure personal injury/negligence claims against a professional camist, the premia should be low because the risks are low. The therapies have no effects and minimal physical harm to the patient. The harm of camistry is to society by its endorsement of irrational mind sets.

    For patients insurance to receive camistry, the insurers will need to do their actuarial analyses – regularly as more patients develop irrational desires.

    But what is essential is that the insurance companies act honestly and with integrity and offer some policies which cover camistry, and some which exclude it.
    And make it clear which is which.

    Why should patients who do not want camistry cover subside those who do?

    Now that would be competition.
    Are insurers really up for it?
    Or are they hypocritical when they claim to be competitive – but are not?

  • You only have to look at the range of food supplements and beauty products on sale to see that what matters to business isn’t evidence of effectiveness but simply whether anybody will buy them. RNA creams anyone? Collagen supplements? Vitamins targeted at particular groups of people? Companies’ primary legal obligation is to their shareholders, not their customers, and provided what they are doing makes a profit isn’t demonstrably illegal, anything goes.

  • Why Insurance Companies Might Pay for Acupuncture

    I could not venture to guess why insurance companies would pay for ineffective treatments but I could to offer insights on a type of information you may not be aware of that U.S. insurance companies would be inclined to review when considering paying for acupuncture.

    American Specialty Health (ASH) is the largest insurance company in the U.S. that specializes in the development and management of managed care plans for the non-pharmacologic therapies of acupuncture, chiropractic, massage therapy and physical (physio) therapy. ASH contracts with the major U.S. health insurance companies to manage these specialty therapy services for them.

    ASH participates in the reporting of a standardized consumer (patient) satisfaction/experience survey “Clinician & Group Consumer Assessment of Healthcare Providers and Systems” (CG-CAHPS®) developed by the Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ). These “CHAPS” surveys were designed to provide a standardized tool to measure patients’ experiences with healthcare providers, health plans and health systems and are considered the “gold standard” of patient satisfaction/experience surveys. They are administered by independent, accredited contractors. The results are fed into a national database and compiled to establish national benchmarks of patient satisfaction. These “real world” surveys provide an important compliment to the evidence base in addition to results of controlled clinical trials.

    In 2016, ASH published the results of 2 years of their CG-CAHPS surveys “Does Acupuncture Provided Within a Managed Care Setting Meet Patient Expectations and Quality Outcomes? A 2-Year Retroactive Study of 89,000 Managed Network Patients” These were primarily musculoskeletal pain patients with lower back and neck pain being the most common conditions. They were treated by AHS’s national network of 6,000 credentialed Licensed Acupuncturists.

    This was perhaps the first published study of a large number of acupuncture patients using a standardized survey tool administered by independent contractors that captured patient’s ratings of several quality measures including how successful their acupuncturist was in addressing their primary compliant. These finding reflect the experiences reported by real patients with real health problems who sought out and were treated by real acupuncturists.

    The link to the published study follows but here are some of the main findings:

    85%-93% said their acupuncturist was successful in addressing their primary complaint.

    95%-99% rated their overall quality of care as good to excellent.

    0.014% (13 out of 89,769) patients reported a minor adverse event and no serious ones.

    An important subset of these patients were those in the California survey who were referred for acupuncture by a pain management medical doctor. In order to be referred for acupuncture under this program, these patients had to first be seen by their primary care physician then, if deemed necessary, were referred to the pain management specialist who would have the option to refer their patients for acupuncture. In other words; these were patients first seen by two levels of medical doctors that had already attempted several conventional pain management approaches with limited success before they referred them for acupuncture. 85% of these intractable pain patients reported their acupuncturist was successful in treating their primary complaint.

    I am quite familiar with this referral program as I treat a couple hundred of these patients a year. And, in the spirit of full disclosure, I am also a consultant to American Specialty Health (receiving less than $3,000 U.S. a year for my consulting services), so I am familiar with the management of this program as well.

    As someone who has spent over 20 years as a consultant in the U.S. insurance industry, I thought bringing the results of this survey may prove informative to Dr. Ernst and his readers. My sense is that many acupuncture critics don’t have any first-hand knowledge about what is really happening with the delivery of acupuncture services in the real world. I often read remarks suggesting or outright accusing acupuncturists of being either unethical for profiting off an ineffective therapy or lacking critical thinking ability.

    The actual truth is that many of us are successfully helping the millions of patients that fail to respond favorably to conventional medical care. Once even skeptical doctors see the results many of their most difficult patients have with acupuncture, they are grateful to have another resource to offer these patients. That is what happened in that particular pain management referral program – it started slowly over 10 years ago with the pain management doctors only referring their most stubborn cases for acupuncture and then expanded once they saw the positive results. Acupuncture is rapidly gaining in acceptance in the West despite the best efforts to stop it by very determined people like Dr. Ernst because it consistently gets results for even stubborn cases. This survey strongly supports that claim.

    Here is the link to the study of the survey: http://files.clickdimensions.com/ashcompaniescom-a7oce/files/acupuncturecahps.pdf

    • do you believe that survey data can prove effectiveness?

      • Hello Dr. Ernst. Thank you for your question.

        A survey by itself does not “prove” effectiveness, no. But quality consumer satisfaction/experience surveys provide an important window into what the end user of medical services themselves experience and that information should be considered when deciding how to manage those patients. That is why those surveys were developed by the AHRQ – the lead U.S. government agency for advising the government about medical research.

        If someone in pain goes to their medical doctor seeking relief and their doctor tries several different conventional approaches and the patient does not find satisfaction with those and then he/she is referred for acupuncture and reports success with that treatment, you could well say that the treatment was “effective” for that patient. Does that patient’s personal experience with the treatment being “effective” for them constitute “proof of effectiveness” in the context of medical “research”? No. However, when a high percentage of such patients report effectiveness with a given therapy, this should go into the mix of information constituting the “evidence base”. Why do we undertake medical research? To learn what treatments are safe and effective so we can deliver those services to the patient – the end user of such services. Should we then ignor what the end user has to tell us about their experience with those services?

        • I beg to differ!
          survey data can be (and often are) highly misleading.
          medicine started making progress in terms of finding effective treatments once we gave up relying on such pseudo-evidence.

          survey data do not control for
          placebo,
          natural history,
          regression towards the mean,
          social desirability,
          etc., etc.

          • So, it seems your answer to my question is –“Yes – we should not consider at all what the patient tells us about their experience with the effectiveness of any medical service.”

            Good to know your position on that. It seems seriously out of step with the trend toward “patient centered” medical care policy but, so be it.

          • “Yes – we should not consider at all what the patient tells us about their experience with the effectiveness of any medical service.”
            please do not put things into my mouth – especially not stupidities like this one.

            A controlled clinical trial usually relies on patient experience – and crucially, it is less prone to error.
            certaily less than surveys.
            proper research is largely an exercise in error elimination.

          • I apologize for putting words in your mouth and won’t do so again. It just seemed to me that you were completely discarding what should be seen as a useful addition to the body of evidence regarding acupuncture. I am still unclear about what you think of the value of study I cited. I thought such information would be seen as having some value.

          • it seems to me that you need to be reminded of the difference between evidence and experience:
            https://edzardernst.com/2012/11/what-is-and-what-isnt-clinical-evidence-and-why-is-the-distinction-important/

          • Thank you for alerting me to that previous post of yours. I agree with most of what you had to say. However, your blog post on what does or does not constitute evidence was focused on what an individual clinician may experience with their own patients: “Clinicians often feel quite strongly that their daily experience holds important information about the efficacy of their interventions.”

            I was attempting to bring to your attention a study about a survey regarding the experience of tens of thousands of patients treated by hundreds if not thousands of credentialed acupuncturists. That is not the same as an individual practitioner’s personal experience as you blog post focused on. This sort of survey should be seen as carrying more weight than the experience of individual practitioners.

            When clinical trials find a therapy to be effective but patient experience surveys find otherwise, it presents a conundrum that should warrant further investigation. Conversely, when clinical trials find a therapy to be ineffective but patient experience surveys find otherwise, that too presents a conundrum that should warrant further investigation.

            As far as I know, there has never been such a large scale patient experience survey on acupuncture published before, let alone conducted by accredited, independent survey administrators. That 85%-93% of patients reported that acupuncture was effective in addressing their primary complaint should at least give those interested in the subject of acupuncture (and why insurance companies might pay for it) something to think about, especially considering the great variation in effectiveness rates seen in acupuncture clinical trials: https://acunow.org/2017/04/the-lack-of-clinical-quality-guidelines-causes-underestimation-of-efficacy-in-sham-controlled-acupuncture-trials/

          • “I was attempting to bring to your attention a study about a survey regarding the experience of tens of thousands of patients …”
            THE PLURAL OF ANECDOTE IS ANECDOTES, NOT DATA!
            “When clinical trials find a therapy to be effective but patient experience surveys find otherwise, it presents a conundrum that should warrant further investigation. Conversely, when clinical trials find a therapy to be ineffective but patient experience surveys find otherwise, that too presents a conundrum that should warrant further investigation.”
            THE FIRST CAN HAPPEN, WITH TREATMENTS THAT HAVE ADVERSE EFFECTS OR REQUIRE EFFORT [FOR EXAMPLE EXERCISE FOR WEIGHT LOSS]. THE SECOND CAN HAPPEN FOR A RANGE OF REASONS, FOR INSTANCE, IF A TREATMENT IS FASHIONABLE OR MIS-SOLD VIA MISINFORMATION. THE LATTER MIGHT BE THE CASE WITH ACUPUNCTURE.

          • THE PLURAL OF ANECDOTE IS ANECDOTES, NOT DATA! –

            When I said your position was that we should not consider what patients tell us about their experience with a medical service, you seemed to get upset for me putting words in your mouth but here you seem to confirm that by saying the results of such a survey are nothing more than anecdotes. But insurance companies utilize these CAHPS surveys as part of their quality control monitoring so it seems they place a higher value on such information than you appear to. You then state:

            THE SECOND CAN HAPPEN FOR A RANGE OF REASONS, FOR INSTANCE, IF A TREATMENT IS FASHIONABLE OR MIS-SOLD VIA MISINFORMATION.

            This seems like a far-fetched possibility but OK, and here are some other possibilities within that “range”: it could be that these patients enjoyed a high rate of success with their primary compliant because, (unlike controlled trials) these acupuncturists were allowed to do their full range of treatments such as adding modalities like heat therapy, acupressure/massage, cupping, and offering self-care advice. It might also be that because these acupuncturists were better trained than many involved with acupuncture trials in the West, they were able to perform their treatments at a higher level. It might also be that because these patients had insurance coverage, they were not as limited in the number of treatments as often happen with acupuncture trials in the West. It might be any combination of these possibilities. Or it might be that there are serious problems with how many acupuncture trials in the West are designed and carried out that causes false negatives such as under-treating or under-trained acupuncturists. All of these are in the range of possibilities. But the bottom line is back to this: A very high percentage of acupuncture patients report (anecdotally, yes) high rates of satisfaction with their acupuncture treatments and that is one reason why some U.S. insurance companies will pay of acupuncture – as they should.

          • ” you seemed to get upset for me putting words in your mouth”
            it needs more than that to get me upset.
            “results of such a survey are nothing more than anecdotes”
            I am saying they are not what I and most scientists consider to be evidence.
            “insurance companies utilize these CAHPS surveys as part of their quality control monitoring …”
            and you think that this elevates such survey data to the level of evidence?
            “This seems like a far-fetched possibility but OK, and here are some other possibilities within that “range”
            yes, of course.
            do you know what evidence is? it means showing hich of the many possibility is true.

          • Good to know I did not upset you. I get no pleasure in that. I will be happy to offer some evidence although I am seeing patients today and it may take a bit for me to gather this together for such a critical judge (I have some of that handy but others are recent and not yet organized). But before I offer that evidence, I hope you will do me the honor of answering a very serious question I have on trial methodology that I believe is important to this subject:

            Is it not the case that in order to produce accurate data on a therapy’s efficacy, you must take steps to design the trail in such a manner as to give the active therapy a reasonable chance to achieve its maximum therapeutic benefit (MTB)? For example, establishing the appropriate therapeutic dosage of a drug before comparing to a placebo or in a trail for a surgical procedure making sure the surgeon(s) have adequate training in the procedure before comparing to a sham control.

          • the way you frame this question, the answer is self-evidently: yes, this is one of the many preconditions for generating reliable evidence.

          • Thank you very much for your reply. My next question if I may is: what criteria do you see being employed in acupuncture trials to see that this particular set of preconditions are being met? My belief is that these preconditions are too often not being adequately met.

          • there are several thousand such trials; many are inaccessible (for me) because they are published in Chinese. I therefore find it impossible to give a general answer. having said that, i also find it impossible to imagine that acupuncture trialists – mostly proponents – do not do their best to employ what they think is the optimal treatment.
            BUT WHAT IS THE OPTIMAL ACUPUNCTURE.
            as you may know, we did some research on that question and found that, by and large, acupuncturists do not know!!!

          • “i also find it impossible to imagine that acupuncture trialists – mostly proponents – do not do their best to employ what they think is the optimal treatment.
            BUT WHAT IS THE OPTIMAL ACUPUNCTURE.
            as you may know, we did some research on that question and found that, by and large, acupuncturists do not know!!! “

            As impossible to believe as it may be, sir, the unfortunate fact is that many involved with acupuncture research either don’t know how to apply acupuncture in such a way as to afford it a chance to reach its maximum benefit or they never set out to design their trials with that precondition in mind! I do not fault researchers for this failing so much as the “acupuncture profession”. Because that field has never produced Best Practice Guidelines to guide practitioners and researchers, what you tend to get with acupuncture trials in the West is a hodge-podge of clinical protocols and a hodge-podge of results.

            I am not at all surprised that you could not find agreement amongst acupuncturists over what constitutes optimal acupuncture although I am certain such consensus can be reached. 20 years ago, I took part in what I believe to be the most intensive (and successful) consensus building process regarding acupuncture best practices that has ever taken place (in the West, anyway). The insurance company I consult with hired a dozen of us to help them develop treatment guidelines that would allow them “to authorize not one more treatment than necessary or one less treatment than necessary”.

            We were comprised of individuals trained in mainland China, Taiwan, Korea, and the U.S., most of us with over 10 years of FULL TIME private practice. We told them it would not be possible to reach consensus but they locked us in a room, fed us and paid us for our time and had someone very skilled guide us through the consensus building process. It took us dozens of hours but a consensus did emerge – not over what points to use or needling techniques to employ, but on the number and spacing of treatments.

            Unfortunately, those guidelines are proprietary and the call I have been putting out to the acupuncture profession to undergo a similar consensus building process has largely fallen on deaf ears. Of course, no one has the money to pay people for the needed time like this insurance company did as an investment in their managed care insurance products.

            While I cannot share the exact details of the proprietary guidelines, I can share the big picture if you are interested. I can also tell you that cost concerns have led to a strong tendency of acupuncturists in the West to under-treat their patients and that pattern of under-treatment dominates acupuncture research in the West. In China, as I suspect you are aware, they like to start treatment for most conditions at a daily of every other day frequency and often end up doing dozens of treatments – far more than seen in most Western acupuncture trials. This great disparity in treatment frequency/numbers is the elephant in the acupuncture research room no one seems to want to address.

            I so very much appreciate the dialog you have had with me and hope we might continue. If you are interested, I will offer examples of research trials where it was found that doing more frequent acupuncture treatment over longer periods of time allowed the verum acupuncture to start to overtake the sham in effectiveness.

          • I know, this is hard for you – but think for a minute of acupuncture as an elaborate, theatrical placebo. if that were so, you might find a consensus as to what is the optimum, but it would be an unreal and meaningless consensus. I honestly think it might be impossible to define the right or the wrong acupuncture; and that this is an important reason for why this is so.

          • I want to stress that I am not saying there is no placebo effect involved with acupuncture –surely there is. And, I am well aware of the theory that acupuncture is an “elaborate, theatrical placebo” but I find that hypothesis to be highly unlikely for reasons so numerous it would really take a book to list them all. I hope to reduce my patient-load someday soon and may attempt to write that book!

            For now, I would just offer you of this: It is my understanding that the elaborate, theatrical placebo hypothesis is primarily based on findings in some (but not all) sham controlled trails that the verum acupuncture does not outperform the sham (plus, perhaps, the perceived implausibility of traditional acupuncture theory). However, you and I have established that one of the many preconditions for generating reliable evidence is to take steps to insure that the verum arm of multi-arm sham/placebo controlled trials are designed in such a manner as to afford the active therapy a reasonable chance to reach its maximum therapeutic benefit.

            We have also established that there are not best practice clinical guidelines available to researchers to help them meet that precondition. So, meeting this important precondition of a well-designed trail does not currently exist for acupuncture trials. That (to my mind) means these sham controlled trails cannot be relied upon to meet their objective of passing judgement on whether or not acupuncture has or does not have specific therapeutic benefit beyond placebo. I would love to see those involved with acupuncture researchers admit this crucial missing precondition exists and that this undermines the strength of evidence behind the placebo hypothesis.

            If not the elaborate, theatrical placebo hypothesis then, what else could explain so many trails showing the real acupuncture to not outperform the sham? Another possibility is that in many of those trials found this because researchers did not do frequent enough treatments over a long enough period of time or the acupuncturists involved in the design and/or clinical application of the acupuncture were not well enough trained to allow maximum benefit or both. There is some evidence to support this “poor clinical design and implantation” hypothesis although I am not saying I have enough evidence on this to make as strong a case as should be attempted. I have been trying to get volunteers to help me do such a study but have struck out.

            I will put the limited list I have of such trials together if you would like to see this evidence. Would you be interested in a list of research trials where it was found doing more treatments over a longer period of time made the difference between verum and sham acupuncture in favor of the verum?

          • I am not convinced by your arguments.
            ” the elaborate, theatrical placebo hypothesis is primarily based on findings in some (but not all) sham controlled trails that the verum acupuncture does not outperform the sham (plus, perhaps, the perceived implausibility of traditional acupuncture theory). ”
            the placebo hypothesis is also supported by the fact that there is no optimal way of doing acupuncture.
            you think it has not been defined.
            but I think it cannot be defined because it does not exist.

          • Thank you again for taking the time to reply. I very much appreciate it. Sorry my replies are so long but I want to do justice to the subject. You said:

            “the placebo hypothesis is also supported by the fact that there is no optimal way of doing acupuncture. you think it has not been defined. but I think it cannot be defined because it does not exist.”

            There is rarely a single “optimal way” of doing anything in medicine but there are “better ways” and “sub-optimal ways.” And yes, those better ways have been established for acupuncture, especially by the Chinese (and also by the insurance company I consult with). A key feature of the Chinese better ways is the frequency and number of treatments over time. However, their protocol was developed within a fully socialized medical system (that is now mostly socialized).

            Unfortunately, many in the West where acupuncture is rarely covered by insurance think cost concerns means we cannot follow the Chinese treatment frequency protocol. What has emerged in most areas of the West is a model of treating “what the market will bear” rather than what is clinically a better way. It was been tragic to witness these sub-optimal ways of treatment dominate Western research on acupuncture. Researchers here seems to have been following how often the acupuncturist around the corner may treat their patients rather than following protocols designed to reach acupuncture’s maximum effectiveness. Here is a quite recent example of what I am referring to:

            The U.S. National Cancer Institute (NCI) recently released a summary of research on acupuncture for treating cancer related disorders. Here is what they had to say about treatment frequency: “Length and frequency of treatment vary according to the condition being treated. Chronic conditions usually require a longer treatment period. Typically, two or three sessions per week are required initially and may decrease to once a week after several weeks of treatment.” That is correct!!! They got that right. Unfortunately, if you look at the research trials they review in this summary, almost none of those more than 116 trials followed this treatment frequency protocol!!

            As I looked at their review of acupuncture for treating hot flashes, I found the usual mixture of studies that show verum acupuncture outperforming sham and other trials finding verum to not outperform sham. But guess what? The trails where the verum did not outperform the sham did not use 2 treatments a week for at least 5-6 weeks where most the ones where verum outperformed sham did. Had reviewers only selected trails to review that followed the NCI recommended treatment frequency protocols, they would have found verum acupuncture routinely outperforming sham (at least for hot flashes).

            Several trials have found that verum and sham acupuncture have similar effectiveness in relieving symptoms for around 8 weeks (likely due to the placebo effect or real effects of needling or simulated needling anywhere) but if enough treatments (like the protocol mentioned in this NCI review) are done, then the effectiveness of the verum acupuncture grows while that of the sham stalls or diminishes.

            Doing acupuncture at once a week or a few weeks at twice a week is a suboptimal dosage and simply not enough for it to reach its maximum effectiveness in most subjects, especially in treating chronic conditions. That sub-optimal dose may be the way it is done by many acupuncturists but most all of them would rather have the chance to treat more often if the market would bear it. Researchers trying to address the issue of if acupuncture has specific effects beyond placebo need to follow the NCI’s recommended treatment frequency protocol at a minimum. Until that happens, there should be an acknowledgement that reviews of acupuncture trials dominated by sub-optimal dosing are not a reliable way to address the question of acupuncture’s specific effects over sham.

          • “There is rarely a single “optimal way” of doing anything in medicine…”
            COME ON! we all know that, but you know that I meant some sort of consensus which you claimed you once established
            “…those better ways have been established for acupuncture…”
            our research fails to show that. are you sure you are not thinking wishfully?
            you seem to advocate doing acupuncture daily; that would not make it more effective, I’d argue [I do not trust Chinese acupuncture findings further than I can throw them] but only less cost-effective [very good for acupuncturists’ cash-flow though!!!].

          • I promise you I was not trying to be snarky but precise in my language. I am also not trying to be snarky with this statement but feel it appropriate: You said “you seem to advocate doing acupuncture daily; that would not make it more effective, I’d argue [I do not trust Chinese acupuncture findings further than I can throw them] but only less cost-effective.” Do you have any data to back up your statement that daily treatment would not be more effective?

            I am advocating that daily treatment would be more effective but I am not saying that to meet the precondition of seeing that acupuncture is given the chance to reach its maximum effectiveness in controlled trials that it must be done daily. It must, however, be done as the NCI advised – 2-3 times a week for several weeks (5-6 at a minimum) and then reduced to once weekly for several more weeks for chronic conditions. This is what we pay for in managed care where we are legally obligated to pay for the number and frequency of treatments that are deemed “medically necessary”. Most acupuncture trials in the West do such a low number of treatments that they would be violating the law if that was the maximum total number of treatments a managed care insurance company allowed.

            I also think it is unprecedented that you feel justified in rejecting all the research regarding acupuncture done in the country that has by far the most experience with that therapy. I am not saying all their research has no bias but to completely reject it in its entirety raises questions of cultural bias.

            Sorry I forgot this earlier -here is the link to the NCI study. https://www.cancer.gov/about-cancer/treatment/cam/hp/acupuncture-pdq#link/_35

          • ” Do you have any data to back up your statement that daily treatment would not be more effective? ”
            my statement was based [as you should know] on the assumption that acupuncture is a placebo. it’s an assumption for which there is plenty of evidence [as you know] and which I think is closer to the truth than your assumptions.
            “It must, however, be done as the NCI advised – 2-3 times a week for several weeks (5-6 at a minimum) and then reduced to once weekly for several more weeks for chronic conditions”
            are you saying that there are no trials that use this or a similar schedule?
            “I also think it is unprecedented that you feel justified in rejecting all the research regarding acupuncture done in the country that has by far the most experience with that therapy.”
            I assumed you have been reading my blog before:
            https://edzardernst.com/2016/10/data-fabrication-in-china-is-an-open-secret/
            https://edzardernst.com/2014/05/and-this-is-why-we-might-as-well-forget-about-chinese-acupuncture-trials/
            and many other posts

          • You asked ”are you saying that there are no trials that use this or a similar schedule?”

            No, I am not saying that. Unfortunately, there are not many that do (other than the Chinese) and I wish I had a comprehensive database of those Western trials that did. I have been trying unsuccessfully for 3 years to get support for doing a study comparing trials with such numbers of treatments to trials with lessor dosages. The trend I (and some others) have seen is that when higher treatment frequency and numbers over longer periods of time are done, the effectiveness rates go up often clearly surpassing sham. This NCI summary had a good example of this:

            The section on hot flashes starts off with summaries of two trials – one that found the real acupuncture did not surpass the sham and used 2 treatments a week over 4 weeks and one that did clearly surpass the sham and used 2 treatments a week for 5 weeks followed by 1 treatment a week for 5 weeks. Furthermore, the trial that used the higher numbers of treatment found that subjects in the real group reported an additional 30% reduction in their hot flashes over the 12 weeks after treatment was stopped. “During the treatment period mean number of hot flashes at day and night was significantly reduced by 50 and almost 60%, respectively from baseline in the acupuncture group, and was further reduced by 30% both at day and night during the next 12 weeks. In the sham acupuncture group a significant reduction of 25% in hot flashes at day was seen during treatment, but was reversed during the following 12 weeks.”

            The problem with this summary is the reviewers then say – “The evidence generated from these two trials suggests that acupuncture effectively decreases hot-flash frequency, although it is not clear whether it is superior to SA.”

            What they should have said was “The evidence generated from these two trials suggests that acupuncture effectively decreases hot-flash frequency at a greater and more sustained level when treatment is given at the frequency and duration the NCI suggests, while lower dosages of treatments decreases hot flashes at a lower and temporary level”.

            This trend that more frequent and longer administration of acupuncture finds the real acupuncture surpassing the sham and that the effectiveness of the real builds over time while the sham fades over time is not limited to these trials on hot flashes. It has been found in two trails on osteoarthritis of the knee and one on carpal tunnel syndrome as well. There are probably quite a few others out there with the same pattern but, again, no one has done a proper study to find this out before.

          • Dear Matthew Bauer,
            It was very interesting following your dialogue with Prof. Ernst.
            Your positions seems to be that acupuncture is (or could be) effective beyond placebo if done correctly and for an adequate number of times.
            You admit, however, that this is NOT proven and even the acupuncturists do not agree on the “correct” protocols, which is your explanation why efficacy is not reliably demonstrated when RCTs are performed.
            Prof. Ernst points that there is a chance that a “correct” protocol will never be established, because the evidence for the theory behind acupuncture (meridians) is outdated and unproven. And if it just doesn´t work, you can try forever to create an effective protocol.
            For me, from a practical point of view, the logical conclusion is:
            * At present, NOBODY should be advised to get acupuncture treatments for ANY health issue, since it either does not work at all or it is often done incorrectly, because acupuncturists do not agree on what to do.
            Would you agree with this conclusion?

          • No, I don’t agree with that conclusion. I offered an independent survey of 89,000 patients that found about 90% saying their acupuncturist was successful in addressing their primary compliant. If we followed your advise, those people as well as millions of others would not have had the chance to enjoy the real benefits from acupuncture they enjoyed. The trend in those who follow acupuncture research as been more and more to disagree with people like Dr. Ernst. They find the evidence actually supports the notion that acupuncture has proven itself more effective than sham and that is why acupuncture is now listed as a treatment option in so many practice guidelines. https://www.ncbi.nlm.nih.gov/pubmed/29912569/

          • PS:
            Dear Matthew Bauer,
            I just saw the first part of the PR video “documentary” “Getting to the point”, published on the “Acupuncture Now Foundation” webpage, that you, Mr. Bauer, have founded.
            The “documentary” starts with an interview of Audra and Justin Wilford, parents of Max, a child who was diagnosed with brain cancer at age 4, 5 ½ years before the interview.
            According to his parents (who also founded the MaxLove project and have a facebook page), the boy was treated with (at least):
            1. Surgery, partially removing the tumor
            2. Chemo therapy for 1.5 years (!)
            3. Gamma Knife radiosurgery
            4. Intensive physiotherapy
            5. Speech & occupational therapy
            6. Change of diet
            7. Acupuncture (2x per week for an unknown duration)

            The film maker then spins this case in a way that suggests that the classical “western” treatments were responsible for the adverse effects (e.g. impairment of speech and motility from the surgery), whereas acupuncture and the “holistic approach” were responsible for the positive aspects of recovery during and after the initial treatment.
            I find this shameless, one-sided PR video repulsive.
            If your comments on this blog were sincere (which I now highly doubt), the video should be removed immediately.

          • I am sorry you feel that way about our documentary. No one else has given us such feedback. I suggest you finish watching the entire film.

            CHOC hospital is one of the leading children’s hospitals in the United Stated and the acupuncturist we feature in our film has now been working there for 17 years. We interview CHOC’s Chief Medical Officer and she tells us how once the doctors in that hospital saw the results patients were having with acupuncture services, getting their buy-in was easy. That may not fit with your uninformed belief system, but it is a truthful depiction of the story. CHOC hospital was happy with the film as being truthful and did not feel we portrayed “western” treatments in a negative way at all. You had several facts wrong in your critique.

          • Dear Matthew Bauer,
            Thank you for your reply. Please don´t feel sorry for me, just take down this shameless PR video, which exploits cancer patients to sell acupuncture treatments that are, from a scientific point of view, not effective beyond placebo and, because of the side effects, have an unfavorable risk/benefit balance.

            Regarding your reply:
            *Quote#1: “I offered an independent survey of 89,000 patients that found about 90% saying their acupuncturist was successful in addressing their primary compliant.”

            *Reply: Let me repeat what Prof. Ernst said so many times: The plural of anecdote is anecdote, not data/evidence. Even if it´s true that 90% of the 89,000 patients said that they feel that acupuncture was “successful” (to some degree), this only shows that many people (who obviously believe in CAM, have great expectations and most likely paid some good money for the acupuncture sessions) seem to feel a placebo effect and demonstrate confirmation bias. As you should know, RCTs have to be done to investigate specific effects of a treatment, patient surveys are simply the wrong tool.

            *Quote#2: “I suggest you finish watching the entire film.”
            *Reply: Will do when I find the time and motivation to go through with it. Before watching, let me take a guess:
            I DO expect to see more exploitation of sick people for PR purposes by further presentation of unique case histories and anecdotes that are intended to prove the great health benefits that the patients (or parents of the children) experienced because of acupuncture.
            I DO NOT expect to see any evidence for efficacy, scientific evaluation of the IDEAS behind acupuncture or a presentation of the health risks vs. benefits balance of acupuncture for cancer treatment.

            *Quote#3: “(…) the acupuncturist we feature in our film has now been working there for 17 years.”
            *Reply: And what exactly does this prove?! I know people who smoke (or do other stupid things) for MORE than 17 years. Does this make it a good thing?

            *Quote#4: “(…) That may not fit with your uninformed belief system, but it is a truthful depiction of the story.”
            *Reply: I am a sceptic, an atheist and do not follow any other belief system (e.g. CAM). I apply the METHOD of science and find that this method -better than any other method that humans have invented- can make the most valid explanations of the reality that I experience and the most accurate predictions of previously unknown things or future events.

            *Quote#5: “ You had several facts wrong in your critique.”
            *Reply: Are you sure that you know what facts are? Holding a PhD in molecular biology, I find it somewhat funny to be lectured about facts from a person who believes in acupuncture and other forms of TCM for many years, which are not at all fact-based.
            Let me repeat what I posted (this time with the sources, so you can fact-check them):
            “According to his parents (who also founded the MaxLove project and have a facebook page), the boy was treated with (at least):
            1. Surgery, partially removing the tumor
            [source: your repulsive, exploitative PR video, 0:20 f.]
            2. Chemo therapy for 1.5 years (!)
            [source: your repulsive, exploitative PR video, 5:36]
            3. Gamma Knife radiosurgery
            [source: https://www.facebook.com/teamsupermax/%5D
            4. Intensive physiotherapy
            [source: your repulsive, exploitative PR video, 5:38]
            5. Speech & occupational therapy
            [source: your repulsive, exploitative PR video, 5:39]
            6. Change of diet
            [source: your repulsive, exploitative PR video, 5:47]
            7. Acupuncture (2x per week for an unknown duration)
            [source: your repulsive, exploitative PR video, 5:43]”

            I can of course not confirm that the parents were telling the truth, but I made clear that I was referring to them as the source of my information by stating “According to his parents (…)”.
            SO: PLEASE POINT OUT WHERE I HAD “SEVERAL FACTS WRONG”!

          • I have to chime in with Jashak’s evaluation. This film is a commercial not a documentary. It contains a cavalcade of the usual naive confirmatory fallacies. No convincing arguments for sticking needles in children for the purportedly added benefit of acupuncture, which is firmly preconceived by the people writing the script for this advertisement.

            As a surgeon, I was profoundly saddened by the colleague who sat there in scrubs parroting a well rehearsed script, almost as if reading from a teleprompter:

            “I take care of the disease but I don’t take care of the patient. And I think that’s a fatal error in our medical system right now.”

            This sentence is so wrong, so immensely “not even wrong” that my adrenaline stores are depleted from listening repeatedly (also in the trailer) to this abomination.
            Even surgeons are people. The great majority of us are, despite the stereotypical tropes, not automatons without feelings or compassion. We have a task we are dedicated to. Our task is indeed to take care of the disease. But we DO take care of the patient as well. Of course you can find heartless bastards among us who may fit the description but taking care of the patient IS the reason the majority of us became doctors and stay with the task at any hour in any situation. Taking care of the patient IS taking care of the disease AND taking care of the disease IS taking care of the patient. Claiming that one excludes the other is a fallacy cknown as ‘false dichotomy’.
            BUT what is more important to keep in mind, sticking needles in children without better reason than the belief of a blue-eyed scholar of Chinese medical history, AKA “acupuncturist”, IS NOT TAKING CARE OF THE PATIENT. These kids have enough of iv needles, surgical wounds and tubes in orifices. What they need least of all is an ill advised medical novice (read: “acupuncturist”) idiot sticking needles in them that have never been properly shown to be efficacious. .
            If we were talking about chanting rhymes, giving massage or waving hands over the kids, then I would not be as concerned. But here we are talking about delusion based care-taking that involves sticking potentially hazardous needles in children who are sick and suffering enough !!

            Americans tend to be immune to the notion that the world is indeed larger than the United States.
            Alternative medicine may be pervasively embedded in US medical institutions and health companies, but the reason for this is neither scientific nor medical necessity. The only reasons are politics and marketing.
            Generating demand on false pretenses is the purpose of infomercials such as the one we are discussing. providing fake medicine to fill perceived and real gaps in the ability and capacity of modern medicine generates more patient satisfaction points and revenue, not clinical benefit. The need for sticking unnecessary needles in children is neither scientifically based nor on compassion and care, it is based on greed and grandiose delusions.

          • This film is a documentary and was 100% UNSCRIPTED. You may find that difficult to believe but that is the truth.

            Dr. Loudon, a highly regarded pediatric neurosurgeon, was sharing his personal opinion about the need to improve aspects of “patient centered care”. That is a legitimate concern shared by many in medicine today. Chinese medicine can be an excellent compliment to modern medicine especially in improving quality of life issues where modern medicine has relative weaknesses.

            There is no greed here – this hospital does not charge for these services, they are paid for by philanthropic donations. There are also not grandiose delusions – the acupuncturist is still there after 17 years because the doctors, staff, administration, children and their parents have all seen firsthand that these services are very helpful, safe and well tolerated. Again, you having no firsthand experience in the delivery of such services may find this hard to believe, but reality is reality. Maybe it is possible that your view is inaccurate?

          • Dear Matthew Bauer,
            First, you did not address my initial question.
            WHERE DID I HAVE “SEVERAL FACTS WRONG”?

            Second: Scripted or unscripted, this does not make any difference in that it is a shameless, repulsive PR video, dressed up as a documentary.

            Third: I followed your advice and now watched the complete PR video and am not surprised that my expectations were confirmed. Let me summarize:
            We get to know Mr. and Mrs. Quack, aka Dr. William Loudon (neurosurgeon at CHOC hospital) and his wife, acupuncturist Ruth McCarty. They both seem to have made quite a good business by him referring his cancer patients to her for TCM treatment (first as outpatients, later they were able to convince the hospital to be part of the cash flow by employing her directly at the hospital). This scam seemed to have worked out very well for Mr. and Mrs. Quack, since at the end of the video you learn that they were able to afford opening a new TCM-clinic! Congratulations!
            I find it hard to believe when you say, “there is no greed here”. Even if the patients are not charged in the hospital, the Quacks and the hospital obviously make money from the philanthropic donations.
            As I suspected, another child´s health history (Cade Spinello) was then exploited in a similar fashion as Max Wilford was before. According to the shameless PR video, he was diagnosed with brain cancer at age 5, six years before the interview and underwent surgery and 18 months of chemo therapy. He had a stroke during the surgery (which apparently was performed by Mr. Quack), which resulted in impairments of his ability to speak and move. As part of his recovery therapy, Mr. Quack recommended acupuncture from Mrs. Quack (can´t help but wonder… could this maybe be a conflict of interest?! But what do I know about TCM…).
            The gullible “reporter” and the parents once again credit the progress of recovery of the boy to the acupuncture treatment, without considering other explanations, a typical post hoc ergo propter hoc fallacy.
            But I have to admit I was wrong in one prediction, i.e. that I did not expect to see any REAL evidence for efficacy or scientific evaluation of acupuncture for cancer treatment. Boy was I wrong. Not less than THREE convincing pieces of evidence were presented:
            1. A quote of the “reporter”: “who better to know than a mum and a dad if it´s working or not?” [repulsive, exploitative PR video, (23:50)]
            2. The statement of Cade´s mother, claiming that a big indicator if it´s working is a simple look in the waiting room of Mrs. Quack. Quote: “Mom´s know. Mom´s don´t do things that don´t work. We don´t have time” [repulsive, exploitative PR video, (24:00 f.)]
            3. The insinuation that Mrs. Quack is blessed by her creator [repulsive, exploitative PR video, (29:17)]

            So if you ask me if my view is inaccurate, you have not provided any FACTS that would indicate so.

          • So – I take it you’re not interested in donating to our film fund drive?

            I am happy to debate the evidence relating to acupuncture and I really am grateful to Dr. Ernst for engaging with me to this degree and hope we might continue. I consider it somewhat of an honor. I also have fairly thick skin and can shrug off some personal attacks when the debate gets heated. But I am not going to bicker with someone impugning the integrity of the subjects in our documentary because they are of the highest character, compassion, and intelligence. They have dedicated their lives to helping seriously ill children and do so with the highest degree of professionalism. You, apparently, went looking to find something on me rather than consider the points I was raising on their merits, found the documentary and started the trolling. I don’t see this line of discussion leading to anything constructive. Have a nice life.

          • This film is a documentary and was 100% UNSCRIPTED

            Your viewpoint obviously differs from mine.
            I am a surgeon with decades of experience and I have my strong views on my vocation. You are a promoter of acupuncture, guided by your own interests and beliefs. You may be licensed to stick people with needles and might have been considered medically qualified a hundred years or more ago, but you are NOT medically qualified in reference to modern medicine.
            Acupuncture may be an accepted add-on in US health care but in the majority of civilised societies it is limited to high-street parlours with Chinese characters on the signpost and the odd spa or backwater clinics that cater mostly to alternative needs of the worried well.

            I happen to have some insight into film making and documentary work and I can tell you that the term ‘scripted’ is a matter of definition. Documentary making often starts with ad-hoc, more or less planned collection of material but scripting is always a necessary part of the post production and editing. That is where the message of the film is constructed, largely by inclusion and omission along with the voice-over and/or subtexts, which make up a very important scripted part of the always intentional message of a documentary.
            In this film, the classic techniques of propaganda are certainly applied.
            The sentence I refer to is very offensive to me as a surgeon. It may have been taken out of context, that in itself constitutes ‘scripting’ by omission. The message of this film is not objective, it is blatantly promotional for acupuncture and the sentence in question constitutes false dichotomy as I explained before.
            It implies with impunity that the purported lack of taking care of the children can be filled by sticking them with needles, a practice that is extremely dubious at any age and circumstance!
            This infomercial is produced solely to promote the practice of acupuncture, which is as we have repeatedly confirmed here on this blog, little more than a theatrical placebo. Even if there are the odd research or review that claims efficacy of acupuncture above sham, this is always of minor magnitude and very questionable as regards clinical significance.
            Out of about sixty Cochrane reviews of acupuncture for this and that, only a handful show a small hope for an intrinsic efficacy of acupuncture. This fact alone should make it glaringly obvious that it should not be used on children, for anything!!

            We have here on this blog established with certainty that it is highly unethical to apply placebo in clinical practice. I find it particularly repulsive that placebo methods involving injury are applied in care of cancer stricken children. The magnitude of this, in my opinion veritable atrocity, is indescribable. Needles are not sugar pills, they can cause fear, hurt and adverse effects in children (I recall my own experience at age 6) especially in children who need to be stuck and cut and whatnot to treat their deadly diseases.
            When the benefit is doubtful, such practice borders on criminal maltreatment in my honest opinion.

          • Dear Matthew Bauer,
            I assume that you want to end the discussion with me without addressing my question where I did get any facts wrong… guess this means I did not.

            Quote#1:” So – I take it you’re not interested in donating to our film fund drive?”
            To some degree, I appreciate your humor. Unfortunately, I don´t think that this film or the topic in general is very funny, as I think that this film abuses and exploits sick children and could lead to other people applying acupuncture (or other TCM methods) when unnecessary, worst case delaying effective forms of therapy. Expect anecdotes, you have not provided any evidence that my opinion is wrong.

            You accuse me of committing personal attacks, impugning the integrity of Dr. William Loudon and Ruth McCarty and even trolling you. This I don´t appreciate.
            When I started posting on this site a couple of months ago, I decided to use a pseudonym because I work at a somewhat exposed, senior position at a German University and was not sure if and how much of my personal information I would like to write about. I have posted about my own health issues and health issues of my relatives and friends, which I would not have done under my real name. In fact, my own cancer diagnose in 2015 and the death of a good friend of mine from lung cancer last year (after she battled it for one devastating year), were the trigger for me to spend much of my spare time with question of religion, science, medicine, CAM, self-delusion and truth vs. deception in general, including following this blog.
            However, in my posts I refrain from ad hominem attacks. I will, however, use the term “Quack” that you seem to find offensive, when I talk about a person working in the health industry who uses scientifically unproven treatments for health issues, like acupuncture.
            So yes, Mr. Bauer, this includes you as well as your acquaintances, Dr. Loudon and Mrs. McCarty. In this context it does not matter at all for me if the persons are (according to you opinion) of “highest character, compassion, and intelligence”. They perform (Mrs. McCarty, you) or profit (Dr. Loudon, Mrs. McCarty and you) from quackery, so I label them as quacks.

            Regarding the evidence, I agree that I might have been side-tracked by your repulsive PR video. I am still waiting for you to present any REASONABLE EXPLANATION WHY acupuncture could work in the first place (where is the scientific evidence that meridians, acupoints, are real?) as well as CONSISTENT SCIENTIFIC EVIDENCE (via proper RCTs) that acupuncture treatments work BEYOND the placebo effect, regression to the mean, etc. ?

            Quote#2:” Have a nice life.”
            Thank you, same for you. And please consider taking down the repulsive “documentary”.

  • Dear Dr. Geir – I respect your work as a surgeon as I respect anyone that dedicates themselves to the humbling work of helping ease pain and suffering through medical care. Of course, I have a completely different perspective on the role acupuncture/Chinese medicine is playing and can play in modern healthcare. My perspective is based on my actual experience of helping thousands of people over the last three decades who were unsatisfied with the care they were receiving plus the work I have done over these years to learn how this particular healing system is being used all over the world.

    The name of the foundation I started – The Acupuncture Now Foundation – is meant to represent trying to understand what the practice of acupuncture is now, in today’s world, and how we can best utilize it. You made a statement about Americans not knowing the world beyond the U.S. and while that is true for too many Americans I am afraid, I would say you seem to have a complete ignorance regarding how traditional medicine is being used in the Far East. Go to some hospitals in China if you want to get informed and see how traditional medicine is being used and the dedication those those trained in both traditional and modern care. That is what the acupuncturists in our documentary did and what (as she states in the film) she decided to dedicate herself to incorporate in the U.S.

    The filmmaker had a younger brother that had a serious stroke and when he was deteriorating after his insurance ran out, the older brother did a lot of research, learned about a program in China, and took him there for treatment in a hospital program that incorporates traditional and modern medicine. He was very impressed with what he saw in the 4 months he spent with his brother in the program but when he returned to the U.S., his brother was unable to get this type of East plus West care and he deteriorated again. The filmmaker wanted to do a follow up film to see if there was more progress with getting Chinese medicine into U.S. hospitals and I wanted to produce a film showing what happens when mainstream facilities take a chance with incorporating acupuncture services into their operations. I learned of this acupuncturist who had been working for 15 years in a top children’s hospital, asked her if she would introduce the filmmaker to some of her patients and hospital personnel and see if they would agree to be interviewed on film, and the filmmaker did the rest.

    I hate to break it to you but Dr. Ernst’s blog is not the world court for passing final judgement on what constitutes valid scientific proof. Just because your group of like-minded self-proclaimed skeptics all see things the same, does not mean the case is closed. The evidence is still mounting and is leaning more and more heavily in favor of acupuncture being a legitimate therapy with an excellent benefit to harm ratio.

    • @Matthew Bauer

      “I hate to break it to you but Dr. Ernst’s blog is not the world court for passing final judgement on what constitutes valid scientific proof.” I’m sure you’re not the only reader of this blog to understand that. What constitutes valid scientific proof will never be found on a blog post. Valid scientific proof of any particular — single — point lies in a body of evidence where the point is investigated by properly designed experimentation with independent replication.

      As to your “Getting to the Point” video: it’s one of innumerable similar demonstrations that videos can make any point they care to, and I’m unsurprised some readers of this blog find it grossly offensive. It consists almost entirely of positive publicity testimonials for acupuncture and provides zero other kinds of supportive evidence. I hate to break it to you but a video is not the world court for passing final judgement on what constitutes valid scientific proof.

      I noted the weasel words at 5:03 — “We can help with his fatigue, we can help with his nausea, we can help with his pain”. [My italics] Notice there’s no word about the extent to which acupuncture can “help”, nor any attempt to provide evidential support that acupuncture had any effect whatsoever, beyond the tired old post hoc ergo propter hoc fallacy.

      I stopped watching around 5:50 when the mother states “He handled the chemotherapy like no-one else had ever seen”. Pure puffery and palpable hyperbole.

      If you want to see how worthless testimonials are, just take a look at any product on Amazon that has more than a dozen or so reviews. The 5-star ratings are usually accompanied by 1-star ratings. The devil’s in the detail and you need to take all the reviews with a pinch of salt anyway. Subjective opinions are the achilles heel of the human psyche: the scientific approach is so far the only successful antidote to providing reality and not fooling ourselves repeatedly.

      You said: “The evidence is still mounting and is leaning more and more heavily in favor of acupuncture being a legitimate therapy with an excellent benefit to harm ratio.” There you go: that belief statement demonstrates your own mental achilles heel.

    • I plan to reply to >>Matthew Bauer on Wednesday 04 July 2018 at 20:48<< but have no time just now. Please see my recent response to GG

  • It is not only insurance companies that are paying for “ineffective” treatments, but the NHS is also burdened with this problem.

    e.g. http://www.dailymail.co.uk/health/article-5593469/Tens-thousands-patients-given-useless-pain-injection-year.html

    There are numerous examples of procedures being carried out in clinics that have no clinical justification. Bjorn Geir would be able to highlight these better than any one else. But epidurals, the use of paracetemol for back pain as well as the prescription of unproven and non-scientific physiotherapy exercises are some that spring to mind. There are many others.

    • @GG
      The difference between modern medicine (let’s call it MSBMS for Modern Science Based Medical System) and other medical systems (aka So Called Alternative Medicine Systems – SCAMS) such as TCM is that in the first, procedures are constantly evaluated and eventually such methods that are found ‘useless’ or associated with an unacceptably high risk/benefit ratio will eventually be abandoned, albeit often slowly. This happened with blood-letting, lobotomies, mammary artery ligation to name some strong examples.
      Promoters of SCAMS like to call attention to knee surgery without understanding it. Arthroscopies are very useful, when correctly applied to the correct patients. What is being abandoned are unnecessary arthroscopies, joint lavage etc.

      This self-regulatory mechanism is unfortunately but as a matter of fact not at play in SCAMS. If it were, we would by default not have any SCAMS because we would only have MSBMS on one hand and useless, abandoned medical ideas on the other. The few SCAMS methosds that are found to work, will inevitably be automatically added to MSBMS

      Acupuncture, both the shallow “eastern” type and to a lesser extent the more recently invented deep “western” kind (aka dry needling or trigger point needling etc.) have been extensively researched and the totality of evidence has shown that they should not be used under any circumstance because their possible but doubtful benefit is very limited in both magnitude and durability. When this is contrasted with the risk of both minor and major adverse effects, even if these are relatively rare, the conclusion and inevitable consequence according to MSBMS should be to abandon this modality of treatment totally. The reason this is not happening is the same as with all other SCAMS, greed and excessive pride*. There is money in selling it and there are people who have built their professional pride on TCM, even if it is based on more or less fantastic philosophical ancient ideas, often referred to as TCM, that fly in the face of known facts. Pride is almost as strong a motivator as monetary interests.

      *I admit that the term ‘grandiose delusions’, which I used previously in this thread for the same argument, may be somewhat excessive seeing as most acupuncturists are delusionally compromised, not mentally disturbed

      • Time is tight so just a quick reply.

        The problem with your logic is you fail to address the dozens of modern medical groups/ authorities who evaluate the evidence for acupuncture and do not reach the conclusion that acupuncture is only a placebo as people such as yourself do. The U.S. National Cancer institute does not agree with your conclusions and nether does many other medical or governmental groups. Some of these groups will say the evidence is inconclusive, some will find it is conclusive in favor of acupuncture but very few will say the evidence is conclusive that acupuncture is placebo.

        https://www.ncbi.nlm.nih.gov/pubmed/29912569/

        https://www.cancer.gov/about-cancer/treatment/cam/hp/acupuncture-pdq#link/_25

        • I am not aware of many who state that find the evidence is conclusively in favour of acupuncture. can you provide the links to such statements, please?
          [btw: inconclusive means it might be a placebo]

          • A few quick ones:

            http://annals.org/aim/fullarticle/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice

            https://www.ncbi.nlm.nih.gov/books/NBK350276/

            https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0063214/

            And I understand “inconclusive” means it “might” be a placebo but that is a long way from proclaiming the evidence is in and acupuncture has been “proven to be nothing more than placebo”. If I could get you to admit that, I would consider that quite significant. You have legions of followers that think you believe acupuncture has been “proven” to be only a placebo and that is not how other neutral parties see the evidence.

          • I am sorry, but I don’t see any clear statements in these documents claiming that acupuncture is more than a placebo therapy.

          • Dear Dr. Ernst – I am sorry you don’t see it as well.

            All three of these groups of reviewers reviewed the research and in some instances, but not others, found that the verum acupuncture had outperformed the sham. That is what the “American College of Physicians’” Recommendation 1 and 2 is about – the specific therapies that their review found met the burden of proof and for acupuncture that included evidence that real acupuncture outperformed sham. So acupuncture was recommended for treating both acute and chronic low back pain with a “strong recommendation”. For chronic low back pain, they recommend that physicians should opt to employ those non-drug therapies (including acupuncture) as “first line” treatments before any drugs. The therapies where the evidence did not show the verum to clearly outperform a sham/placebo control did not make the list as a recommendation.

            The same goes for the findings of the “Agency for Health Research Quality”. In their review, they found that for chronic low back pain, acupuncture had a moderate effect over sham for pain but not for function. When they say the evidence found a moderate effect for real acupuncture over sham for pain that means they found it to clearly not be a placebo. For acute and subacute low back pain, acupuncture showed a “small” effect over sham acupuncture and no effect over sham for function. Even a “small” effect over sham means beyond placebo. If a therapy did not show effects beyond the sham/placebo control, it would have been rated as “no effect”. In the case of the different pharmacological treatments for chronic low back pain only NSAIDs and Tramadol scored as high as a moderate for reducing pain and a “small” magnitude for improving function. Most drugs did not show any measurable reduction of pain or improvement of function while opioids showed “small” effects for both pain and function. Acupuncture was the only non-drug therapy inb this review of the evidence measured against medications for chronic low back pain and was found to have a small effect favoring acupuncture over medications for both pain and function.

            The “Department of Veterans Affairs’” Evidence Map study should have been called the “Efficacy Map” because what they were rating was the evidence of real acupuncture vs sham. They rated in 4 levels: 1. Evidence of no effect, 2.Unclear evidence, 3.Evidence of potential positive effect, and 4. Evidence of a positive effect. They found the evidence that real acupuncture vs sham had a positive effect (not placebo) for headache, chronic pain, and migraine. And, by the way, V.A. hospitals are now hiring Licensed Acupuncturists.

            The “American College of Physicians”, The “V.A.” and the “Agency for Health Quality Research” all have highly professional and fully qualified reviewers whose very job description is to provide unbiased reviews to guide decision makers in these institutions. These are not “promoters of acupuncture”. Their findings all disagree with anyone that says the evidence “shows that acupuncture is only a placebo”. This can be clearly seen in that they all had a mixture where they found the evidence of real acupuncture over sham in some conditions/instances but not others. That you and your followers can’t see this or won’t accept this as a legitimate challenge from qualified mainstream medical authorities to your long-held position speaks volumes.

            From my perspective, acupuncture critics such as yourself have continually kept “moving the goalposts” (a US saying perhaps, but I hope you get the meaning). 35 years ago, critics were saying “there is no scientific evidence acupuncture works”. When studies on acupuncture showing it to be effective began to get published in western medical journals the critics then said “All the studies showing acupuncture works are methodologically flawed and the only methodologically sound studies are the ones showing acupuncture is not better than sham”. Then when some methodologically sound studies (like the those chosen for the Trialists Collaboration) found real acupuncture beyond sham the critics said “the effect size seen beyond sham was not big enough” (even though it met the criteria for “statistical significance”). I have also heard the ridiculous statement that “exceptional claims require exceptional evidence” – the very definition of a “double standard”. I further hear when journal articles find acupuncture effective beyond sham that those journals “don’t have a high enough impact factor”. Really? The “American College of Physicians” practice guideline was published in “Annals of Internal Medicine”.

            Here is another possibility – rather than everyone that see the evidence differently and disagrees with you no matter how qualified and unbiased they may be either being of low ethics or low intelligence, maybe, just maybe – you are wrong. That happens in science.

          • YES, OF COURSE! I COULD WELL BE WRONG!!!
            but that would mean that other institutions (such as NICE and the Germans) are wrong as well.
            ANYWAY
            I did not ask for your interpretation of the 3 links you provided.
            I said, I cannot find clear statements in them where they say that acupuncture is not a placebo.
            you obviously did – so, please could you quote them for me?
            (I might even put them on a slide to show during my lectures on the subject)

          • Dear Dr. Ernst – now I think you are just having fun with me.

            You asked for sources that found “conclusively in favour of acupuncture” and I showed you three. Of course there are no “clear” statements saying that “acupuncture is not a placebo”. Such a statement – yes or no – was not what these reviewers were tasked with producing. What they said and I highlighted for you (and my explanation of these reviews was more for your blog readers than yourself) is that for some conditions/indications their evidence review found that real acupuncture was more effective than the placebo controls. When an active therapy is found to be more effective than a placebo control it strongly suggests the active therapy is not a placebo. Now, whether or not you consider that “conclusive” is matter of semantics.

            You mentioned the NICE review (on low back pain, I assume). In 2009 the NICE reviewers found in favor of acupuncture for low back pain. Did you support their findings back then? Many found substantial problems with NICE’s methodology in their recent review for low back pain. But we can go around and around over the quality of the methodology when one review finds in favor of acupuncture and another does not. The issue I find not defensible is when critics proclaim that the evidence is clear that acupuncture is no more than placebo. It is one thing to say the evidence is inconclusive, quite another to acupuncture is clearly placebo.

            Unlike most of my colleagues, I am far less concerned about the sham arm of these trials (although I agree they are problematic) and far more concerned with the verym arms. I disagree with you about there being no way to know how to do acupuncture in more optimal manner. It starts with acupuncturists with better training and experience doing enough treatments. Until it becomes the norm to place as much emphasis on clinical quality as is placed on trial methodology quality, research on acupuncture will not give an accurate picture of that therapy’s efficacy and true clinical potential.

            You, Dr. Ernst, have expertise on assessing the quality of a trails methodology. I have expertise in assessing the quality of an acupuncture trials clinical quality – if the trial was designed in such a manner to allow the real acupuncture to reach its maximum benefit. I can tell you the many trials that find verum acupuncture to not outperform the sham had poor clinical design that did not allow the real acupuncture to reach its maximum benefit.

            That being the case, I have the following five recommendations:

            1. Acupuncture researchers need to acknowledge that in order for sham controlled trails to legitimately gauge true acupuncture’s potential efficacy, steps must be taken to insure the verum arm of the trial allows the true acupuncture a chance to achieve MTB and justification of these steps needs to be described.

            2. If a sham controlled trial is not intended to gauge true acupuncture’s potential efficacy but rather to test the potential efficacy of some limited application of acupuncture techniques, this needs to be clearly stated in the title and description of the research when published.

            3. Experienced acupuncture clinicians need to work at developing best practice clinical quality guidelines to guide both researchers and clinicians to reach, at very least, an understanding of how many treatments over what period of time acupuncture therapy may need to be applied to achieve MTB.

            4. Until such time that best practice clinical quality guidelines can be established to guide both future acupuncture research and systematic reviews of acupuncture trials, panels of clinical experts should be formed and used to guide researchers in understanding how to distinguish optimal from suboptimal clinical quality protocols to reduce the number of poor clinical quality RCTs and foster more accurate analysis and sub-analysis in systematic reviews.

            5. To help guide future research and clinical practice, more systematic reviews of acupuncture trials should be undertaken contrasting effectiveness and/or efficacy findings relative to the use of different factors influencing clinical quality including (but not limited to) treatment frequency/total numbers and the training and experience of involved acupuncturists. The largest review that attempted this to date had only 21% of included trials that utilized two treatments per week, no trials utilizing more than two per week, and was dominated by trials using acupuncturists with quite limited training.

            I am very grateful you have heard me out over these posts and hope you will offer your feedback on the recommendations.

          • IN OTHER WORDS: you do not have quotes from these documents that acupuncture is not a placebo. I suppose such statements do not exist in the documents you cited.

          • No. All I have are their findings that their reviews found clear enough evidence that real acupuncture was effective beyond sham/placebo controls for some conditions/indications. And for the “American College of Physicians” we have their strong recommendation that physicians and patients should consider using acupuncture for treating low back pain.

            I apologize to others for not responding directly to their comments. I may be able to do so over my weekend but tried to get to some in my replies to Dr. Ernest.

          • Your reasoning Matthew, is fundamentally flawed. Inert methods cannot be ´proven´ to be inert. There are two prerequisites for determining if some method is inert, one is to assess prior probability, the other to attempt to prove it is not inert. You cannot prove the negative, you can only fail (or succeed) to prove the positive. This is the essence of the scientific process. In addition, you have to design your research and analyse your results in order to take the factors that cause false positives out of the equation.
            Acupuncture research shows a lot of conflicting results, but it is evident that the better you adhere to all these principles and the more you sort out the research that is not testing acupuncture (electroacupuncture etc.), the less likely the research is to be positive for an effect of the needling. This means we have to infere that the method lacks inherent efficacy, i.e. it is inert, but also that it is very prone to produce false positive results, which is what fuels your faith in it Matthew.

            The first principle I mentioned, that of prior probability, fails as well in the case of acupuncture, but that is a long story :). Now, off to work, the coffee is finished.

        • Did you read the material you reference, Matthew?
          Neither is objective, both are riddled with problems and present an overoptimistic presentation of the subject. This is the work of people who want acupuncture to be effective. The first is published in an extremely biased journal and in effect represents a survey. It is like doing a survey of catholic schools in ÞRime asking them for their opinion of Mary, mother of God.
          The second is a dead duck from the first page. They do not even bother separating research that has nothing at all to do with acupuncture. Everything is bunched together in a cherry-picked glorified icon of acupuncture.

      • @ Dr. Geir,
        well said.
        Science and evidence-based medicine have made such HUGE progress over the last 200 years, and the most recent developments in molecular biology and genetic cell engineering (e.g. CRISPR/Cas9//Cpf1 or recent developments in cancer immunotherapy with monoclonal antibodies and tyrosine kinase inhibitors) are so extremely exiting, as they open new ways to effectively treat cancer and other serious diseases.
        CAM practitioners like to claim that they -in contrast to the evidence-based “western” medicine- would treat the INDIVIDUAL person. In fact, the opposite is true. Acupuncturists always use their needles for treatment. Homeopaths always use their diluted “nothing” to cure health issues. And so on, and so on.
        In contrast, evidence-based medicine uses a portfolio of vastly different treatment options, specific for the individual person. And, with the new developments mentioned above, this trend will continue and intensify. It is foreseeable that in extreme cases, tailor-made drugs will be developed specifically for ONE individual person. One impressive example was published recently in NATURE:
        A seven-year-old boy with a life-threatening form of skin disease (junctional epidermolysis bullosa) was successfully treated via a full body regeneration of his epidermis with genetically modified skin tissue, derived from his own body tissue:
        Summary:
        http://www.sciencemag.org/news/2017/11/boy-rare-disease-gets-new-skin-thanks-gene-corrected-stem-cells

        Full article (for Nature subscribers) :
        https://www.nature.com/articles/nature24487

        I always wonder why CAM believers seem to think that it is a POSITIVE thing that the specific Voodoo treatment that they chose to believe in has NOT changed for centuries or even millennia.

  • I could not resist jumping into the discussion, although I have tried to hold back for quite a while.

    First of all, I have to point out that Matthew Bauer has been a very kind and well-tempered interlocutor thus far, the kind that this blog has really not seen that often from the alternative-medicine side, at least in the last few years that I have been following it, that is. This is not to vindicate alternative medicine, but, whoever you are, Mr. Bauer, it appears that it is possible to have a discussion with you. I apologize for stating the obvious, but smooth and reasonable discussions with alternative-medicine practitioners have not emerged often here for quite a while.

    The opinions of most commenters thus far, I agree with, but I don’t feel that you have been completely done justice to, Matthew. I think that if you could share a brief memoir of what it was that made you so keen on acupuncture, we could take things from the proper point. I am saying this because I get the feeling that, for some reason, you have an emotional connection to acupuncture that very effectively precludes you from seriously considering that it simply might be wrong. You have to keep in mind that anything and everything you present as opinion or argumentation is going to have a conflict-of-interest style of bias that does not serve to make a productive discussion, because you are actively involved in the field, and the field is very controversial in and of itself. In short, I cannot know why you love acupuncture so much, this is why I was compelled to ask, in all due respect, always.

    I also watched the trailer and felt very sad, because it really has the potential to misguide people and cause them to make wrong and misinformed choices. I was especially disappointed in the point where the anatomy model with acupuncture points shows up…there is virtually no science or observation data regarding why these points or the meridians should matter at all! I am sorry, but this was very bad.

    I would like to distance myself a bit from the earlier established theme, about patient opinion and experience playing a part in the evidence base. I admit it has its due significance, but, more often than not, I would argue that it is almost completely unreliable, because it is influenced by a flooding multitude of factors that no perfectly-designed study would be able to adequately control for, which is why the only choice to make good science is to leave experience out. Patient experience provides hints to pinpoint study hypotheses, but that’s pretty much it. Keep in mind that I am talking about both patient and researcher experience, and I am, of course, referring to the “incident” meaning of the word, not the “skill”.

    Then, I would like to repeat the very often repeated statement that, in medicine, you cannot be bothered to show that something doesn’t work. It has to be the null hypothesis and research is carried out to disprove it. While at it, experience should be ignored because by including it, it is very easy to show that something can be effective for anything under the proper circumstances (and by ignoring the totality of the results, sometimes). And, also, whatever it is anyone comes up with, it has to first be evaluated in terms of what we call prior probability. If there is no mechanism ever observed about how needling a point on the skin might have an effect on some specific organ or condition, we have to seriously doubt the idea all along.

    To offer an analogy, consider buying a new computer and choosing the parts. Let’s stick with the CPU, for the sake of clarity. Your first option is to “ask around” for expert opinions. While this is not bad in and of itself, it is far from the optimal. Whomever you ask, you are going to get a general consensus that every CPU is great. Think about it for a moment…you are asking whether people are satisfied with their computers. You are almost never going to get a negative response, because people bought their computers in advance, so they (a) will not easily admit of having made a bad purchase, (b) will definitely have taken satisfaction into account when buying their computer, so it’s pretty much like asking someone whether they like their new shoes. Of course they do, they wouldn’t have bought them otherwise.

    Now, take some distance from this opinion-based (and biased, due to emotional connection) satisfaction survey. We have developed very powerful and precise tools to measure computer efficiency in almost all different dimensions that are involved. We call them benchmarks (cf. RCT) and they are programs tasked with “overdoing” it with one’s computer, to see how well it responds to an overload of tasks specialized for each part. These things supersede opinion, as RCTs supersede surveys in terms of quality-of-evidence. Check for example here.

    Now, to offer an analogy to the second problem, that of prior probability and quality of evidence, let’s assume the following two CPUs (cf. treatments):
    Intel Core i7-5930
    Ryzen 7 – 1700X

    Let’s go to the direct page of result comparison, based on identical scoring-criteria used for both:

    13,024 User Benchmarks for Intel Core i7-5930
    31,532 User Benchmarks for Ryzen 7 – 1700X
    I’d say that’s plenty!

    As is evident on the corresponding distribution charts, there have been benchmarks for the first of the two CPUS ranging from 75% to 106% and for the second CPU from 81% to 99%. This clearly shows that not taking into account the totality of the evidence, it could easily have been the case that some tests would have shown a result pair of, for example 95% for the first CPU versus 82% for the second CPU. To further show that all parameters have to be taken into account, it can be seen on the same page that, on average, for the CPU pair:
    436 pts versus 415 pts –> Quad-core speed performance.
    877 pts versus 1166 pts -> Multi-core speed performance.

    This is to say that if you ignore even one aspect, any one of the two can be shown to be faster than the other one. Also, by basing a claim on an inadequate number of benchmarking tests, again, any one of the two can be shown to be faster than the other. Apart from that, of course, things are not so simple, as it has to also be tested in conjunction with the rest of the accompanying pieces of hardware comprising a PC.

    For the sake of this comparison, consider one of the two CPUs as acupuncture, and the other as the placebo. You are always going to have conflicting results in terms of efficiency. However, on average, it won’t really matter. Especially in medicine, but also anywhere in science, in general, persistently producing conflicting results is the number 1 indicator of lack of efficacy, at least when many of the involved trials are of adequate-quality in terms of design and execution. Because lack of efficacy may sound a bit harsh, we have to call it simply a failure to outperform nonspecificity of effects, which is a rather fancy statistical to formulate the simple fact that a hypothesis is wrong. And, in the case of acupuncture, I think there have been enough relatively good-quality trials for a consistent difference to have emerged by now.

    And, as is always the case, the slight difference in performance in the two CPUs I chose to compare above, can be represented in whichever way one wishes. Intel-lovers will focus on the faster single- and quad-core speed, and AMD-lovers will focus on the faster multi-core speed. When taking the price into account, things are much more favourable for the 1700X, but this is also irrelevant to the hard-to-deny fact that the performance of the two CPUs is almost identical and there is no strong reason to suggest choosing one over the other (cf. acupuncture vs. placebo). This is to say that one can interpret the evidence base in practically any way they like, as long as they ignore the totality of the available evidence.

    Now, consider an average user opining that the Intel i7-5930K CPU is perceivably faster than the Ryzen 7 – 1700X because (they go on to argue) they have been using the i7-5930K for many years, it has been a very satisfactory experience, they never had problems surfing the internet or playing video games (these are intentional examples) and it has a base clock frequency of 3.5Ghz vs. 3.4GHz of the 1700X. Oh well…

    Their hypothesis here clearly lacks prior probability for the sole reason that i7-5930K has 6 cores and 12 threads, whereas the 1700X has 8 cores and 16 threads, which is, technically, jargon for the fact that it has a larger processing capacity (as it has more processing units). Their arguments are also irrelevant because surfing the internet is not too much of a CPU burden since quite long (let alone it depends on other factors too, such as a fast internet connection), and playing videogames is governed by the confounding factor of the performance of the accompanying Graphics Processing Unit (GPU).

    This is to say that, success in treating minor ailments (such as migraines, cf. surfing the internet) that are self-resolving or present natural fluctuations anyway (cf. connection speed also being dependent on the total traffic requests serviced by the Internet Service Provider’s equipment and infrastructure) is not a strong piece of evidence for a given treatment. Also considering low-back pain as being successfully treated by acupuncture is also an overstretch (cf. videogame performance being strongly dependent on the GPU, not the CPU), as a patient may have taken up exercise (as per his doctor’s suggestions) or been avoiding cumbersome and demanding tasks that require intense body strain over prolonged periods of time for the last few weeks (i.e. resting), so other confounding factors are always into play, often uninvited, thus bothering whoever takes up “making good science”!

    The reason I have elaborated so much on this analogy is to make the point that, in order to accept and incorporate any treatment in medicine, it has to outperform placebo or sham not by a mere “few points”, “some of the time”, but clearly outperform placebo or sham, most of the time!

    I know there are humans, sentiments, personalities, cultures, ethics, and lots of other hard-to-ignore factors involved, but, after taking it all out and diving into the core of the problem, you are practically doing the equivalent of advocating the purchase of the i7-5930K over the Ryzen 7 – 1700X CPU. We feel it would not be wise to spend extra money on something that can never be shown to clearly and consistently outperform our cheap baseline alternative, while, at the same time, the failure has been easy to predict all along.

    • @James:
      very interesting and eloquent post! I appreciate your interesting analogy to CPUs.
      Not sure that it will convince a true believer, but interesting none the less.

      Two quick comments:
      * I felt the same about Matthew Bauer… until I clicked on the link behind his name and saw the video.
      * Would you mind me asking you for advice when I buy my next notebook?
      🙂

      • 🙂 I am glad you found it interesting, Jashak. Of course I am at your disposal in any way I may be of assistance, at least to the extent my knowledge allows me to. I will do my best to give an evidence-based opinion, for what it’s worth 😉

        I like analogies very much, primarily because they offer the quite unique element of translocating any situation to another domain, potentially invalidating conflicts of interest. I mean, why have double standards in one’s own ways. If one is strict wih the value of their purchases, why be so lax with their beliefs and profession?

        I don’t know why, but I honestly admired Matthew’s good temper in the flow of this post’s line of commentary, regardless of his persistence with acupuncture. I also feel, naturally, that this video/documentary is indeed promoting dangerous ideas and has the potential to cause harm, but I also feel Matthew is honestly trying to help. I wouldn’t feel ok if his good temper is not reciprocated with the maximum possible hospitality, at least on my part. I am saying all this because, regardless of our exchanges in here, this video is not going to be removed and the accompanied efforts are not going to take the right direction, no matter how many times we ask or repeat things. I believe Matthew reached this blog knowingly and he is very well aware that it is “infested” (in the good sense) with rationalists being critical of alternative medicine. I feel that he will be best served by having his beliefs and thoughts challenged appropriately, based on sound argumentation and a lot of patience. And if he properly understands what we mean, it is his own responsibility to do what he feels is the right thing afterwards.

        See, as, I think, everyone in their own good time, I have also had my share of challenged beliefs, and I feel grateful towards the people, circumstances and situations that led to some more-or-less serious mind bending and worldview fine-tuning.

        I hope Matthew does not, in any moment, feel like he is being made fun of, this is not what goes on in here, definitely not when someone shows respect and good temper as he has.

    • Thank you James for you thoughts. I am unexpectedly busy today as we have a terrible heat wave in Southern California (45.5 Celsius yesterday) and our air conditioners in our and my son’s homes gave out. I will reply when time (and body temp) allows.

      • No problem Matthew, I wish you manage to have the a/cs fixed or get access to some cooling soon! Be well and take care for now.

    • I wanted to reply to James’ post because I appreciated his openness to the possibility I might not be such a bad guy (paraphrasing). I think what has happened between acupuncture supporters and detractors has been very unfortunate and if I could in any way help those who are highly critical of acupuncture to at least better understand where some of its defenders come from, I think it worthwhile to make the effort.

      Woody Allen had a joke about him getting kicked out of his Metaphysics class at Ney York University when we attempted to look into the soul of the boy sitting next to him. I am not trying to look into your collective souls here but it has been my perspective that most of those who identify themselves as skeptics or supporters of science based medicine are trying to do a public service by protecting the erosion of the scientific method. I also think you further feel that the scientific method is humanity’s best protection against ignorance and the many abuses humanity has suffered and continues to suffer by those who claim authority based on elements of faith. I agree and support this perspective. So do many of my colleagues although some of us may also believe there are additional valuable truths in life that the scientific method might struggle with confirming so straightforwardly. That does not mean that we give up on the scientific method but that it might take longer to find the right application of it to tease-out the truth of some subjects. I mean, we still don’t understand things like Dark Matter that is believed to make up the majority of the physical universe. I also think much of the work of the old quack-busters was valuable because I also worry about quacks taking advantage of the naive. I just think you got it wrong when you lumped acupuncture in with the many other “alternative” methods.

      James asked about my background, something I was not thinking of sharing but, after giving it more thought, maybe it would be constructive to do so. I will keep this as short as I can.

      My first exposure to acupuncture came when I was 11 and my elementary school teacher who had been a Christian missionary in Japan showed our class a picture of a middle aged Asian gentleman with a bunch of acupuncture needles jabbed in his face. During recess my best friend and I took some straight pins from our class cork board and tried to acupuncture ourselves, found it hurt like the Dickens, and decided acupuncture was the stupidest thing we had ever come across. I did not think about it again until I was 19 and went to a library to find a book on back exercises to try to help my daily low back pain I had been experiencing since I injured my back 2 years pervious. I found a book on acupressure in the same section and read it and found it interesting. I practiced some martial arts so had some respect for the accomplishments of East Asians. Many of us in the West of my (now ancient) generation became interested in the East Asian arts including the healing arts by way of the martial arts. The book I got from the library was more of how to do acupressure on others so was not any help to me but it did suggest to me that there was a great depth to acupressure.

      When I was 21, my first son was born with a serious case of Hirschsprung’s disease and had his first surgery at 9 days old. He had a complete lack of ganglion nerve cells in all of is large intestine and up to and including the distil third of his ilium. He spent 2 months in intensive care and had 4 surgeries the forth of which was an ileostomy. We were told there was only one other child in the world at that time (in Russia) that had survived with such a short segment of bowel. The time I spent in the hospital with him gave me tremendous respect for the miracle of modern medicine and the incredibly dedicated surgeon, doctors, nurses and support staff. No doubt my son’s life was saved by modern medicine and would continue to be saved several times in his childhood as his short bowel (and some other birth defects) caused many serious complications. My son is now 41 and in OK health although he has permanent learning disabilities perhaps caused by the heavy sedatives he had to be given when he went into seizures after an emergency surgery (his third).

      He was discharged at 9 weeks as a 6 pound infant with an ileostomy. His mother and I had to find was to care for his ostomy ourselves as there were no other infants with an ileostomy at that time in the U.S. He had trouble gaining weight and at 6 months old was only 7 pounds. It was not until we put him on whole milk that he began to gain weight although all of his milestones were delayed. Needless to say, caring for him was highly stressful and his mother’s health began to fail. She was hospitalized and diagnosed with an advance case of hyperthyroid and told she needed radiation-iodine treatment to destroy half of her thyroid gland. She was discharged with thyroid suppressing medication and an appointment made for the radiation treatment.

      But by this time, I had taken a course on acupressure and learned more about East Asian medicine. I also learned of a Chinese Doctor and thought we could consult with him. He was a Taoist Master who came to the U.S. to teach Taoism. He told us he believed he could help and that my wife’s condition was partly due to the stress of caring for our child, some family (genetic) tendencies, and poor diet. He began acupuncture, put her on a strict diet and gave her herbs. We began this treatment the day she was supposed to check into the hospital for the radiation procedure. My wife began to feel better within a few days and stopped her thyroid suppressing meds after 2 weeks. Her Endocrinologist called several times telling her she was putting herself in danger because she had a bad case and nothing could help her. After 6 weeks he convinced her to have another thyroid scan done to prove to her that she was not better but that scan came back showing her thyroid back to normal. Of course, the doctor said the Chinese medicine had nothing to do with it and it was just one of those spontaneous healings that sometimes happens. We felt differently.

      I began to study Taoist philosophy from this teacher having no idea of doing this medicine myself. I was a construction worker and needed to support my family (we also had an older child from my wife’s previous marriage). I found the Taoist philosophy a fascinating subject (still do) and felt fortunate to be learning from someone I still consider the world’s leading authority on the subject of Taoism. There is far more to Taoism than any of you know I assure you, but that will take a book to explain. I would occasionally take friends and family to this doctor (almost always seeing very good results) but it was not until some 4-5 years later that I decided I wanted to dedicate myself to helping others and eventually decided to go to acupuncture/Chinese medicine schooling. Having the experience I had with my son and seeing modern medicine at its best and then seeing Chinese Medicine first hand and learning the philosophy behind it, I like to say I was incredibly fortunate to have seen the best of both worlds at such a young age. Since beginning my practice, I have worked full time helping thousands of patients and got involved with many aspects of the acupuncture profession. This allowed me to expand my understanding well beyond my personal experience, especially working 20 years within managed care.

      OK – that is my early background. Now, I would like to offer my perspective on where I think many of you have gotten it wrong about acupuncture. Although I stated above that there may be valuable truths in life that the scientific method might struggle with confirming so straightforwardly, I am not at all saying that you can’t prove acupuncture’s efficacy with modern research trials. It is just that what has taken place with acupuncture research has gone so horribly wrong both in the West and in the East. I don’t know if the problems in the East can be fixed but I do believe what has went wrong with acupuncture research in the West could be fixed if the will was there.

      Before getting to the details of research methodology, let’s look at the difficulties we face trying to separate placebo (non-specific) effects from real (specific) effects of acupuncture:

      We should first start out by acknowledging that when critics say acupuncture’s effects are due to the placebo effects, the effects being referred to are the positive clinical improvements enjoyed by the many thousands of test subjects. There is no doubt that some people (and animals) get health benefits from acupuncture the only question is how the benefits happen. There are three possible ways those benefits happen but sorting those three out is the challenge that acupuncture research has thus far done such a poor job at sorting.

      The first possibility of course is the placebo effect but teasing out where the placebo effect is at play is quite difficult to do because of the overlooked second possibility. The second possibility is that needling anywhere in the body (and perhaps even simulated needling) causes the body to produce some endogenous pain reliving and anti-inflammatory chemistry as the body senses it has been injured. That acupuncture could stimulate such chemistry as has been clearly demonstrated especially in animal mechanism research. Now, if needling anywhere can produce symptom-relieving body chemistry, that can mean following traditional theories behind acupuncture might not be needed at all and so calls those theories into question. But this possibility also calls the placebo hypothesis in to question. The third possibility is that traditional point theories and applications do have validity (point specificity) and following those theories will produce better results. The fact that there are three possibilities involved with acupuncture greatly complicates research trial design and such trials have not been well designed to track which of these three possibilities may be at play in any given case.

      Ask yourself – if all three of these factors are involved with acupuncture, how do you sort the specific from the non-specific? If sticking needles or even simulating needle sticks can produce natural body chemistry that eases the symptoms being measured in a study, how do you develop a truly inert placebo control that will allow you to accurately measure placebo effects? There are at least five types of sham acupuncture methods employed in various research trials. That there would be so many different types of “inactive controls” should tell you right there that there is something fishy about acupuncture research.

      But the problems with finding a truly inactive control is less of an issue as the problems with the verum arm of these trials. Dr. Geir said in a post that “you have to design your research and analyse your results in order to take the factors that cause false positives out of the equation.” Of course that is true. It is also true that you have to design your research and analyze the results in order to limit the factors that cause false negatives. This is what is so badly missing in acupuncture research!

      Dr. Geir a surgeon. Would a surgeon trust the results of a trial comparing a surgical procedure vs a sham surgery control if the surgeons who designed the trial and the surgeons carrying-out the surgery clearly had substandard training? This problem is rampant in acupuncture research. Would you trust a systematic review of placebo controlled drug trials comparing a specific drug for a specific health problem if you saw the dosages of the drug given in the different trials varied by 100% to over 1000% or more and no rational was given for why the different trials employed such greatly varying dosages? This problem has also infected acupuncture research.

      Both substandard training and suboptimal dosing can led to false negatives in acupuncture trials and there is good reason to believe this has happened in many such trials. That is probably a major reason why we see some trials showing acupuncture to outperform sham and other trials that do not. It is my hypothesis that if acupuncture trials are designed and the acupuncture carried out by better trained acupuncturists and enough treatments were done to allow for acupuncture’s maximum benefit, you would see verum acupuncture routinely outperform sham. Then no one would have cause to say “acupuncture is all placebo”. We may still have trouble figuring out how much of the benefits seen in the control were from placebo or the real effects of needling anywhere but at least we can move past the notion that acupuncture is placebo and so doctors should not refer for that therapy.

      The main message I am trying (and so far failing) to get across is that without protecting against false negatives as vigorously as some try to protect against false positives, we don’t yet have the right kind of data to reach conclusions over which of these three possibilities are at play in any given acupuncture trial. To any of you who actually read this whole missive, thank you.

      • First.

        perhaps caused by the heavy sedatives he had to be given when he went into seizures after an emergency surgery (his third).

        Why do you think that? There are hundreds of other, more likely reasons to cause learning difficulties in a case like this. One explanation is totally independent from his congenital condition and everything it caused, i.e. he would have had it anyway. a course of sedatives for seizures does not damage the brain, on the contrary it might have protected it. Whatever caused the seizures is more likely to cause learning disabilities, e.g. hypoxia.
        One suspects this is an example of your indoctrinated prejudice against drugs that is leading you on to make invalid conjectures.

        Then:
        Your question regarding incompetent researchers is a fallacy in itself. The answer is self-evident. The problem is not that there are researchers of acupuncture who are incompetent, the problem is that AP itself is nowhere near being a standardised therapy mode. If we forget for a moment the glaring problems with its history and development and with the total failure of finding a mechanism of action, we come to the problem of standardising technique.
        Let’s look at the simple question of where to stick and how deep. If we try to find a common denominator there, it soon becomes obvious that there is no common standard. Those who have tried to find any sensible pattern in them, have come to the conclusion that if you collate all the different varieties, Chinese, Japanese, Korean, auricular, hand… etc. etc. you are left with a map of points that covers almost the entire body, (apart from the genitals fro some reason? 🙂 ) . The most likely explanation is that there is no system upon which this therapy modality is based. It has developed out of nothing and the practitioners made it up as they go.

        I have tried reading texts on AP technique, trying to understand its methods and indications and find it mildly put, bewildering. Even silly, as in the texts describing the utility of the Ren-1 point, which is supposed to be practical in the revival of the drowned and comatose.
        There is no sensible explanation anywhere to be found of how and why each point is chosen. Why on earth is nausea supposed to be alleviated by stimulating a point on the wrist… and why on earth should a fetal breech position be corrected by heating a point on the pinky toe with a lighted herb-cigarette? You might as well just whack the patients bottom with a stick to release a few endorphins and a dash of adenosine into the system. Or drop a fire extinguisher on you toes for back ache. As we know, that helps no one.
        All that Gish-gallop about Yin/Yang, Qi, heat/damp etc. is demonstrably derived from archaic philosophical magic and has no coherent connection to the function of the human body, which we know pretty well by now.

        OK, Matthew. It seems like you have an idea, that your particular system of pricking the skin is a standard that should be followed when constructing trials of AP.
        That is the same idea so many have had before you. But how can you be sure that the “protocol” you have been taught or you have made up is the correct one? Because you believe yours is the correct one? But that is the idea all the other got too.
        AP research is, as you correctly point out, a veritable mess, not because the researchers are incompetent but because AP has not developed into a standardised set of procedures. Now why is that? Could it be because it does not make any difference how you prick, all have the same apparent effect.
        Systematic reviews were developed, to make some sense of such messy situations. Usually much less messy.
        If you look over the field of SR’s of AP you will see that the less the reviewer’s interest in AP is vested, the less likely the result is to be positive.

        Have a look at the list of Cochrane reviews here:
        http://www.scienceinmedicine.org.au/wp-content/uploads/2018/03/Cochrane-acupuncture-2018.pdf
        It is quite recently updated. If AP was an inherently efficient therapy mode, one would at least expect a good deal of the reviews to be positive and to have a clinically significant effect. But only a few of them are at best hopeful and the effect is small.

        • Dear Dr. Geir – thank you for your thoughts. I will offer my own a bit later. I have a deadline on an article due tomorrow I have been putting off to make these replies.

          • your comment prompted me to do a Medline search; This seems to be the ONLY Medline-listed article you have authored (https://www.ncbi.nlm.nih.gov/pubmed/29103410):

            “Acupuncture has been shown to be effective for the management of numerous types of pain conditions, and mechanisms of action for acupuncture have been described and are understandable from biomedical, physiologic perspectives. Further, acupuncture’s cost-effectiveness can dramatically decrease health care expenditures, both from the standpoint of treating acute pain and through avoiding addiction to opioids that requires costly care, destroys quality of life, and can lead to fatal overdose. Numerous federal regulatory agencies have advised or mandated that healthcare systems and providers offer non-pharmacologic treatment options for pain. Acupuncture stands out as the most evidence-based, immediately available choice to fulfil these calls. Acupuncture can safely, easily, and cost-effectively be incorporated into hospital settings as diverse as the emergency department, labor and delivery suites, and neonatal intensive care units to treat a variety of commonly seen pain conditions. Acupuncture is already being successfully and meaningfully utilized by the Veterans Administration and various branches of the U.S. Military, in some studies demonstrably decreasing the volume of opioids prescribed when included in care.”
            And a few clicks further, I find this from an organisation that you seem to have initiated (https://www.mindbodygreen.com/articles/can-integrative-medicine-save-us-from-opioids):
            “According to the Joint Acupuncture Opioid Task Force, the use of acupuncture is “a powerful, evidence-based, safe, cost-effective, and available treatment” for the treatment and management of various types of pain. The task force states not only that acupuncture should be recommended before opioids are prescribed, but that it is also an effective “adjunctive therapy” in the treatment of opiate dependency.”
            It sounds very different from what you are proclaiming on this blog:
            ” without protecting against false negatives as vigorously as some try to protect against false positives, we don’t yet have the right kind of data to reach conclusions over which of these three possibilities are at play in any given acupuncture trial. To any of you who actually read this whole missive, thank you.”
            Or am I misunderstanding something here?

          • Dear Dr. Ernst – I am afraid you may be misunderstanding something, apparently. There is no conflict between the paper I co-authored on acupuncture’s role in the opioid crisis (although I was not entirely happy with some of the final language in that paper, including its title) and my statement: “without protecting against false negatives as vigorously as some try to protect against false positives, we don’t yet have the right kind of data to reach conclusions over which of these three possibilities are at play in any given acupuncture trial.”

            The statement against guarding against false negatives reflects my hypothesis that research is frequently underestimating acupuncture’s efficacy through false negatives. So, while we can’t say with certainly which of the three possibilities I detailed in my pervious statement is at play in any given trial, we do know all three reflect real clinical benefits test subjects enjoyed with very low side effects and that there is good reason to believe the placebo effect is smaller than the manner in which the current evidence is being interpreted. Please read my blog post on that subject and another paper I co-authored on problems with acupuncture research here: https://acunow.org/doctors/challenges-with-acupuncture-research/

            My contribution to this Medline published article came from an earlier paper I co-authored and submitted to the U.S. FDA as part of their process of rewriting their opioid guidelines. I actually prefer this FDA paper to the Medline one. The FDA paper had what I thought was a more appropriate title than the Medline one: “Acupuncture in Pain Management: Strengths and Weaknesses of a Promising Non-Pharmacologic Therapy in the Age of the Opioid Epidemic.” You can find that FDA Position Paper here along with other submissions to other agencies including NICE. https://acunow.org/government-agencies/

            The North American (US and Canada) opioid crisis is just that – a major health crisis caused by the overuse of a pain management drug with a quite poor benefit to risk ratio. People are literally dying in the streets and whole communities are devastated by this crisis. That is not an exaggeration. Many of us believe the current evidence is already strong enough to call for a greatly increased role for acupuncture in managing this crisis.

            While I am a very easy going guy, I will tell you something I find quite upsetting and perhaps even unethical is the way acupuncture critics address the issue of acupuncture’s effectiveness. I often see people saying acupuncture has never been proven effective for any medical condition when what they are referring to is acupuncture’s efficacy in some controlled trials. Take for example the GERAC trials on low back pain that was followed by the Dan Cherkin (toothpick) trial. The GERAC trial found acupuncture to be TWICE as effective as conventional care and the Cherkin trial found it to be 1 ½ to twice as effective. The “conventional care” mentioned here was any combination of drug therapy (including opioids) and physio/physical therapy, etc.

            Low back pain is one of the most common and difficult conditions to manage as well as one of the most expensive and is a condition for which opioids were (maybe still are) often prescribed. So here we had two studies that found a safer, drug-free therapy to be twice as effective as the more harmful conventional care and what did the critics pounce upon? That real acupuncture did not do better than sham, even toothpicks! Had the emphasis when the GERAC trial was published 11 years ago been on benefit to harm concerns rather than preventing the use of a possible placebo, this research should have been seen as a call to expand acupuncture’s role rather than the call to stop its use the critics emphasized. Had acupuncture been widely promoted as a safer and more effective front line treatment back then (as the American College of Physicians now does) who knows how many deaths and how much devastation from opioids could have been prevented?

            So here is my question to you as a physician: Should the emphasis in medicine be to “First do no harm” or “First do no placebo”? If first do no harm, you should be a supporter of an expanded role for acupuncture at least in some conditions such as low back pain. If you think first do no placebo is more important, please be straightforward in identifying yourself as such. I would be most happy to debate those two perspectives.

            Thanks again for your responses.

          • Excellent! So happy to lean you have given this some thought. I agree that the idea of “first do no harm” is an over simplification (although one could suppose the inference today is to first do no “unnecessary or avoidable” harm) but I hope you might honor me by considering the position the Acupuncture Now Foundation has articulated on this question. The following is from our FDA position paper and was first published in our response to the NICE low back pain position. In all seriousness I consider this issue quite important in today’s medical climate and hope you will find some logic and ethical significance in this position.

            “If the likelihood of benefit is greater than the likelihood of harm, this is considered a positive benefit-to-harm ratio and a good recommendation. In this day of “evidence- based medicine,” however, there is a need to undertake side-by-side comparisons of different therapies to measure their benefit-to-harm ratio in relation to each other. When comparing therapies for potentially life-threatening conditions, the likelihood of a higher rate of benefit may be worth a greater chance of harm. But when comparing therapies for common pain conditions that are largely self-limiting and not life threatening and whose severity is primarily gauged by the subjective assessment of the patient, ethics demands that a greater emphasis be placed on reducing potential harms, especially if those possible harms are more serious than the condition being treated. With an emphasis on the ethics of safety, we at the Acupuncture Now Foundation believe the strength of recommendations when comparing different pain management therapies should follow this order:

            1. Less harm and greater benefit
            2. Less harm and equal benefit
            3. Less harm and slightly less benefit
            4. Equal harm and slightly greater benefit
            5. Slightly more harm but significantly greater benefit

            Therapies that would be the most unethical to recommend follow this order:

            1. Greater harm and less benefit
            2. Greater harm and equal benefit
            3. Equal harm and less benefit

            As we will show, acupuncture typically demonstrates a superior benefit-to-harm ratio compared to most drugs conventionally used for treating common pain conditions and that fact alone should make the public, HCPs, and health policymakers take acupuncture seriously as a powerful resource in the fight against opioid dependency.”

          • “acupuncture typically demonstrates a superior benefit-to-harm ratio compared to most drugs conventionally used for treating common pain conditions”
            even if this were true, I would recommend exercise before acupuncture for most of the conditions in question.

          • Of course, exercise can be tried. Most all of the patients sent for acupuncture by those pain management physicians in that program I described regarding the patient experience/satisfaction survey had already be prescribed exercise therapy without success. Those physicians were at first not convinced acupuncture was a legitimate thing (thanks in part to your work) but when they saw the results their patients enjoyed they began to refer more and more patients. This program has now been running more than 10 years despite the additional costs this insurance company/hospital group pays for this program referring patients outside their own system. I have tried to get this huge company to publish about this program but have not as yet been successful.

          • Surprise, surprise… could it be that Mr. “soft-spoken” Bauer is in fact not as sincere as he wants us to think he is?! I was worried about this when I noticed the discrepancy between his apparently reflective blog comments and the PR-video he published. Well, let´s not jump to a conclusion just yet.

          • Quote:
            “(…) the paper I co-authored on acupuncture’s role in the opioid crisis (although I was not entirely happy with some of the final language in that paper, including its title) (…)”

            Weird statement. I am still not sure if you are sincere or not, Mr. Bauer. So difficult to tell with so many trolls around on the internet.
            Everybody who has published a paper must know that as a co-author, it is your responsibility to correct the things that you do not agree with before publication. In all journals that I have published in, all co-authors had to sign a statement for the journal that they agree that the paper will be published. I have, however, no experience with low impact CAM journals like the Journal of Integrative Medicine… does this rule not apply here?

          • Dear Dr. Geir – I honestly do appreciate that you are taking time to weigh if I am sincere or not and had a thought. Here is a link to an article I wrote for Acupuncture Today back in 2001 that I think may help you realize how serious I have been about the subject of how getting good results for patients with acupuncture can be difficult especially when you don’t do enough treatments. https://www.acupuncturetoday.com/mpacms/at/article.php?id=27733

            And here is a link to the more than 20 articles I have written for them since 2000. You will also find there a tongue-in-cheek article I wrote about attending a skeptics conference “A Quack Among Skeptics”. I will get back with more later. Thanks – https://www.acupuncturetoday.com/mpacms/at/columnist_previous.php?id=113

          • Looking over those old Acupuncture Today article I realized there was one I forgot was published there that will, I believe, let anyone here who is interested get the best idea of where I am coming from. I wrote this article in 2009 after the Dan Cherkin (toothpick) low back pain study and it was published in a tiny journal of a state acupuncture association and republished a few years later by Acupuncture Today.

            This is really the beginning of me realizing that I needed to get more involved with what was happening with acupuncture research. I had resisted that because I did not have training in research methodology and figured others who did would take care of this. Here, I am starting to realize the research people may not know enough about how to make acupuncture work clinically especially what successful acupuncturists expect the average range of effectiveness should be for different conditions. You will no doubt think my ideas about qi are lame but I hope you will also see that I advocate that acupuncturists need to listen to what the research is telling us:

            “I also respect scientific research and feel it would be a great mistake for those of us in the OM profession to criticize these studies just because they tell us something we don’t want to hear, without looking critically at both the studies and our own beliefs.”

            The one thing I regret about this article was I was not yet zeroed-in on the issue of treatment frequency in research as I became after this was published and I started reviewing a lot of trails on acupuncture. Oh – you may also find this interesting: I sent the lead researcher, Dan Cherkin, an advanced copy of this as a professional courtesy before it was published. He emailed my back thanking me for the courtesy and also said he “agreed with most of what I had to say”.

            Here is the link to that article. https://www.acupuncturetoday.com/mpacms/at/article.php?id=32551

        • Dear Dr. Geir –

          I had meant to reply to this post of your straight away but got sidetracked by replying to other post. The possibility that my son’s learning disabilities might have been from the sedatives he was given for his post-surgical seizures was explained to me by his doctors as one of several possibilities. It is my understanding that sedative drugs that are given to neonates as part of their recovery from surgery are known to have the potential for causing neurologic damage and that is why there is a lot of interest in reducing those drugs as soon as safely possible.

          You shared several different thoughts. As for the points you raised about the difficulty in finding agreement on best practices for acupuncture, you are partly right, partly wrong. I like to say acupuncture has been around more than 2,000 years and there are probably more than 2,000 ways to do it. There are several thousand “acu-points” that were identified over those years and perhaps going back quite a bit further. I wrote a book that goes into some detail in an attempt to offer theories about how acupuncture first began and how the theories we see expounded in the first known book, “The Yellow Emperor’s Classic” likely came to be. I wrote that material after years of research, pondering, and struggle with learning how to write in some semblance of readability. The main reason I wrote that book was because I felt not being able to at least put forward a rational theory for how acupuncture and its traditional theories of practice were first developed added to the skepticism behind it. I put forward a theory that acupuncture evolved from a series of logical discoveries; one leading to the next. To the best of my knowledge, no one has put forward such a complete set of theories about the origins of acupuncture and acupuncture theory before. If you really have an interest in this subject, the title of my book (chosen by my publisher) is “The Healing Power of Acupressure and Acupuncture – A Complete Guide to Timeless Traditions and Modern Practice”. I just did a quick search and saw 2 sources offering free down loads but I don’t know if they are trustworthy. I make no money on the sale of this book as it did not sell enough copies (according to my publisher) to cover the modest advance I was paid upon publication. I like to believe my book provided a useful explanation for the origins of Chinese Medicine including a section contrasting the similarities and differences Taoist science/philosophy has with modern science. My editor cut several chapters saying the material was better suited for a university press rather than a popular press but what was left does still get my main message across.

          The TCM system that emerged out of the 1950s and 60s in mainland China was itself a kind of consensus process (no doubt a heavy-handed one). But that system is pretty consistent and reproducible to those who learn it and stick to it. A really helpful book that gives a good account for how that TCM system is applied for acupuncture in the hospitals in China is “Acupuncture Case Histories from China” by Chen Jirui, M.D. That book describes how the TCM system is applied to diagnose a wide range of different medical conditions, how the acupuncture points are selected and then often modified based on the patient’s response (something rarely done in controlled trials) and how acupuncture is done in a “series” of treatments consisting of a series of 10 or 15 treatments on a daily or every other day basis. They often end up doing several series of treatments. Of course, you won’t really understand it and will no doubt think it rubbish, but you should still be able to see that there is a formal process- a system – at work here and those doctors often augment their monitoring of the TCM signs with modern diagnostics where applicable.

          Finally, when it comes to the issue of why sticking a needle in a specific spot should cause a specific positive medical reaction in the body, the best research on this is from a research team at California’s University of California at Irvine who have studied acupuncture’s role in modulating blood pressure for more than 20 years. I believe their work to be by far the best research ever conducted on acupuncture. Their team was led by a Cardiologist named John Longhurst who recently passed away. They wrote a nice summation of their research that can be found here: http://www.scientia.global/defining-acupunctures-place-western-medicine/

          Here is the intro to that paper: “Western medical practitioners have often approached acupuncture with scepticism. There are a number of reasons behind this, including a lack of verification of the underlying concepts such as Qi and meridians, and the overall absence of the scientific method. Clinical trials have produced mixed results and are open to bias and the placebo effect. It should also be noted that around one third of patients do not respond well to treatment.

          Upon observing acupuncture in practice for the first time in the early 90s, Dr John Longhurst was similarly sceptical, due to an insufficiency of scientific evidence. ‘I was asked to consider collaborative research in acupuncture. My initial reaction was no, but my future collaborator, Dr Peng Li, then Professor and Chair of the Department of Physiology at Shanghai Medical University, showed me his curriculum vitae containing publications in respected western journals on the central neural mechanisms underlying acupuncture’s cardiovascular actions,’ Dr Longhurst tells us. This led to a long-term collaboration between the two scientists, exploring the neural mechanisms underlying the actions of acupuncture on cardiovascular function. Dr Stephanie Tjen-A-Looi soon joined them, and the team went on to carry out over 40 experimental and clinical studies on the effects of acupuncture on myocardial ischaemia (reduced blood flow to the heart), reflex induced hypertension (high blood pressure), sustained hypertension and reflex hypotension (low blood pressure), as well as identifying mechanisms that underlie the physiological effects of acupuncture.

          One of the most significant areas of study in acupuncture has been the role of the nervous system. Multiple studies suggest that meridians are in fact neural pathways along which nerve bundles are located. ‘We have conducted a large number of studies – over 40 in total – showing that electro- and manual acupuncture applied at specific acupuncture points lowers short-term elevations (by about 50%) and long-term elevations in blood pressure through stimulation of sensory nerve fibres underlying the acupuncture points,’ Dr Longhurst explains. A 2005 study by the team showed that the transection (cutting) of sensory nerve fibres eliminated the modulatory effect of acupuncture on cardiovascular responses. They did not observe similar outcomes with eliminating the actions of motor nerve fibres, suggesting an important role for sensory neural pathways in acupuncture.”

          • @Matthew Bauer

            I have read the discussions between yourself, Bjorn Geir and Jashak with interest but a mounting sense that the support for your side of the argument comes from your unshakeable belief based on personal experience, rather than dispassionate reason. The points you make increasingly resemble those we often hear from convinced believers in a particular religion: you cite the thimble of apparent evidence (however flimsy) that supports your case while ignoring the barrel of contradictory evidence, sticking your fingers in your ears and saying “la..la..la..”.

            An example of this was your response to this comment from Jashak. He recommended you read a previous post from Prof. Ernst about Cochrane reviews of acupuncture efficacy. That post lists forty-two Cochrane reviews of acupuncture treatment for various conditions, all of them failing to provide any positive evidence for clinical relevance of acupuncture.

            You replied that you picked up from the comments on that post that there was one review that showed a small positive effect of acupuncture in migraine that was not included among the 42 others. Do you not understand that, among more than 40 Cochrane reviews on a particular altmed therapy there is a high statistical probability that one will provide a different conclusion from the rest? You also ignored the other comments from that thread that raised valid criticisms of the review in question. To me, this comes over as blinkered scholarship. Prof. Ernst has pointed out, repeatedly, that it is the totality of evidence that needs to be considered. Even Shakespeare understood this point: “One swallow doth not a summer make”.

            In your most recent comment (above) you detail your extensive involvement in acupuncture research (thank you for that). You cite at length John Longhurst’s work, but you don’t explain why his (extensive) publication list should be regarded as more important than the many other studies that don’t confirm his findings, except that you happen to agree with them.

            You have extensively documented your personal successes with acupuncture treatments. You have made the point that Western acupuncture research may have been flawed by insufficent ‘dosing’ of acupuncture treatments, but you seem to want to treat people so often and for so long… might it not be simpler and better in most cases just to use a well-established pain killer?

            I do not doubt the sincerity of your belief in acupuncture, but that sincerity just might have impaired your objectivity on the topic.

          • Hello Frank – Thank you for following these posts. I will try to respond to the several points you raised. You said “You have extensively documented your personal successes with acupuncture treatments.” I barley mentioned my personal experience until Jashak asked me to relate them. I know my personal experience is not important in a discussion about evidence. You asked “might it not be simpler and better in most cases just to use a well-established pain killer?” Do you mean like opioids? I believe that we in healthcare should prioritize care based on the evidence of the benefit to harm ratio and that the evidence is clear that for many common pain conditions, acupuncture has been shown to have a better benefit to harm ratio than most pain meds. That being said, I am not at all opposed to the use of those drugs if the less harmful therapies are not working. I call this “Going up the risk ladder” – we start with the safer therapies like acupuncture and then go up the risk ladder when necessary. In clinical practice, (supported by some research) we often find that combining those types of drugs with acupuncture is better than using either alone and patients do better with less dosage of those risky drugs than if taken alone.

            You said “You cite at length John Longhurst’s work, but you don’t explain why his (extensive) publication list should be regarded as more important than the many other studies that don’t confirm his findings..” I was impressed that Dr. Geir had tried to read books about acupuncture and was giving him a reading list I thought would be most helpful. I am trying to be sensitive about the length of my posts and explaining Dr. Longhurst’s team’s 20 plus years of research would take some space. I was not sure if people were really interested so thought I would give the link to a brief summation. I am happy to discuss this work with those who read that summation.

            When it comes to those Cochrane reviews on acupuncture, it is concerning but quite telling how you are misreading the evidence. There are not 42 Cochrane reviews that have been undertaken investigating whether or not acupuncture has “clinical relevance”. There have been Cochrane reviews on the evidence of acupuncture’s efficacy for SEVERAL DIFFERENT MEDICAL CONDITIONS. The acupuncture critics have for decades been saying that there is “no evidence” that acupuncture is more than placebo. Of course, there are many studies including systematic reviews showing acupuncture to outperform sham but people like Dr. Ernst reject all of those as being unreliable studies that have a risk of false positives. So, what is the one source of review that you critics will accept as not having false positives, the gold standard of the gold standard? Cochrane, according to you. That being the case, all it should take is one Cochrane review finding that acupuncture did better than sham for ANY medical condition to show that you critics are wrong to keep asserting that there has never been ANY research showing acupuncture to be more than placebo. But you will even dispute a Cochrane study when it finds acupuncture better than sham! The pattern is clear – it is not that there is “no evidence” showing acupuncture is more than placebo, there is just no evidence that your lot will ever accept, even Cochrane. You won’t admit that your own biased, unsupported rejection of every source of evidence but Cochrane has painted you into a corner. If you now want to assert that even Cochrane got it wrong in that migraine study, that means you are saying that only Dr. Ernst is a reliable source of interrupting the evidence. If he says Cochrane got it right, then Cochrane got it right. If he says Cochrane got it wrong, then Cochrane got it wrong. That is known is some circles as being a “ditto-head”. Whatever your leader says, you say “ditto”.

            It seems to me that you are the one who is like a religious fundamentalist who will not admit that your “all or nothing” position has been undermined by the very standard of evidence you used all these years to proclaim acupuncture ineffective. You seem afraid if you admit that if the evidence shows acupuncture to be better than sham for any one condition then this means you were wrong all these years. And, if you have to admit you were wrong about acupuncture for any condition that could mean you were wrong about other conditions as well.

            I, and most acupuncture supporters, on the other hand, am not at all afraid to admit that acupuncture is ineffective for some medical conditions. I even teach a course called “What acupuncture can and cannot treat and why”. But your all or nothing position is one that is completely out of step with many mainstream modern medical institutions who are more and more seeing the “clinical relevance” of acupuncture despite the best efforts of the acupuncture critics to stop it. This is happening because, unlike you, those mainstream medical institutions don’t just look to one source but trust the many long respected sources of evidence that find acupuncture clinically relevant.

          • “the evidence is clear that for many common pain conditions, acupuncture has been shown to have a better benefit to harm ratio than most pain meds.”
            WOULD YOU PLEASE LINK SOME EVIDENCE?
            “There have been Cochrane reviews on the evidence of acupuncture’s efficacy for SEVERAL DIFFERENT MEDICAL CONDITIONS.”
            indeed, and the evidence is rather disappointing:
            https://www.ncbi.nlm.nih.gov/pubmed/21440191
            https://www.ncbi.nlm.nih.gov/pubmed/18789644
            “Of course, there are many studies including systematic reviews showing acupuncture to outperform sham but people like Dr. Ernst reject all of those as being unreliable studies that have a risk of false positives.”
            not true! which such review did I ‘reject’?
            “there is just no evidence that your lot will ever accept, even Cochrane.”
            like which one? don’t fantacise, provide concrete evidence for what you are claiming, please.
            “you are saying that only Dr. Ernst is a reliable source of interrupting the evidence”
            DON’T BE RIDICULOUS!
            “you are the one who is like a religious fundamentalist”
            and here we go: the ad hominems.

          • Hello Frank – I wanted to return to your post with some more specifics. You had said “Prof. Ernst has pointed out, repeatedly, that it is the totality of evidence that needs to be considered.” It is ludicrous to say that one has considered the totality of evidence about acupuncture when one refuses to consider the all of the evidence from China. Dr. Ernst offers his personal rational for why Chinese research should not be considered but that is his own biased opinion. There are over 4,200 TCM hospitals in China treating millions of patients churning out many dozens of studies and reporting very high success rates. Those success rates are so high that Dr. Ernst thinks they should be rejected in total. That is his personal prerogative, of course. However, something is wrong when someone claims their opinion on acupuncture is based on the “totality of evidence” without making clear that this “totality” is minus the biggest body of evidence from the one country that utilizes acupuncture on more people, at the greatest level of integration within their national health care system, and with the highest reported success rates. Don’t you at least wonder about this unique situation? Might it be possible the Chinese do get higher success rates because they have more expertise and do a lot more treatments on average that are done in the West? When they report 90% success rates, do you really think they are only getting the 40-50% success rates so often seen in Western trails? Do you have any objective proof they are falsifying their success rates by nearly doubling them? One fact should be very clear to anyone trying to be objective: “Without us having a clear picture of the actual success rates the Chinese are having with acupuncture, we don’t have a clear picture of how effective that therapy is.” It is not just me saying this, the Chinese have been trying to point out that Western research is getting false negatives as well. Here are two studies that touch on this. : “Analysis and Thoughts about the Negative Results of International Clinical Trials on Acupuncture” Wei-hongLiu,YangHao,Yan-jingHan,Xiao-hongWang,ChenLi,andWan-ningLiu Evidence-Based Complementary and Alternative Medicine Article ID 671242
            “Is acupuncture no more than a placebo? Extensive discussion required about possible bias” (Review) SHIZHE DENG1*, XIAOFENG ZHAO2*, RONG DU1, SI HE1, YAN WEN1, LINGHUI HUANG1, GUANG TIAN1, CHAO ZHANG1, ZHIHONG MENG1 and XUEMIN SHI1 EXPERIMENTAL AND THERAPEUTIC MEDICINE 10: 1247-1252, 2015

          • at it again?
            ““Prof. Ernst has pointed out, repeatedly, that it is the totality of evidence that needs to be considered.”
            what I do say often [because it is true] is that one has to consider the totality of the RELIABLE evidence. by and large the Chinese trials do NOT fall into this category [a statement which is based on the totality of the reliable evidence].

          • And who gets to decide what evidence is “reliable”? Sounds ripe for subjective opinion rather than data driven.

            Being that I have been responding to several posters, I can find it difficult to keep up. Please remind me of any specific questions you have for me and I will respond.

            Sometimes, what you see as me putting words in your mouth is my repeating what others here have said you have said.

            As for insults, I am pretty sure I only responded in kind and then apologized when I realized I went too far. However, two wrongs don’t make a right so I will refrain from those in kind responses.

          • “And who gets to decide what evidence is “reliable”? ”
            I am surprised by this question from someone who pretends to understand research!
            there are accepted and validated instruments for estimating the quality of clinical trials.
            if you want to see how unacceptably poor most Chinese studies are, there are many posts on this blog and elsewhere about the issue. here is one of many papers: https://www.ncbi.nlm.nih.gov/pubmed/?term=ernst+e%2C+tang+bmj
            now Sir, tell me something: when will you answer the questions I put to you [feels a bit one-sided to answer yours and not get answers of mine]?

          • I did answer several of your questions directly but I will review and look for those I did not get to and offer my answers although I believe most of those answers will be found in the following two sources:

            https://www.evidencebasedacupuncture.org/present-research/acupuncture-scientific-evidence/

            https://acunow.org/wp-content/uploads/2017/10/Acupunctures-Role-in-Solving-the-Opioid-Epidemic-_Final_September_20_2017.pdf

          • Dear Dr. Ernst – You asked me to answer the questions you had asked that I had not yet responded to. As near as I could tell reviewing those questions you asked that I did not answer, I found 4:
            #1.On 7/2 you asked: do you know what evidence is?
            My answer – yes.

            #2. On 7/14 I had stated “Of course, there are many studies including systematic reviews showing acupuncture to outperform sham but people like Dr. Ernst reject all of those as being unreliable studies that have a risk of false positives.”
            You said: “not true!” Then asked: “which such review did I ‘reject’?”
            My answer: It is my understanding that you have rejected the findings of at least these reviews. I add quotes from those reviews’ findings. If, in fact, you accept any of those findings please advise which ones and I will stand corrected.

            Acupuncture Evidence Project-
            “Key results: Of the 122 conditions identified, strong evidence supported the effectiveness of acupuncture for 8 conditions, moderate evidence supported the use of acupuncture for a further 38 conditions, weak positive/unclear evidence supported the use of acupuncture for 71 conditions, and little or no evidence was found for the effectiveness of acupuncture for five conditions (meaning that further research is needed to clarify the effectiveness of acupuncture in these last two categories).
            https://www.acupuncture.org.au/wp-content/uploads/2017/11/28-NOV-The-Acupuncture-Evidence-Project_Mcdonald-and-Janz_-REISSUED_28_Nov.pdf

            Acupuncture Trialists’ Collaboration – Acupuncture for Chronic Pain Individual Patient Data Meta-analysis:
            “Results : In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition”
            https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1357513

            Cochrane Review – Acupuncture for preventing episodic migraines
            “Bottom Line: The available evidence suggests that a course of acupuncture consisting of at least six treatment sessions can be a valuable option for people with migraine.”
            https://www.cochrane.org/CD001218/SYMPT_acupuncture-preventing-migraine-attacks

            #3. On 7/14 I had posted: “the evidence is clear that for many common pain conditions, acupuncture has been shown to have a better benefit to harm ratio than most pain meds.”
            Then you asked: “WOULD YOU PLEASE LINK SOME EVIDENCE?”

            Again, the Cochrane review on preventing migraines found: “ In five trials, acupuncture was compared to a drug proven to reduce the frequency of migraine attacks, but only three trials provided useful information. At three months, headache frequency halved in 57 of 100 people receiving acupuncture, compared with 46 of 100 people taking the drug. After six months, headache frequency halved in 59 of 100 people receiving acupuncture, compared with 54 of 100 people taking the drug. People receiving acupuncture reported side effects less often than people receiving drugs, and were less likely to drop out of the trial.”

            A 2015 network meta-analysis comparing treatments in addition to exercise for shoulder impingement syndrome found that acupuncture was the most effective adjunctive treatment out of 17 interventions, outperforming all other adjuncts such as steroid injection, NSAIDs, and ultrasound therapy. (Dong W, Goost H, Lin X-B, et al. Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis. Medicine (Baltimore) 2015;94:e510. doi:10.1097/MD.0000000000000510)

            A 2016 comparison of 20 treatments for sciatica ranked acupuncture as 2nd most effective after the use of biological agents, outperforming manipulation, epidurals, disc surgery, opioids, exercise, and an invasive procedure called radiofrequency denervation, which came in last. (Lewis R, FLCOM NHWPF, PhD AJS, et al. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal 2015;15:1461–77. doi:10.1016/j.spinee.2013.08.049)

            In 2018, a network-meta-analysis found that acupuncture was more effective than drugs for treating chronic constipation and with the fewest side-effects. (Zhu L, Ma Y, Deng X. Comparison of acupuncture and other drugs for chronic constipation: A network meta-analysis. PLoS ONE 2018;13:e0196128. doi:10.1371/journal.pone.0196128) (I know constipation is not a “common pain condition” but medications for common pain conditions often causes constipation.)

            #4. On 7/13 you asked:
            “are you claiming that, in China, there is a uniform treatment schedule? I think this is fantasy! “

            My answer: “Not exactly a “uniform treatment schedule” but certainly a uniform treatment schedule approach. The exact number and timing of the treatments will depend on the patient’s progress. The basic ratio is that in the beginning stage for chronic conditions is you see the patient more frequently (in China that will be daily or every other day) then, when the patient has made enough progress, you start to stretch the treatments out to about ½ the initial frequency until they reach the maximum benefit. And that is another BIG problem with acupuncture RCTs in the West – the acupuncturists aren’t allowed to change the treatment frequency based on patient response like we do in practice.

            I would like to correct how some here seem to have misunderstood about my statement about Western acupuncture trials not being done in such a manner as to allow the real acupuncture to reach its maximum benefit. I have been saying that this happens either because those involved in the trials don’t know how to preform acupuncture to its full clinical potential OR the trials were never designed to allow acupuncture to achieve its full potential. Both have happened. There are trials where the “acupuncturists” involved in the design and/or doing the needling were woefully undertrained and unable to achieve the maximum benefit. In many of the trials where there are better trained acupuncturists involved, the acupuncture proponents you called them, it seems clear they did not think it necessary to allow acupuncture to reach its maximum clinical potential. So the precondition of a legitimate multi-arm sham controlled trail to offer evidence about if verum acupuncture can outperform sham was not built into those trails design. I can give examples of this if you are interested. I hesitate to go through the trouble to give those examples if you don’t care to see the evidence. It seems strange to me though that someone who has a record of picking apart the methodology of trials that find in favor of acupuncture and claiming they are giving false positives would not care to see evidence of methodological problems in acupuncture trials causing false negatives.

          • Goodness me, Mr. Bauer. You do like to put words in peoples’ mouths, whether in your videos or your comments.

            So, what is the one source of review that you critics will accept as not having false positives, the gold standard of the gold standard? Cochrane, according to you.

            No, sir! I linked via a comment from Bjorn Geir on this thread which linked to a previous post on this blog detailing Cochrane systematic reviews of acupuncture.

            If you want my opinion of Cochrane reviews it is as follows. The Cochrane database probably offers the most independent and dependable information on clinical trial data we have available at present. As such it is the ‘least worst’ source. I personally dislike the hyperbolic term ‘gold standard’. It can be too freely used as a marketing slogan.

            Because Cochrane systematic reviews have gained such a positive international reputation they have become sullied by selective quotation by people with an agenda. Acupuncture has been tested in blunderbuss fashion against a large number of medical conditions for the very good reason that it has an extremely low prior probability. No-one has a coherent explanation of how it might work, and ardent proponents, such as yourself, proffer feeble excuses for its lousy performance in clinical trials by arguing that the people using it don’t really know what they’re doing.

            I repeat that a single, weakly positive systematic review of acupuncture among more than 40 in the Cochrane database is evidence of nothing. You are simply clutching at straws.

            If you now want to assert that even Cochrane got it wrong in that migraine study, that means you are saying that only Dr. Ernst is a reliable source of interrupting the evidence. If he says Cochrane got it right, then Cochrane got it right. If he says Cochrane got it wrong, then Cochrane got it wrong. That is known is some circles as being a “ditto-head”. Whatever your leader says, you say “ditto”.

            This comment has to be the most offensive I have ever read on this blog. The suggestion that I have no mind of my own is the vilest ad hominem accusation. Professor Ernst is definitively NOT my leader. I have never met him, he is not my friend, we are not related. I knew of him before he started this blog only in the context of someone who was prepared to stick his head above the parapet and call ‘foul’ on the deplorably low scientific standards that pass for research in the community of pseudo-medicine practitioners. His own many research publications were a long-overdue attempt to redress the balance.

            The two final paragraphs of your comment attempt to throw back in my face my own line about “convinced believers in a particular religion”. These words do not define a ‘religious fundamentalist’: they relate to any believer. I could (and perhaps should) have phrased it as “self-convinced believers in any superstition unsupported by reliable, scientific evidence, including all religions, the paranormal, New Age, ghosts, the Loch Ness Monster and too many others to name individually”. My only ‘belief’ is that Carl Sagan hit it on the button when he wrote that “Science is a way not to fool ourselves”. He might have added “but you have to understand and do science properly”.

            Finally…

            But your all or nothing position is one that is completely out of step with many mainstream modern medical institutions who are more and more seeing the “clinical relevance” of acupuncture despite the best efforts of the acupuncture critics to stop it.

            This is the first time I’ve seen the argument from authority used without even specifying the authority!!

          • One of the difficulties I have had in this series of posts back and forth here is trying to respond to specific individuals who have offered their sometimes harsh opinions of my positions while also trying to speak to what I have seen over time as the overall “acupuncture critics” among whom Dr. Ernst is recognized as a leading proponent. I probably conflated some of those and then my response to one was not as targeted as it should have been. Frank, I apologize for the ditto-head comment. I think Dr. Ernst has those types following him and parroting what we says but I can’t say I saw enough of that from you to include you in that group. I hope you all here will appreciate that I have (freely) stepped into the lion’s den and that I have tried to bring up specific evidence that suggests the position “there is no convincing evidence of clinical benefit” from acupuncture is misleading and not supported by the evidence.

            Maybe relating a story here will help: 25 years ago I was to debate someone about acupuncture who part of the U.S. “National Council Against Health Fraud” and I had a phone call with one of their representatives (a Medical Doctor) to help to establish the ground rules for the debate. He seemed a nice fellow and at one point I said to him “ Come-on, doctor, you know acupuncture is helping people, why are you guys so against it?” He told me, “ In medicine we have a system to determine if something really works and acupuncture circumvented that system. It does not really matter if it works. What matters is that we follow the system. If we allow something like acupuncture through without going through the system, then the system could break down and that would be very bad.”

            Unfortunately, that debate never took place but, as far as I have been able to tell all these years, this same argument is really at the heart of the efforts to stop acupuncture. It has nothing to do with if acupuncture works clinically – it obviously does that. It has to do with if acupuncture is believed by those who see themselves as protecting the scientific method as passing the scientific test to THEIR satisfaction. It is kind of like what some will say in legal circles – “it does not matter if an innocent person is found guilty or a guilty person is found innocent, what matters is we adhere to the rule of law. Otherwise, the rule of law will break down.”

            I am not insensitive to that argument. I just believe that acupuncture has passed the test of the scientific method often enough even though there are real problems with false negatives in Western acupuncture research. It is not only the acupuncture advocates who feel acupuncture has passed the test but several mainstream medical authorities as I have shared in earlier posts. Acupuncture is innocent of the crime of being a placebo although it has been found guilty in an ever increasing minority of courts.

          • you have run out of arguments, put words in people’s mouths, tried ad hominem and now offer purely your very biased opinion.
            WELL DONE!

          • Actually sir, far from ruining out of arguments, I have been concerned about my postings going into too much detail. I wanted to ask if it would be more appropriate for me to share the fuller details (not my own biased opinions) here or post on my foundation’s blog and link here? I really don’t want to breech protocol. The opinions I just shared was only me hoping this would help your readers better understand where I come from. I much prefer to stick to more objective details.

          • after not answering my question, putting repeatedly words into my mouth, insulting your opponents … you are worried about protocol!
            I sometimes wonder where you come from!

          • “at it again?
            ““Prof. Ernst has pointed out, repeatedly, that it is the totality of evidence that needs to be considered.”

            That was actually Frank putting words in your mouth.

          • @Matthew Bauer

            “Might it be possible the Chinese do get higher success rates because they have more expertise and do a lot more treatments on average that are done in the West?”

            I very much doubt that. Since it reopened to the West in the 1970s, China has had a particular difficulty. While its economy has blossomed amazingly over the past 40 years, it numbers only a few internationally elite scientists among its citizens. Its government has therefore taken steps to rectify the situation, but the attitudes and cultures of the Chinese population (in common with most populations) are slow to move. They remain steeped in traditional beliefs, which are particularly notable in medicine, and the catch-up is a tedious process.

            You should first read this article so you can appreciate I am not exaggerating the problem. Like the article explains, a focus on short-term positive results from scientific experiments is unhealthy: it is likely to tempt some investigators into publishing data they know won’t be reproducible. (The same thing happens all over the world when scientists are pressured to publish, but a government reward scheme has to be an exceptional pressure.)

            Now look here, here and here. (That last link is a news report describing the previous link in easy-to-read language.) Lest you think the cheating described is a recent problem, you should take at look at this and this.

            As an academic, retired after a career of 45 years, I can assure you that most of my colleagues involved in biomedical research are aware of a ‘China problem’. While the best of young scientists from China who spend time doing research in the West are often first-class, even superb, there seem to be some to whom falsifying research results is almost second nature. I have personally refereed papers in my own field (broadly, medical microbiology/infectious disease) submitted by Chinese groups that contained blatant examples of crudely fiddled data, but all this is mere personal anecdote and you can disregard the comments if you wish.

            Lest you should think I have some kind of cultural/racist bias against the Chinese (I definitely don’t!), this paper puts the relative contributions of nationalities for scientific paper retraction into perspective; the USA leads the field for research fraud, with China a poor fourth. But those are figures for all types of research, and they’re based only on publication retractions: most fraudulent or otherwise dodgy papers never get retracted.

            For clinical research publications, China has a more serious problem. This article is one of many reporting the 2016 Chinese government revelation on data fabrication in 80% of new drug trials. You may say this is not evidence for a similar problem with acupuncture trials and other types of Chinese altmeds, but, against the background I set out above, I’d suggest such a view is over-optimistic.

            Up to this point I hope you notice I have not referred so far to any material on the Ernst blog, which always seems to aggravate you, but I’m now going to link to this post from 2014. Please re-read it carefully. It contains what I would characterize as unassailable logic; but I’m sure you will have a different perspective.

            In science (and, dare I say, particularly in medical science?) I consider it is essential to maintain a sceptical eye about everything you read, particularly when one’s ‘personal experience’ may be an influence. Experience is a valuable asset, but history shows us it can lead us down many wrong paths. Perhaps the discovery that peptic ulcer is an infectious disease might serve as a recent example of the triumph of science over collective medical experience.

          • Frank – I tried to bring to everyone’s attention the sub analysis in the Cochrane review on preventing episodic migraines that showed acupuncture did do better than the sham control and that when higher treatment numbers were used the effectiveness rates went up considerably. Did you see that post? Those higher treatment numbers in that sub analysis are much closer to the numbers I would use myself so that is some evidence from a respected source supporting the manner in which I treat. It also supports the main point I have been trying to make about optimal vs sub-optimal treatment dosages in acupuncture trials and reviews; dosage matters.

          • @Matthew.

            I was going to respond to you but I see that Frank has addressed practically all the points I was going to make and in a much better way than I could have.
            I am not giving this blog much attention these days, seeing as the weather has finally improved. This summer we had rain twice, first for 45 days, then for 35 days. Between these periods there was one (1!) day with some sun. 😀

          • @ Mr. Bauer,
            Quote (from Saturday 14 July 2018 at 17:22)
            “You said “You have extensively documented your personal successes with acupuncture treatments.” I barley mentioned my personal experience until Jashak asked me to relate them. I know my personal experience is not important in a discussion about evidence.”

            So many times we went back and forth on this. I have even tried different styles to make you understand, but still you do not get the point, it seems. This makes me think that it is not a language barrier, but a “brain barrier”.
            I WAS NEVER ASKING YOU FOR PERSONAL EXPERIENCE OR ANECDOTES! Quite the opposite, PLEASE STOP trying to use your personal anecdotes as prove! I was asking for EVIDENCE that you method works!
            Maybe you get it if I illustrate it with an example (as a new style, I will try pre-school writing style):
            *Ten persons with lower back pain visit your colleague, Mr. White.
            *He uses HIS acupuncture protocol on them (let´s say, several acupoints, 2 times per week for 6 weeks.
            *In his satisfaction/experience survey, five persons report back positively (i.e. 50%) .
            ______
            *Ten other persons with lower back pain visit YOU.
            *You use YOUR acupuncture method/protocol (let´s say, several acupoints, 4 times per week for 18 weeks).
            *In YOUR satisfaction/experience survey, nine persons report back positively (i.e. 90%).
            ______
            You now claim that this is proof that YOUR way to do acupuncture is correct, resulting in maximum benefit and that Mr. White does it incorrectly. Guys like him would have screwed up all the RCTs that have not shown benefit of acupuncture beyond placebo.
            I say that your claim is a fallacy, because without proper controls (placebo, no-treatment), MANY OTHER REASONS could explain that you get a better feedback than Mr. White does. (Maybe I should have called him Mr. Impatient or Mr. Body-Odor, instead of Mr. White…).
            My point is that YOUR METHOD must be evaluated independently via RCTs (which must include all necessary controls and far greater patient numbers for statistical analysis) before you can make ANY claim of efficacy beyond placebo.
            I hope that you now finally get the intention of my question. If not, I might well try baby-speech next time.

  • Quote:”(…) I am starting to realize the research people may not know enough about how to make acupuncture work clinically (…)”

    Let me ask an obvious question: how can you tell that YOU know how to make acupuncture work clinically (beyond placebo)? You seem to be convinced of this.
    Or vice versa, do you know ANY colleague of yours who is NOT convinced that he/she is doing it correctly and that it is working?
    And if you and all of your colleagues know that it is working, why are metaanalyses as done e.g. by Prof. Ernst do NOT conclusively demonstrate efficacy of acupuncture?

    • Thank you for these constructive questions. I will get back with my replies later as my time allows.

    • “Let me ask an obvious question: how can you tell that YOU know how to make acupuncture work clinically (beyond placebo)? You seem to be convinced of this.”

      I will start by explaining from my personal experience then my experience working with other acupuncturists. There are so many ways to tell. For example, I just gave a treatment to a patient with neuropathy in his lower extremities. This type of patient is a bit unusual because they allow for a type of objective testing acupuncturists don’t always get to take advantage of. Neuropathy patients will have different degrees of loss of sensation. This is usually strongest in the feet and then may move up the lower legs toward the knees. Experienced acupuncturists can test for levels of sensation/loss of sensation with their needles – we know what degree of sensations most people will feel when we insert needles of specific thicknesses (gauge) in specific acupuncture points.

      Some neuropathy patients will have no sensation in different points in their feet even with lager gauge needles but will start to feel those needles as you move up the leg. So you test to see how much these patients can feel at what points with what size needle. When you see this type of patient becoming less hypo-sensitive and being able to feel the needles closer to the normal range most people will feel, it is a good precursor to them feeling their numbness subside. Often, you can put a needle in a point, stimulate it as much as you can and the patient will not feel it at all. You can then leave the needles in place for 20 minutes or so and then stimulate it even lightly and the patient can now feel the needle! Once these patients start to feel the needles closer to the normal range of sensations, they will begin to feel the numbness levels subside. When you see their numbness gradually subside over weeks of treatment at the same time they are beginning to feel the needles at the normal range, we know you have made a difference in the underlying cause of the numbness. If you do enough treatments over a long enough period of time, these improvements can last months or longer. If you stop the treatments too soon, the numbness returns much sooner.

      I would say, though that one of the important, eye-opening aspects of these sham controlled trials for me was forcing me to recognize that there is likely more placebo effect from acupuncture than any of us knew before. I say “likely” because it is impossible to know how much of these non-specific effects seen in sham controlled trials are from the placebo effect vs how much is the result of real, physiologic changes (like the production of endogenous analgesics and anti-inflammatory chemistry) triggered by needling anywhere or even simulated needling. This being the case, it may be that when some patients (mine or any acupuncturist’s) are given a suboptimal number of acupuncture treatments and report improvements, those improvement may have been placebo or those real but non-point specific effects.

      Other than the above, the main reason I have confidence in knowing how to get the maximum therapeutic benefit (MTB) from acupuncture is the more than 20 years I have spent working in the US managed care industry. In US based managed care, an insurance company is required by law to pay for treatment that is deemed “medically necessary” (that means there is good reason to believe the treatment will be medically beneficial to the patient) but not required to pay for treatment deemed not medically necessary.

      Our original think thank had acupuncturists with 10 years or more of full-time practice from China, Korea, Taiwan, and the U.S that practice a range of different style although all of us were also trained in TCM. We had what I believe to be the most intensive and lengthily deliberations on the issues of how can you tell if acupuncture is working or not that has taken place, in the West, anyway. The Chinese probably went through a more intensive process when they developed their TCM protocols. For us, we were considering not just one style like TCM but the bigger issue of how to know if different styles of acupuncture were working. What eventually emerged from these deliberations was a consensus on how many treatments it would likely take to; 1.see if the treatment was working or not, and, if so- 2. how many more treatments to reach MTB.

      The protocols we developed on managing all this provided this insurance company with an expert panel consensus (Level V11) guideline that became their original policies for determining medical necessity and thus staying within the law. Since that original set of guidelines 21 years ago, this company has continue to refine their guidelines based on the best available evidence. They use those evidence-based guidelines to justify why they would allow or not allow requests for services from their contracted providers. These guidelines are proprietary. However, while these proprietary guidelines have been augmented and refined with higher Levels of evidence based on recent research, they have not changed a great deal from our original consensus panel of experts.

      Over these years, I not only have helped to refine that guidelines as a consultant (and now member of their Board of Directors) but I have continued to work as a provider within their credentialed Acupuncturists network where I have to provide rational for why I am requesting the number of treatments within a specified time period for my patients.

      So here is a an example of something that happened to me 15 years ago that may illustrate why I find so many trials on acupuncture to be using a suboptimal treatment dose:

      I received a phone call from a “case manager” from this insurance company who told me she wanted to talk to me about a patient I requested treatment for because it seemed to her that I was not doing enough treatment. “Oh really” I said “tell me more”. She told me that I had requested x number of treatments over y weeks for this particular patient but considering where this patient was in the treatment process, it appeared I was not doing the treatments frequently enough. Looking at this patients file I saw why she thought that. I had added some weeks to the time period I actually wanted to does those numbers of treatments for that patient because sometimes patients miss treatments and I would have to do the extra paperwork to request a time extension on the treatment approval process. The case manager asked to not do this as they had to base their decision on the number of treatments over specific period of time the acupuncturist requested.

      That case manager did not know that I had helped to develop the guideline she had been trained to follow to manage these treatment requests. I was very happy to get that call because it told me this company was serious about seeing patients get enough treatments.

      But here is my point in all this – if acupuncture trials were to have a “case manager” following a consensus treatment frequency guideline like we have with this insurance company, there would be very many of trial researcher getting phone call saying – “it looks like you are not doing enough treatments to allow this patient to reach maximum therapeutic benefit. When Dr. Ernst says acupuncturists cannot reach consensus on treatment guidelines that is simply wrong. We did it for our network of 6,000 US acupuncturists, the Chinese did it for their TCM guidelines, and the US National Cancer Institute did cancer related patients. AND ALL OF THESE GUIDELINES CALL FOR CONSIDERABLY MORE TREATMENTS THAN ARE TYPICALLY USED IN WESTERN ACUPUNCTURE TRIALS.

      Sorry – all I have time for for now.

      • @Matthew.

        You were asked: “how can you tell that YOU know how to make acupuncture work clinically (beyond placebo)?”
        You have given us one anecdote that got better at the same time you were pricking the patient. This is not evidence, and a hundred anecdotes is not evidence either, it’s just more anecdotes.
        You have no idea if your patient got better because of your pricking or because he just recovered from whatever was the problem, that may well have been getting better on its own, or due to some other factor like improved nutrition for example.
        The rest of your long winded comment contains a lot of speculation that seems to me to be saying simply that the longer you persevere with needling, the more likely the patient gets better, over time. Why do you think this is evidence or proof that you know AP is working at all?

        • everytime someone confronts you with facts , you bring the A word i.e. Anecdotes . you like to use it whenever it does not go your way.

          • You call something that someone tells you a fact?! OK, yesterday I watched a rabbit climb a tree; and if you don’t believe me I can show you the tree. Fact.

          • @ “Observer”
            I am getting rather weary of trying to explain simple principles to nameless commentators that think they are clever enough to put me down.

            Let me tell you an anecdote that is a fact.
            The other day my back hurt. I did not take acupuncture. My back got better.
            This is a fact. It is also an anecdote.
            If I was silly enough to infer from this fact that not using acupuncture helped for my backache or backache in general and tried to tell Frank that my story shows that not using acupuncture is beneficial, then I would be trying to argue my conclusion using an anecdote. Then I would be guilty of using a logical fallacy.
            The anecdote I would be telling would in no way be valid evidence.
            Even if I told Frank that a million people got better from their backache by not going to an acupuncturist. Then this would not be any more proof, even if it is a fact. It would only be a million anecdotes that prove nothing, even if they are an irrefutable fact.

          • You could debate the possible risk/benefit of not using acupuncture. You could speculate about not using acupuncture compared to other treatments for a hurt back. You could wonder why proponents of not using acupuncture have never done a proper study. Etc etc.

            But if you have a million anecdotes that are irrefutable fact, and try to make the argument that it’s fantasy because there isn’t data from a controlled trial…you’re obviously not dealing with reality. You’re a fundamentalist, blinded by your beliefs.

      • Mr. Bauer,
        My question was how YOU (or any of your colleagues in the field of acupuncture) can tell with certainty that his/her treatment has any specific benefit beyond placebo, which would make it superior to less invasive alternatives like e.g. doing some mild exercise, as recommended by Prof. Ernst. Most of you certainly THINK that your treatment has a specific effect and you also certainly have positive patient feedback, but when you guys are tested in RCTs, specific effects of your acupuncture treatments (beyond placebo) are NOT conclusively demonstrated. However, some serious side effects (even deaths), have been reported.

        Now let me break down your answer to my question (hope that I am not offending, but I am not a native speaker and furthermore, Germans are said to be rather direct, which may come across as not very polite).
        1. You start your somewhat long-winded answer with a case example of a patient with neuropathy. But: WHY DO YOU DO THIS?! You know that single case examples are of NO scientific proof at all that your METHOD works, so this cannot help to answer my question.
        I do not doubt that you and all your colleagues often see apparently positive effects after applying acupuncture. But this is also true for other CAM practitioners, e.g. homeopaths, Reiki healers, ghost healers, etc. etc. etc. So, do ALL these stupid CAM practices work in your opinion? If not, I would really love to see a heated debate between you and a convinced homeopath…

        2. Next, you mention that you recognize that acupuncture elicits a placebo effect. You even state that you DO NOT KNOW how big the unspecific placebo effects are. So, your statement rather underpins my doubts in acupuncture, in contrast to answering my question.

        3. Next, you state: “the main reason I have confidence in knowing how to get the maximum therapeutic benefit (MTB) from acupuncture is the more than 20 years I have spent working in the US managed care industry.”
        This just baffles me. You just admitted that you do not know the extent of placebo in your treatment, but still you know that a specific benefit exists. This is not logical. 20 years of ignorance to this flawed logic are no accolade of your work.

        4. The following paragraphs of your post are quite confusing to me. You mention US insurance policies, some Asian countries, TCM protocols, Level V11 (?!), your involvement as a consultant and telephone calls with some unknown insurance case manager. All this is weird to me and off-topic, I can´t see how this addresses my question.
        Just as one comment to the whole insurance story:
        Coverage by an insurance company is of course not at all a prove that a treatment WORKS. As an example, many German insurance companies pay for homeopathy.

        5. Your final statement is that MORE acupuncture treatments are called for. I have no clue why this would make any sense at all. Without any good scientific explanation for the MECHANISM that acupuncture could work (sorry, in contrast to you I am a molecular biologist, not a Taoist, therefore I believe in ATP, not in Qi…) and such conflicting study results, I must favor the rational explanation that most -if not all- effects that you (and e.g. the ghost healers) see, are caused by placebo, regression to the mean, natural course of the disease, confirmation bias, etc.
        So up to now, my conclusion is that you do not seem to be able to explain HOW YOU PERSONALLY CAN KNOW THAT YOU DO MORE THAN JUST ELICIT A PLACEBO EFFECT IN YOUR PATIENTS. And if this is true, is in not ethical for you to pretend that you have some unproven, ancient healing power that you apply to cure your patients.

        • I misunderstood your question. I thought you were asking for how I know when I treat my own patients that the benefits they enjoy was not placebo.

          You seem to confuse different issues. One issue is if real acupuncture outperforms sham consistently in controlled trials. My answer to that is that I think it would for many common conditions if: 1. the real acupuncture was designed in a way to allow the active therapy to achieve its maximum benefit and 2. if the sham acupuncture were actually inactive I believe most trials are not successful in these two critical areas.

          You then bring up the mechanisms but that is a different issue. I would direct you again to the report just issued by the U.S. National Cancer Institute. They begin their review with a review of “animal/laboratory/pre-clinical studies.” Those studies show acupuncture changing body chemistry in positive ways in lab animals.

          In that review they also say “For acupuncture to become part of the standard of care for cancer patients, further education about acupuncture, improved insurance coverage, and accessibility to qualified acupuncturists are needed” and that “Acupuncture is acceptable and safe for children”. That means the US NCI is very much in agreement with the goals of our documentary that you and others found so offensive and a sign of my questionable character.

          I am trying to have a constructive discussion about acupuncture trial methodology with a group who has a habit of using such trials to argue against acupuncture with what I believe to be faulty logic.

          • @ Mr. Bauer,
            Quote: “ I misunderstood your question. I thought you were asking for how I know when I treat my own patients that the benefits they enjoy was not placebo.”

            No, you did not, this is EXACTLY what I was asking you. Still waiting for an answer. I hope Dr. Geir and me made it very clear that anecdotes from your patients are NO PROVE that your method works, because you have no control of what would have happened to the patient without your acupuncture treatment. Maybe his condition would have improved faster without your needles? You cannot know, because nobody can. This is the reason why the best way to find out if a treatment works or not is by Randomized Controlled Trials.

            Regarding that you “think” that “real acupuncture” would outperform sham consistently if done correctly (whatever this means..)… well, this is just your BELIVE. The available evidence does not support your believe. So you might consider modifying your BELIVE. I am aware that it must be EXTREMELY difficult to question your belief, especially if your income depends on it. But some former CAM people were able to do it, like e.g. the former homeopath Natalie Grams. I´m not so naïve to think you will change your whole life as a result of our exchange, but I still wanted to mention that some CAM believers could change their minds and followed scientific evidence and reason, instead of following an unproven belief system (based on Qi, meridians, etc.).

            Regarding the U.S. National Cancer Institute document, let me quote:
            “The evidence from most of these clinical studies is inconclusive, despite their positive results; either poor research design or incompletely described methodologic procedures limit their value.[75] There is controversy about the most appropriate control for acupuncture, which also limits the interpretability of the results of clinical trials.”
            Sounds not very convincing to me.
            Furthermore, I don´t know how independent the U.S. National Cancer Institute is. As a federal agency, their statements could be dependent on politics or lobby work. I find Cochrane Reviews far more convincing, because they are done financially independent and free of conflicts of interests, therefore recognized as the “gold standard” for medical treatment evaluation. And they come to a very different conclusion than you. I recommend you have a look at this post from Prof. Ernst:
            https://edzardernst.com/2018/01/acupuncture-there-is-no-convincing-evidence-that-it-is-an-effective-therapy/

          • I did look over this thread on Cochrane reviews and found one poster, Tom, pointed out that the review on preventing migraine headaches found “Contrary to the previous findings, the updated evidence also suggests that there is an effect over sham, but this effect is small.” Of course Dr Ernst then replied “but the effect is small.” Well, it was not too small for the Cochrane “gold standard” reviewers, was it? You know, the ones that you stated are perhaps the only ones to be “financially independent and free of conflicts of interests”. You seem to place Dr. Ernst opinion even over the Cochrane reviewers.

            But let me ask you and others here this – “If this Cochrane review on preventing migraine had found a larger effect for real acupuncture, would that finally convince you that there is reliable evidence that real acupuncture is more than placebo, at least for preventing migraines?

          • @ Mr. Bauer,
            You have still not answered my question on how you can tell if your method works beyond placebo. Why so hesitant? Is this question not of utmost importance to you? I mean… you practice acupuncture for such a long time and your livelihood depends on it, don´t you want to know for sure IF and HOW it works?
            I see no reason to answer your specific question regarding acupuncture for migraine prevention, since it is a hypothetical question.
            But as a general answer: As a sceptic (or scientist), you should OF COURSE change your opinion, as soon as the best available, reproducible scientific evidence indicates that the new data support a new hypothesis better than the previous one.
            So… if solid scientific evidence for the existence of fairies, dragons, unicorns, homeopathy, acupuncture, ghosts or an almighty god would exist, I would probably:
            *make sure that I am not dreaming or mentally ill
            *bang my head against a wall for a couple of times
            *drink a few glasses of Scotch
            * finally accept it as most likely being reality (and, in case god does exist, rush to the nearest church as early as possible the next day).

          • Maybe it is a language problem (I only speak one language and admire those who speak more) but you seem to be asking for my personal opinion of how I can tell my acupuncture treatments are more than placebo but then you have already let me know that my personal opinion means nothing and only evidence from controlled trials matter so why I would try (again) to relate my personal experience to you?

            As far as my question about if the Cochrane review on migraine showed a higher effectiveness rate for real acupuncture, it was not hypothetical at all.

            I am not sure if you read the article I wrote for Acupuncture Today about my attending a skeptics conference by I closed that article with this

            ” All kidding aside, there are strengths and weaknesses in aspects of both conventional and CAM approaches. We will never be able to rid ourselves of the zealots at both ends of the spectrum who rail against the other, as though these issues were matters of religious dogma. That’s all the more reason the moderate, open-minded people among us need to work together to bring the best of both approaches to the public.”

            You are clearly one of the zealots at the far end of the skeptics spectrum and I made a mistake by trying to engage with you again. I hope some of the more moderate, open minded skeptics here will be interested in continuing this dialog especially about this Cochrane migraine review as there is something of importance I wish to share.
            Hab ein schönes Leben

          • imagine a meeting of the ‘FLAT EARTH SOCIETY’ and a lecture about the pros and cons:
            ” All kidding aside, there are strengths and weaknesses in aspects of both spherical and flat earthers. We will never be able to rid ourselves of the zealots at both ends of the spectrum who rail against the other, as though these issues were matters of religious dogma. That’s all the more reason the moderate, open-minded people among us need to work together to bring the best of both approaches to the public.”
            What I am trying to say is that the call for an open mind has its limits – see also here: https://www.ncbi.nlm.nih.gov/pubmed/19854319

          • I have been trying to bring up a problem with the manner in which clinical quality issues are typically conducted with acupuncture trials in the West and especially the issue of treatment dosage (frequency/total numbers over time). So far, no one seems interested and about the only feedback I received was from Dr. Ernst who stated flatly that treatment dosages don’t matter. However, this Cochrane review on acupuncture for migraine prophylaxis found otherwise.

            They performed a subgroup analysis on the number of treatment sessions given comparing the studies used in the review that used less than 12 treatments vs more than 16. This review excluded studies which were of less than 8 weeks duration. Now, using 16 treatments for preventing migraines is better than 12 but still not the optimal number needed to get the maximum benefit from acupuncture. In all categories of measurements, the outcomes for the 16 or more treatments showed more positive effects than the 12 or less, something Dr. Ernst’s statement suggested should not happen. The “test of overall effect” expressed as a Z number of “response at follow-up” (Outcome 18), for the studies which used 12 treatments or less was Z=2.32, while for studies using16 or more treatments, Z=4.06. The test of overall effect for “headache frequency reduction after treatment” (Outcome 19), for 12 treatments or less was Z=1.64 while for 16 or more treatments, Z=3.52. The test of overall effect for “headache frequency reduction” at follow-up (Outcome 20), for the 12 treatments or less was Z=1.61 while for 16 or more treatments, Z=3.62. The test of overall effect for “response after treatment” (Outcome 21), for 12 treatments or less was Z=2.09 while for 16 or more treatments, Z=3.74.

            In the “Comparison with Sham Acupuncture” summation of this review’s abstract (often the only information people will see about a study like this) they reported the SMD was -0.18 (95% CI -0.28 to -0.08; I² = 47%) after treatment and -0.19 (95% CI -0.30 to -0.09; I² = 59%) at follow-up.

            But that was combining all of the studies together including those with clearly (to anyone that really knows acupuncture) suboptimal 12 or less treatments. When you see the sub analysis, you see this:

            For the 12 or less treatment study the SMD was -0.11 [ -0.24, 0.02 ] and for the 16 or more treatments the SMD -0.30 [ -0.46, -0.14 ] “after treatment” and for “at follow-up” 12 or less the SMD was -0.11 [ -0.24, 0.02 ] and for 16 or more treatments the SMD was 0.35 [ -0.53, -0.18 ]. In both of these measures, the SMD was approximately three times greater for the 16 or more treatment group vs the 12 or less.

            Had the reviewers excluded all the studies that used suboptimal treatment numbers and only selected studies for this review that used a number of treatments closer to what is needed to get the maximum benefit from acupuncture, their review would have found better outcomes. How many more Cochrane reviews might have ended-up with positive finding for acupuncture had the reviewers excluded studies with suboptimal treatment dosages? That is something anyone really interested in science based medicine should want to explore. Until such analysis of these types of reviews can be undertaken, it should be recognized that we cannot trust reviews that do not take critical clinically criteria like treatment dosages into consideration.

          • “… and about the only feedback I received was from Dr. Ernst who stated flatly that treatment dosages don’t matter.”
            I do not remember stating that; are you sure that you do not again put words in my mouth?
            “Had the reviewers excluded all the studies that used suboptimal treatment numbers and only selected studies for this review that used a number of treatments closer to what is needed to get the maximum benefit from acupuncture, their review would have found better outcomes.”
            Instead of going on about this – why don’t you do such a review/meta-analysis?

          • I tried to get volunteers to help with this as I do not have the resources or the expertise in research methodology to do this myself. My expertise is in the clinical delivery of acupuncture and especially the number and frequency of treatments needed to reach maximum benefit. When I did try to pull studies to look at the details of treatment numbers I also ran into the problem that many studies do not bother to give accurate details of this. I have found several individual trials where they did higher numbers of treatments over longer periods of time and found a pattern of real acupuncture eventually pulling ahead of sham after 8-12 weeks of the two running neck and neck. If you have any suggestions for finding researchers who could do such an analysis, please let me know. If such an analysis was done well and the hypothesis about treatment frequency and overall numbers over time was found to not increase the effectiveness of real acupuncture over sham, I would accept it. For most conditions, it has to be a minimum of two treatments a week for 6-8 weeks and then once a weeks for another 6-8 more. That is still far less than the Chinese do.

          • you forgot to answer my questions!
            “… I do not have the resources or the expertise in research methodology to do this myself…many studies do not bother to give accurate details of this. ”
            considering this, I find your prediction what the result would be even more surprising.
            “That is still far less than the Chinese do.”
            are you claiming that, in China, there is a uniform treatment schedule? I think this is fantasy!

          • Mr. Bauer,
            Very well, I have a full-time job as well and write to you in my spare time, and since my girl-friend is beginning to become jealous, I agree that we should end our discourse at this point.
            I do, however, not understand why you think of yourself as open-minded and call me zealot. We both have not moved very far from our initial positions, and in contrast to you, I clearly stated that I would be willing to change my opinion on acupuncture, as soon as convincing, reproducible evidence would show that it works and that the specific benefit outweighs the potential risks. You have not stated under which conditions you would change your opinion.

            One last time I will try to explain my question on how YOU can tell with certainty that YOUR treatment is superior to placebo (or to those of acupuncturists that do it “incorrectly”). This time, I will try it in the form of a dialogue. Hope I don´t distort your position, I do not intend to commit a “straw man” fallacy. If I do, I am sure that my fellow sceptics will soon point it out. 😊

            You say:” Acupuncture is often not better than placebo in RCT trials, because many acupuncturists do not know how to do it correctly and/or for a long enough period.”

            I say: “How can you tell that YOUR way to do acupuncture is better than the way those OTHER acupuncturists do it, or better than what other CAM practitioners do?”

            You say: ”I have had great responses from my patients for decades. Just treated a guy suffering from neuropathy”.

            I say: “That’s exactly what all other acupuncturists (and CAM practitioners in general) say, even those who you claim do NOT do it correctly, because you all will see placebo effects, natural progression, regression to the mean, confirmation bias, ect., from your patients”.

            You say: “Yes, placebo effects exists, and I don´t know how big these effects are, but I achieve definitely more than placebo with my treatment”

            I say: “You can only claim this if your exact method would have been tested via an RCT. Again, how can you be sure that YOUR acupuncture is the correct one?”

            You say: “I think you are a zealot and I regret talking to you”.

            Even if you did not answer my question, I would like to tell you that I appreciated our discourse. You even posted details about your family’s heath issues, which is what I only do when using a pseudonym. I wish you and your family in this regard all the best. I have learned several new things about acupuncture, placebos, placebo effects, and even Taoism because of our discussion, so I consider it quite constructive. See you later!

          • Maybe it is a language issue. I appreciate what you said here but originally, you asked me how I can tell that my treatments are not just placebo not how I can tell that my treatments are doing better than those other acupuncturists in these trials. The question about placebo is very difficult to answer the question about how I know my treatments are better than those in these trials is easy – look at the effectiveness rates. I started this whole thread with a link to a patient satisfaction/experience survey that showed 85-93% of patients saying their acupuncturists was successful in addressing their primary complaints. I know that is not the same thing as a controlled trail effectiveness rates, but when shame and real acupuncture are found in these trials to be the same effectiveness, the effectiveness rates are in the 40-50% range. I know that my treatments and those of the hundreds of acupuncturists in that survey are getting far better than 40-50% effectiveness. We are getting rates similar to the Chinese. In order for me to request treatments for my patients under the managed care system I helped to build and I work under, I need to submit regular progress reports and that includes a form the patients fills out rating their progress with several different metrics including the 0-10 VAS. It is VERY rare that I have a patients that does not have at least a 2 point improvement and also indicated improvements in Activities of Daily Living. I see all of these trials with those 40-50% effectiveness rates and know those acupuncturists did something wrong and the low treatment numbers/frequency is the thing that leaps out.

          • I have just read the Cochrane review on the use of acupuncture in migraine. The authors were clearly faced with a difficult problem of trying to make sense of a highly disparate collection of trials, and they seem to have done a good job under the circumstances.

            Their conclusion was that acupuncture appears to be useful in the prophylaxis of migraine headaches, and I think we have to let that stand until more evidence becomes available.

            Having said that, the authors admit the shortcomings of the review, and classify the level of evidence as moderate.

            Migraine is a chronic problem causing lifelong suffering and tends to follow a natural course of remissions and relapses. Only one of the trials had a follow-up period of more than three months, and that one only twelve months, so none of them addressed the question of whether acupuncture was a useful intervention in long-term prophylaxis.

            We have to be very careful about drawing conclusions from subgroup analysis, which is much more prone to show spurious statistical significance (the more sub-groups you analyse, the more likely one of them will give a p-value of 95% by chance alone). On the whole, sub-group effects tend to get smaller with subsequent trials (or longer-term follow-up), but they can be a useful basis for designing further studies.

            Interestingly, in the discussion the authors concluded that sham treatments appeared to be comparable to previously reported drug prophylaxis, raising the question of a particularly strong placebo effect, or of physiological effects of random needling or cutaneous stimulation.

            If this were a review of a conventional drug I don’t think I would be inclined to adopt it into my clinical practice. And if this is the best evidence of the effectiveness of acupunture in general, then that speaks for itself.

          • @ Mr. Bauer,
            Since you finally addressed my question, I will give a last statement about this issue, although I feel that I have spent way too much time on it already.
            You now clearly state that your prove that YOUR way to perform acupuncture is effective beyond placebo is that you get higher satisfaction/experience ratings (85-93% of “happy customers”) in patient surveys that reported in some other RCT studies (40-50% of “happy customers”).
            Even if the numbers you claim are true, which I don´t know, these numbers do NOT prove that your METHOD is working. And that is what we are talking about: the METHOD-SPECIFIC BENEFIT of acupuncture!
            Again: YOU HAVE NOT MADE ADEQUATE CONTROLS FOR YOUR METHOD! Why is the concept of CONTROLS so difficult for you to understand? I can´t wrap my mind around it, since you ARE aware of the placebo effect, natural progression, regression to the mean, and so on. These things HAVE to be controlled for to find out about the method-specific benefit of your treatment. Only if you know the specific benefit of a treatment, you can compare it with the risk involved and then decide, if the risk/benefit balance justifies application.
            It is very simple for me to come up with several possible explanations why people who go to YOUR practice might report better satisfaction/experience than people visiting another acupuncturist. Let me give just two very obvious ones:
            *You could be a more empathic/likable person. People will then give you better feedback. Just have a look at one of the doctor rating websites; let’s take two dentists working in the same doctor’s practice as an example. Even if they apply THE SAME methods/equipment, you will often find very different grades for the doctors. So why can´t you see that satisfaction ratings are NO PROVE FOR THE METHODS USED?

            *As Dr. Geir already pointed out, if YOU do the treatment for a longer period of time than the other acupunturist does (let´s say twice as long), then more people with a self-limiting condition will feel better at the end, simply because the condition got better on its own during the prolonged time.
            You MUST control for these (and other unspecific) effects if you want to claim that you method has a SPECIFIC benefit. And you do this via well-designed, RCTs with a proper placebo control.
            The only thing that your superior satisfaction/experience ratings show is that the people visiting you get what they expect. It does NOT show that the method of sticking needles into the human body at certain acupoints works in general, and it also does not prove that YOUR special way to do it is more efficient than the next.
            This is all I will say about this topic for now.

          • experience is the name we give to our mistakes!!!

      • May I remind users of the term “Placebo” that the word has a very specific meaning in modern use.
        It literally means “an agent with no efficacy”.

        Matthew (and many more) seems to be using it to describe some mysterious effect of acupuncture or of the subject’s belief that it is being treated. This is not correct.
        It should only be used to denote inert paraphernalia used in research to compare the therapy agentbeing researched, be it a pill, a potion or an instrument, to an inert facsimile i.e. the ‘placebo’.
        From this follows that ‘the placebo effect’ is the (usually positive) change in measured outcome seen in the subject group that received a placebo (an inert facsimile) instead of the therapeutic agent.
        Modern research and reviews of the purported ‘placebo effect’ have shown quite clearly that there is little probability of an intrinsic effect of believing that you are receiving an active agent when you are only receiving a facsimile of it.
        It is very common to hear people quoting that “placebo has a 30% effect”. This figure comes from previous research that was interpreted to show that inert agents (e.g. sugar pills) had an intrinsic effect believed to be some unknown effect of mind over matter. These studies were simply misinterpreted to conclude that the effect seen could be attributed to some mysterious action of belief in being treated. What was omitted was the fact that a large part of the conditions studied were partly self limiting and those who improved in the placebo groups did so simply due to regression towards the mean, i.e. the problem got better by itself.

        Using the words ‘placebo effect’ for an observation you cannot explain otherwise, means simply that you don’t know why the condition improved and the most likely explanation is of course that it got better anyway and would have even if no agent, active or inert, was administered.

        @Matthew
        As Jashak and I have elaborated on above, you have not yet produced any evidence or explanation of the effect you believe AP has. You have talked at length about your experiences. You suggest the effect of placebo and in a way you are right, but it does not mean what you think it means. It simply means that you saw improvement but you don’t know why. The most rational explanation is that it was not AP that caused this improvement. If you attribute it to a placebo effect, what you are saying is that it got better anyway and it was notwithstanding the administration of the (probably inert) agent i.e. AP.
        You suggest AP should be used more and longer, right? That would of course mean you will see more “placebo effect”, in other words, more would become better, not because they were treated more and longer with AP but because more time would be given for spontaneous improvement or the effect of other agents such as concurrent medication, better nutrition etc.

        In other words: If you attribute the effect of AP to placebo, then you are saying in so many words that AP has no effect of its own and you could see the same effect from any other form of entertainment. You might for example perform a song and dance for the patient and observe the same effect.

        • @ Dr. Geir,
          Thank you for reiterating the correct use of the term “placebo”. This made me again aware that I should be extra careful when using it. I admit that I might have done this sloppily in the past, in an attempt to keep my comments as brief as possible (…not always very successful in that regard).
          🙂
          Just to say it clearly:
          When I used the term “placebo” in my last comment (and e.g. suggested that Mr. Bauer “elicits a placebo effect” in his patients), I meant that his TREATMENT METHOD per se (acupuncture) has no SPECIFIC beneficial (or negative, for that matter) effects at all.
          He might have observed that patient symptoms got better after acupuncture, but this does not exclude the possibility that this would have happened even if he had used a sham treatment, other CAM variants, or even no treatment at all. Importantly, depending on the health issue, an adequate “conventional, western” treatment could have resulted in even better patient outcomes with fewer risks involved.
          Without investigation via adequately designed RCTs, a correlation between treatment and patient outcome, as done by Mr. Bauer for the last decades, simply cannot be made.

        • I haven’t read all the comments so perhaps this isnt relevant or it’s redundant, but a few trials have been done on open labeled placebos…actually very fascinating from a psychological view point.

          https://onlinelibrary.wiley.com/doi/abs/10.1111/jebm.12251

          • @Dale

            Alas I cannot access the full text of this review and meta analysis but i find that there is enough information in the abstract to deem this study as unconclusive, which the authors admit in so many words in the conclusion.
            Let me point out the problem points. Here are the Results and Conclusion sections of its abstract. I have highlighted the important parts:

            Results
            We screened 348 publications, assessed 24 articles for eligibility and identified five trials (260 participants) that met inclusion criteria. The clinical conditions were: irritable bowel syndrome, depression, allergic rhinitis, back pain, and attention deficit hyperactivity disorder. The risk of bias was moderate. We found a positive effect for nondeceptive placebos (standardized mean difference 0.88, 95% CI 0.62 to 1.14, P < 0.00001, I^2 = 1%).

            Conclusions
            Open‐label placebos appear to have positive clinical effects compared to no treatment. Caution is warranted when interpreting these results due to the limited number of trials identified, lack of blinding, and the fact that positive messages were included alongside open‐label placebos. Larger definitive trials are now warranted to explore the potential patient benefit of open‐label placebos, to investigate the relative contributions of positive suggestions, and ethical implications.

            Only five trials with 51.2 subjects in each. That is very little to hang your hat on as the authors admit.
            The five studies look at very different problems so that in itself could be enough invalidate this analysis. How they come to the conclusion that the risk of bias is moderate I can doubt but not verify from the abstract.
            The numbers might seem important, a P less than 10^-5 and an I squared of 1% can look impressive but given the paucity of studies and subjects it cannot be taken seriously.

            The Conclusion starts with the weasel words “appear to have” and then in effect says that the studies included are not to be taken seriously and should be repeated in a proper way.

            What this article does not mention, at least not in the abstract, is that open-label placebo is a clear contradiction in terms
            I refer to my most recent elaboration on the term ‘Placebo’ and its definition.
            The entity is simply not possible. If you give an inert agent to someone and tell him it really is inert but it might result in a change in your condition, then you are no longer giving an inert, blinded agent, therefore it is no longer a placebo. You are administering a suggestion of a positive effect and thereby inducing a measurement bias that will not affect the biological outcome but the subjective interpretation of the outcome, i.e. a false measurement.
            All the conditions studied are well known to be affected by psychological factors, namely stress, mood and attitude, and therefore extremely prone to the effect of such bias.

            My conclusion is that there is no such thing as open-label placebo. The term contradicts itself and therefore cannot be studied.
            Any study purporting to administer open-label bias is per definition studying only bias, a “Tooth fairy study” if you will. Whatever result you get cannot be inferred to be caused by any other factor than bias.

          • Bjorn…full text paper. I dont disagree with your analysis. But it does give some insight on the power of positive suggestion. As i wrote, from a psychological view.

            https://www.researchgate.net/publication/316549018_Effects_of_placebos_without_deception_compared_with_no_treatment_A_systematic_review_and_meta-analysis

        • Bjorn,

          Earlier you told Matthew “I have tried reading texts on AP technique, trying to understand its methods and indications and find it mildly put, bewildering.”

          Now you’re telling him “The most rational explanation is that it (improvement) was not AP that caused this improvement.”

          If acupunture is so perplexing and confusing to you, how do you figure your conclusion is rational?

          • No one was addressing you “jm”. Please try not to but in when you have nothing to contribute, it clogs up the thread with irrelevant noise.

          • Oh, sorry Bjorn. Let’s pretend your reasoning makes sense. 🙂

            But really, you’re continually saying that Chinese Medicine makes no sense to you. You’ve had opportunities in the past to ease your bewilderment. (a few well know and highly respected practitioners who also happen to be gifted teachers have appeared…briefly…in the comment streams)

            Now you have another opportunity with Matthew. You should take advantage of it.

          • What makes no sense “jm”, is what your brain makes of what you read. I never said Chinese medicine does not make sense to me, it makes perfectly clear sense to me, just as the history of Gengis Khan’s conquests makes sense to me as ancient history that has no relevance in modern times other than that which history teaches us.
            What I referred to was not that I do not understand TCM but the fact that reading the old texts or reading texts that describe TCM, makes no sense as a knowledge base for a set of interventions and tests that purport to be on par with if not superior to modern therapeutic measures.
            A good example is pulse diagnosis, which is based on nothing but fantasy or acupuncture that consistently fails to show convincing efficacy in proper tests.

            Now be a good girl and try not to disturb this important discussion with your misplaced platitudes and tiring attempts at being clever. You can sit and watch though. Try to learn something from Matthew. He is smart, albeit misguided. He is honest as he does not hide his identity and debates in a civilised manner without dodging questions or building strawmen to attack.

          • From sitting and watchng previous discussions, there’s a pretty predictable pattern. When you start pulling out phrases like “pricking the patient”, “long winded comment”, and someone like you or Jashak brings up unicorns…it’s a good indicator that the “important discussion” has started its descent into fundamentalist blather.

            Shortly after that, you lose your opportunity to learn something. And have to fall back to your standard qi is mysterious magic, pulse diagnosis is fantasy, etc etc.

            Just trying to give you a heads up.

        • I’m not sure that I agree with you on the definition of a placebo. In CLINICAL TRIALS a placebo is a sham treatment or intervention designed to be indistinguishable by the patient (and ideally also by the investigator), from the active treatment under investigation. This often takes the form of dummy pills, but it could be a surgical incision, a short anaesthetic, a dummy dose of radiotherapy or some other intervention. It is not always easy to find a good placebo, particularly when the active treatment might have an obvious effect (such as the smell of ozone due to ionisation of the air in the case of radiotherapy trials).

          The PLACEBO EFFECT is the (supposedly beneficial) effect of an intervention which is due to the patient’s belief in it or to other (presumbaly psychological) mechanisms. It is a very strong effect and can be influenced by quite subtle cues. The converse is the nocebo effect, where the results are undesirable.

          To a CLINICIAN, as opposed to a researcher, a placebo is a treatment which harnesses the placebo effect in order to work.

          An example which comes to mind (to me as an oncologist) is chemotherapy-related vomiting. I had a colleague who once encountered one of her patients on a train – the patient asked her to move to another carriage as the sight of her was enough to provoke nausea. A very strong nocebo effect in this instance. Conversely, although we now have effective antiemetic drugs, it is nevertheless very important to overcome the expectation of a chemotherapy-naive patient that their treatment will make them vomit (if they are sick with the first dose, then subsequent doses become very difficult to manage). Strong reassurances regarding the effect of the antiemetics, a 24-hour telephone helpline so that they feel supported and anything else that they might believe in will be employed, whether it is “sea-bands” worn on the wrists to stimulate accupressure points, ginger biscuits, aromatherapy or what have you. The point is to prevent vomiting by any means available.

          Indeed, I sometimes wonder whether the practice of listing possible side-effects on consent forms, and on the inserts in drugs packages might increase the risk that patients might experience unwanted effects, though I suspect that most people are more influenced by friends, prior expectations, the media etc. than by the official literature.

          I am not familiar with the review that Dr Dale cites, but I have long understood that there is clear evidence that the placebo effect still occurs even when the patient is told that the treatment is inactive (clinical trials along the lines of: “I would like to give you these sugar pills which do not contain any drugs; nevertheless I have reason to believe that they may help your condition”). Indeed this may well have been something that I was taught at some point in my training. Perhaps the mechanism in this instance is that the patient has a belief that their doctor will always do what is best for them, analogous to the belief held by a lot of cancer patients in clinical trials that their oncologist (rather than a randomising computer) chooses the appropriate trial arm into which they should be allocated; a signature on a consent form is no guarantee that the subject has understood the principles of randomisation. (Note that most oncology clinical trials compare one treatment against another rather than against a placebo, though this doesn’t change the principle.)

          Certainly from my clinical experience I have no reason to doubt the effect of an open-label placebo, though perhaps a different terminology might be better.

          On a more general note, trying to extrapolate from well-conducted clinical trials to the mess that is actual medical practice isn’t always easy. Very often the patient in front of you wouldn’t have been eligible for the trial that you are basing treatment decisions on, due to age, sex, fitness, co-morbidity, previous treatment or variations in the disease. They may have their own beliefs influences what treatment they will accept and what they think it will do. There may be lifestyle factors (jobs, family, access to services) that make certain treatments more risky or indeed impossible. As a clinician you have to weigh all this up, using trial data (as you understand it), experience (which by its nature has an anecdotal element), discussion with colleagues and involvement with multidisciplinary teams to come up with a management plan. However hard you try to be evidence-based in your practice, you have to go beyond the limits of the evidence to treat real patients. Happily the system generally has checks and balances in place if you try to go too far.

          • @Dr Julian Money-Kyrle

            I don’t think we disagree Julian. My attempt at defining placebo strives at describing the strictest principal meaning of the term, in practice it is often difficult to achieve the ideal but the principle upon which a placebo should be devised is important, it should be as close to inert as possible. It needs to be able to convincingly subtract the bias of being treated from the sham side of the formula so the true inherent effect of the agent being investigated can be inferred from comparing a treated group to an untreated, verum to sham in other words. I chose the word ‘agent’ to cover all possible therapeutic measures including surgery, radiotherapy etc. The example with radiotherapy and ozone smell is interesting. Simply not turning on the apparatus may not be enough if the subject knows there should be a distinct smell. Therefore you might need to devise an ozone generator to secure the blinding. These are simple to make. You might then say that the apparatus is no longer inert, but another might say it would be an even better placebo as both verum and sham versions exposed the subject to a puff of ozone and this would further isolate the effect of the radiation in the analysis, right?

            My argument is that even an open-label placebo cannot be considered to be non-placebo. It still represents doing something and this introduces effects of its own, e.g. the Hawthorne effect.
            The true non-placebo-placebo would be the waiting-list method but that has its own drawbacks and difficulties.
            Medicine is a complex system and by definition it can never reach perfection. We are constantly working in a mistake-based environment if you will, we make mistakes every day/week/month. Our task is to minimise these mistakes, discover and correct them and progress towards the infinite goal of perfection. I could elaborate better on this theme but work is waiting.
            I like to compare medicine to aviation. Here is an essay that describes how I see our job. We are expected to be flawless, but we are not. (that does not mean any fool can come along with its flying carpet and expect to do better 😀 )

          • @ Dr Julian Money-Kyrle,
            I agree with how you describe a clinical trial placebo. However, I do not agree to 100% with your definition of “placebo effect”.
            You medical doctors discuss the terms placebo/placebo effects at a very complex system. Maybe it helps to clarify the terms when we look at a simpler example first, that I as a molecular biologist am also more used to.
            The simpler your experimental design, the more conclusive the experiment. In our lab experiments, we call placebos “negative controls”. I will illustrate a very simplified example to describe a perfect placebo/negative controlled experiment:
            *First, you have to clearly define WHAT you want to investigate and make a proper experimental design (in a real case, this would include incorporating statistics, e.g. depending on the variance that you expect for your test, you would calculate how many replicates you have to measure and what alpha and beta errors you want to permit. To keep it simple for this example, I skip this part).
            *Let´s say that you want to test a drug for a specific antibacterial effect.
            *You take two test tubes and to each add 5 ml of bacterial suspension (i.e. equal number of bacteria).
            *To tube #1, you add 1 ml of your test drug, which is diluted in water (representing, let´s say, 100µM final drug concentration in the 6 ml final test volume).
            *To tube #2, you add 1 ml of pure water (so same volume, same temperature, same disturbance by mixing, etc.). Ideally, you should be left with only ONE variable, which is the presence or absence of the drug.
            *Finally, the number of dead bacteria is counted in each tube. It is important that the person counting the dead cells does not know which of the test tubes contained the drug and which contained the negative control.
            *You repeat the experiment independently, according to your experimental design.

            Tube #2 represents the “perfect placebo”. Of course, as mentioned, humans are more complex test systems, however in principle, the same rational should apply. Perfect placebos might be hard to find, but you can try to get close. So for acupuncture, depending on the ISSUE that you want to test, you could e.g. take sham needles that do NOT puncture the skin (if you want to test the “puncture” effect) or take real needles but puncture skin areas outside of the acupoints (if you want to test the “meridian” theory). Both things have been done to my knowledge.
            Now comes the part where I disagree: your definition of “placebo effect”. You seem to limit what you call “placebo effect” to the patient’s BELIEF or presumably PSYCHOLOGICAL mechanisms. In contrast for me, EVERYTHING that goes on in “test tube #2” is the placebo effect. So for humans, this would include psychological as well as PHYSIOLOGICAL effects, e.g. importantly, the natural progression of the disease.

          • QUOTE
            In drug testing and medical research, a placebo can be made to resemble an active medication or therapy so that it functions as a control; this is to prevent the recipient(s) and/or others from knowing (with their consent) whether a treatment is active or inactive, as expectations about efficacy can influence results.[4][5] In a clinical trial any change in the placebo arm is known as the placebo response, and the difference between this and the result of no treatment is the placebo effect.[6]

            Definitions

            The American Society of Pain Management Nursing define a placebo as “any sham medication or procedure designed to be void of any known therapeutic value”.[1]

            In a clinical trial, a placebo response is the measured response of subjects to a placebo; the placebo effect is the difference between that response, and no treatment.[6] It is also part of the recorded response to any active medical intervention.[13]

            Any measurable placebo effect is termed either objective (e.g. lowered blood pressure) or subjective (e.g. a lowered perception of pain).[1]

            https://en.m.wikipedia.org/wiki/Placebo
            END of QUOTE

          • @ Pete Attkins,
            I now understand that I was wrong regarding my terminology. The correct term for what I called “placebo effect” is actually the “placebo response”. I thought that these terms would mean the same, but they obviously do not.
            So…the natural progression of a disease is part of the placebo response, but not of the placebo effect. Thank you for pointing this out! Again, I have learned something new, much appreciated!

  • I have never heard the term placebo used in connection with a laboratory control. Of course I am a clinician, not a molecular biologist (though I owe a great deal to molecular biologists, not least the development of the monoclonal antibodies which are keeping my own malignancy under control, and indeed almost everything we know about how cancer causes disease).

    In the clinical setting a placebo is a device intended to fool the patient into believing that he is having an active treatment when he is not, whereas in the context of clinical research it is a device to prevent the subject (and the investigator assessing the results) from knowing whether or not he is receiving the intervention under investigation. They are not the same thing. Placebo is the Latin first person singular future tense of the verb placeo, “I please”, in the sense of keeping the patient happy. Nocebo means “I will harm”.

    The natural progression of the disease would be expected to affect both arms of any trial equally, so cannot be part of the placebo which specifically refers to the inactive arm.

    Generally I would expect the main mechanism of placebo effects to be psychological, though there remains the possibility that there might be other effects, such as an unexpected pharmacological action of the dye used to colour both active and placebo tablets.

    I know that I am being pedantic here about English definitions, but I do expect technical terms to have an agreed and widely accepted meaning, and it does seem that different people are using them in somewhat different ways here.

    With regard to open-label placebos, I was thinking about how they may be employed for clinical benefit, rather than as a control in a trial, where they would seem to be rather pointless.

    • @ Julian Money-Kyrle,
      Sorry, my expression maybe was not clear. Wish we could have this discussion in my native language. In the lab, we indeed use the term “negative control”, not placebo (but I am not in medical research, not sure if they use it there).
      From my “non-clinical” (and non-expert in the medical field) point of view, both, negative control and placebo (in a research setting) are done for the same reason, i.e. to distinguish specific from non-specific effects.

      • I think you are doing very well in English. I certainly couldn’t have a discussion in any other language.

        It seems that a lab-based control and a placebo serve a related purpose, but as soon as you start involving human subjects their expectations start to affect everything you are trying to measure. I think it must be much simpler in the lab when you have much more control over the experimental environment, and you don’t have such large statistical effects arising from variations in the biology and behaviour of the experimental subjects. Though I am not in any way belittling the technical challenges you have to overcome.

        • @ Julian Money-Kyrle,
          Thank you for your compliment… I try. And I appreciate the opportunity to have discussions with you medical experts, since I obviously have no personal experience with the practical aspects of the whole CAM debate. My brother is a pediatrician and I have had some discussions with him about homeopathy, so I know about the pressure that patients (or in his case their parents) can exert if they think that they know what´s best for treatment.
          Regarding the lab experiments, I am not sure that I agree with you in assuming that lab experiments are simpler than e.g. CAM patient trials. I would say we have to face some similar and some different problems.
          Depending on the experiment, you probably would be surprised to see how much variance can occur even when examining simple organisms in a quite stable lab environment, because of biological and technical variance. Furthermore, if I compare an acupuncture trial with, let’s say a study of the metabolome of a plant cell during varying environmental stress conditions, I would imagine that the latter probably is quite more complex than the former. You might have problems with the expectations of the human subjects, number of participants, proper execution of the trial, etc. but at least the evaluation of your set of data (let´s say in the form tumor size or questionnaire results) should be quite straight forward to analyze. Please correct me if I´m wrong. In contrast, our experiments nowadays often result in generation of MASSIVE data sets, which can be very difficult to analyze and make sense of.
          Anyways, this is of course not a competition between our fields of expertise.

          • Jashak,

            It was certainly not my intention to play down the difficulty of lab-based research, particularly as I have no personal experience here. Any research involving biological systems is fraught with challenges arising from the high degree of variation between individual organisms, whether they be humans, plants or bacteria. In all cases the only way to make sense of the data is the use of robust controls and appropriate statistical analysis, and a constant awareness of the shortcomings of the methods used.

  • We have indeed had an enlightening and stimulating discussion here, not the least on the matter of placebo and placebo effect, which is an intriguing one.
    Dale brought up the question of “open-label” placebo, which is in my mind an impossible concept as I tried to explain.
    Dr. Steven novella is a good pen and this article on the matter is really worth reading along with the material he refers to:
    https://sciencebasedmedicine.org/placebo-by-conditioning/

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