experience
Why do most alternative practitioners show such dogged determination not to change their view of the efficacy of their therapy, even if good evidence shows that it is a placebo? This is the question that I have been pondering for some time. I have seen many doctors change their mind about this or that treatment in the light of new evidence. In fact, I have not seen one who has not done so at some stage. Yet I have never seen an alternative therapist change his/her mind about his/her alternative therapy. Why is that?
You might say that the answers are obvious:
- because they have heavily invested in their therapy, both emotionally and financially;
- because their therapy has ‘stood the test of time’;
- because they believe what they were taught;
- because they are deluded, not very bright, etc.;
- because they need to earn a living.
All of these reasons may apply. But do they really tell the whole story? While contemplating about this question, I thought of something that had previously not been entirely clear to me: they simply KNOW that the evidence MUST be wrong.
Let me try to explain.
Consider an acupuncturist (I could have chosen almost any other type of alternative practitioner) who has many years of experience. He has grown to be a well-respected expert in the world of acupuncture. He sits on various committees and has advised important institutions. He knows the literature and has treated thousands of patients.
This experience has taught him one thing for sure: his patients do benefit from his treatment. He has seen it happening too many times; it cannot be a coincidence. Acupuncture works, no question about it.
And this is also what the studies tell him. Even the most sceptical scientist cannot deny the fact that patients do get better after acupuncture. So, what is the problem?
The problem is that sceptics say that this is due to a placebo effect, and many studies seem to confirm this to be true. Yet, our acupuncturist completely dismisses the placebo explanation.
Why?
- Because he has heavily invested in their therapy? Perhaps.
- Because acupuncture has ‘stood the test of time’? Perhaps.
- Because he believes what he has been taught? Perhaps.
- Because he is deluded, not very bright, etc.? Perhaps.
- Because he needs to earn a living? Perhaps.
But there is something else.
He has only ever treated his patients with acupuncture. He has therefore no experience of real medicine, or other therapeutic options. He has no perspective. Therefore, he does not know that patients often get better, even if they receive an ineffective treatment, even if they receive no treatment, and even if they receive a harmful treatment. Every improvement he notes in his patients, he relates to his acupuncture. Our acupuncturist never had the opportunity to learn to doubt cause and effect in his clinical routine. He never had to question the benefits of acupuncture. He never had to select from a pool of therapies the optimal one, because he only ever used acupuncture.
It is this lack of experience that never led him to think critically about acupuncture. He is in a similar situation as physicians were 200 years ago; they only (mainly) had blood-letting, and because some patients improved with it, they had no reason to doubt it. He only ever saw his successes (not that all his patients improved, but those who did not, did not return). He simply KNOWS that acupuncture works, because his own, very limited experience never forced him to consider anything else. And because he KNOWS, the evidence that does not agree with his knowledge MUST be wrong.
I am of course exaggerating and simplifying in order to make a point. And please don’t get me wrong.
I am not saying that doctors cannot be stubborn. And I am not saying that all alternative practitioners have such limited experience and are unable to change their mind in the light of new evidence. However, I am trying to say that many alternative practitioners have a limited perspective and therefore find it impossible to be critical about their own practice.
If I am right, there would be an easy (and entirely alternative) cure to remedy this situation. We should sent our acupuncturist to a homeopath (or any other alternative practitioner whose practice he assumes to be entirely bogus) and ask him to watch what kind of therapeutic success the homeopath is generating. The acupuncturist would soon see that it is very similar to his own. He would then have the choice to agree that highly diluted homeopathic remedies are effective in curing illness, or that the homeopath relies on the same phenomenon as his own practice: placebo.
Sadly, this is not going to happen, is it?
Traditional vaginal practices usually relate to personal hygiene, genital health or sexuality. Hygiene practices involve external washing and intravaginal cleansing or douching and ingestion of substances. Health practices include intravaginal cleansing, traditional cutting, insertion of herbal preparations, and application of substances to soothe irritated vaginal tissue.
One such traditional practice is ‘vaginal steaming’.
Recently vaginal steaming has become a fad promoted by SCAM-promoters (such as the vagina-obsessed Gwyneth Paltrow) with the claim that it leads to a range of health benefits. According to one website, for instance, vaginal steaming, Yoni Eggs, yoni or v-steam, as it is casually known, acts as an internal cleanser of the membranes of the vaginal tissues and uterus. This is considered especially important for stagnant fertility conditions and/or incomplete emptying of menses each cycle. This women’s treatment gently but effectively cleanses, tones and revitalizes a woman’s center, providing a myriad benefits from reduced menstrual cramps to increased fertility and more. Support your natural feminine cycle, help your body to heal, relax, and detoxify both physically and emotionally with a yoni steam.
The method is recommended for a wide range of conditions and is said to achieve all of the following and much, much more:
- Significant reduction of pain, bloating and exhaustion associated with menstruation.
- Significant reduction of PMS.
- Decrease of menstrual flow as well as reduction of dark purple or brown blood at the onset or end of menses.
- Regulation of irregular or absent menstrual cycles.
- Increased fertility.
- Faster healing and toning of the reproductive system following childbirth.
- Assisting in healing uterine fibroids, ovarian cysts, uterine weakness, uterine prolapse & endometriosis.
- Breaking down of reproductive adhesion/scar tissue. Assisting with the repair of a vaginal tear, episiotomy, or C-section scar.
- Assisting with the healing of haemorrhoids.
- Treating chronic vaginal/yeast infections and maintaining healthy vaginal odour.
- Relief of menopausal symptoms such as vaginal dryness or pain during sex.
- Detoxification of the womb/removal of toxins from the body. Release of stored emotions.
- Reconnection with our female bodies and tapping into the sexual energy that is our creative potential.
Frequently, entrepreneurs recommend adding herbal or other ingredients. Herbs often used include:
- mugwort
- wormwood
- chamomile
- calendula
- basil
- oregano
- vaginal steaming arms your bank account;
- it disrupts the normal pH balance of the vagina;
- in turn, this increases the risk of fungal and bacterial infections;
- vaginal steaming can cause burns;
- with added herbs, it can cause allergies.
New Zealand psychologists analysed online accounts of vaginal steaming to determine the sociocultural assumptions and logics within such discourse, including ideas about women, women’s bodies and women’s engagement with such ‘modificatory’ practices. Ninety items were carefully selected from the main types of website discussing vaginal steaming: news/magazines; health/lifestyle; spa/service providers; and personal blogs. Within an overarching theme of ‘the self-improving woman’ the researchers identified four themes: (1) the naturally deteriorating, dirty female body; (2) contemporary life as harmful; (3) physical optimisation and the enhancement of health; and (4) vaginal steaming for life optimisation. The authors concluded that online accounts of vaginal steaming appear both to fit within historico-contemporary constructions of women’s bodies as deficient and disgusting, and contemporary neoliberal and healthist discourse around the constantly improving subject.
For the sake of ‘journalistic balance’, let’s give Gwyneth the last word about the benefits of vaginal steaming. She knows best because she has done it and was quoted uttering these profound and scientific views: “The first time I tried v-steaming, I was like, ‘This is insane’. My friend Ben brought me and I was like, ‘You are out of your f**king mind. What is this? But then by the end of it I was like, ‘This is so great.’ Then I start to do research, and it’s been in Korean medicine for thousands of years and there are real healing properties. If I find benefit to it and it’s getting a lot of page views, it’s a win-win.”
And who would or could argue with that?
Personally, I find our good friend Dana Ullman truly priceless. There are several reasons for that; one is that he is often so exemplarily wrong that it helps me to explain fundamental things more clearly. With a bit of luck, this might enable me to better inform people who might be thinking a bit like Dana. In this sense, our good friend Dana has significant educational value.
Recently, he made this comment:
According to present and former editors of THE LANCET and the NEW ENGLAND JOURNAL OF MEDICINE, “evidence based medicine” can no longer be trusted. There is obviously no irony in Ernst and his ilk “banking” on “evidence” that has no firm footing except their personal belief systems: https://medium.com/@drjasonfung/the-corruption-of-evidence-based-medicine-killing-for-profit-41f2812b8704
Ernst is a fundamentalist whose God is reductionistic science, a 20th century model that has little real meaning today…but this won’t stop the new attacks on me personally…
END OF COMMENT
Where to begin?
Let’s start with some definitions.
- Evidence is the body of facts that leads to a given conclusion. Because the outcomes of treatments such as homeopathy depend on a multitude of factors, the evidence for or against their effectiveness is best based not on experience but on clinical trials and systematic reviews of clinical trials (this is copied from my book).
- EBM is the integration of best research evidence with clinical expertise and patient values. It thus rests on three pillars: external evidence, ideally from systematic reviews, the clinician’s experience, and the patient’s preferences (and this is from another book).
Few people would argue that EBM, as it is applied currently, is without fault. Certainly I would not suggest that; I even used to give lectures about the limitations of EBM, and many experts (who are much wiser than I) have written about the many problems with EBM. It is important to note that such criticism demonstrates the strength of modern medicine and not its weakness, as Dana seems to think: it is a sign of a healthy debate aimed at generating progress. And it is noteworthy that internal criticism of this nature is largely absent in alternative medicine.
The criticism of EBM is often focussed on the unreliability of the what I called above the ‘best research evidence’. Let me therefore repeat what I wrote about it on this blog in 2012:
… The multifactorial nature of any clinical response requires controlling for all the factors that might determine the outcome other than the treatment per se. Ideally, we would need to create a situation or an experiment where two groups of patients are exposed to the full range of factors, and the only difference is that one group does receive the treatment, while the other one does not. And this is precisely the model of a controlled clinical trial.
Such studies are designed to minimise all possible sources of bias and confounding. By definition, they have a control group which means that we can, at the end of the treatment period, compare the effects of the treatment in question with those of another intervention, a placebo or no treatment at all.
Many different variations of the controlled trial exist so that the exact design can be adapted to the requirements of the particular treatment and the specific research question at hand. The over-riding principle is, however, always the same: we want to make sure that we can reliably determine whether or not the treatment was the cause of the clinical outcome.
Causality is the key in all of this; and here lies the crucial difference between clinical experience and scientific evidence. What clinician witness in their routine practice can have a myriad of causes; what scientists observe in a well-designed efficacy trial is, in all likelihood, caused by the treatment. The latter is evidence, while the former is not.
Don’t get me wrong; clinical trials are not perfect. They can have many flaws and have rightly been criticised for a myriad of inherent limitations. But it is important to realise that, despite all their short-comings, they are far superior than any other method for determining the efficacy of medical interventions.
There are lots of reasons why a trial can generate an incorrect, i.e. a false positive or a false negative result. We therefore should avoid relying on the findings of a single study. Independent replications are usually required before we can be reasonably sure.
Unfortunately, the findings of these replications do not always confirm the results of the previous study. Whenever we are faced with conflicting results, it is tempting to cherry-pick those studies which seem to confirm our prior belief – tempting but very wrong. In order to arrive at the most reliable conclusion about the efficacy of any treatment, we need to consider the totality of the reliable evidence. This goal is best achieved by conducting a systematic review.
In a systematic review, we assess the quality and quantity of the available evidence, try to synthesise the findings and arrive at an overall verdict about the efficacy of the treatment in question. Technically speaking, this process minimises selection and random biases. Systematic reviews and meta-analyses [these are systematic reviews that pool the data of individual studies] therefore constitute, according to a consensus of most experts, the best available evidence for or against the efficacy of any treatment.
END OF QUOTE
Other criticism is aimed at the way EBM is currently used (and abused). This criticism is often justified and necessary, and it is again the expression of our efforts to generate progress. EBM is practised by humans; and humans are far from perfect. They can be corrupt, misguided, dishonest, sloppy, negligent, stupid, etc., etc. Sadly, that means that the practice of EBM can have all of these qualities as well. All we can do is to keep on criticising malpractice, educate people, and hope that this might prevent the worst abuses in future.
Dana and many of his fellow SCAMers have a different strategy; they claim that EBM “can no longer be trusted” (interestingly they never tell us what system might be better; eminence-based medicine? experience-based medicine? random-based medicine? Dana-based medicine?).
The claim that EBM can no longer be trusted is clearly not true, counter-productive and unethical; and I suspect they know it.
Why then do they make it?
Because they feel that it entitles them to argue that homeopathy (or any other form of SCAM) cannot be held to EBM-standards. If EBM is unreliable, surely, nobody can ask the ‘Danas of this world’ to provide anything like sound data!!! And that, of course, would be just dandy for business, wouldn’t it?
So, let’s not be deterred or misled by these deliberately destructive people. Their motives are transparent and their arguments are nonsensical. EBM is not flawless, but with our continued efforts it will improve. Or, to repeat something that I have said many times before: EBM is the worst form of healthcare, except for all other known options.
My friend Gustav Born FRS died on 16 April 2018.
Gustav was born into a Jewish family that emigrated from 1930s Goettingen (Germany) to the UK. His father Max, a friend of Einstein, was a physicist who received a Nobel Prize for his work in quantum mechanics. Gustav served in the British forces as a doctor during WW2. After the war, he became a pharmacologist in London and Cambridge who had many achievements to his name. For instance, he discovered the mechanisms through which the body stops bleeding and initiates blood clotting. He also invented the platelet aggregometer that is still used universally to quantify platelet activity and which he never patented so that not he but mankind would benefit from it. Gustav was indefatigable and continued his research for many years after his retirement. His work was crowned with uncounted scientific awards.
There have been numerous, much more detailed obituaries honouring Gustav e. g.:
https://www.theguardian.com/science/2018/apr/26/gustav-born-obituary
https://www.thetimes.co.uk/article/gustav-born-obituary-gt5k9r8jc
Mine is merely a personal tribute. I met Gustav in the early 1990s while working in Vienna. We became close friends, and he took me under his wings, encouraged me to come to the UK, wrote a glowing reference when I applied for the Exeter post, and gave me moral support whenever I needed it.
After I had moved to the UK, we regularly met, and he even came to my 50th birthday party insisting to make a speech. About 15 years ago, he once attended one of my public lectures on alternative medicine; afterwards his comment was: “you know, your work is going to save lives.” Since my retirement, he kept phoning me at home (apparently Gustav had an irresistible attraction to the telephone) and urged me, usually speaking in German, to arrange a meeting. We always concluded that this must be soon; sadly, however, this did not happen.
Gustav was a great story-teller. One of his preferred anecdotes related to homeopathy. He recounted (interrupting himself giggling) that, when Einstein and his father once were talking, someone mentioned homeopathy and asked them what they thought of it. Einstein reflected for a little while and then said: “If one were to lock up 10 very clever people in a room and told them they were only allowed out once they had come up with the most stupid idea conceivable, they would soon come up with homeopathy.”
It is therefore not surprising that, when I invited Gustav to contribute a chapter to my book ‘HEALING, HYPE OR HARM?‘, he agreed to write an essay entitled ‘HOMEOPATHY IN CONTEXT’. Here is a short extract from it: What can be done to counteract the persistence of homeopathy? Its unwarranted claims must be continuously exposed. The diversion of public money from the proper purposed of the NHS must be stopped.
I shall miss Gustav for his clear thinking, his wry humour, his unfailing support and fatherly friendship.
Today, enthusiasts of homeopathy celebrate the start of the HOMEOPATHY AWARENESS WEEK. Let’s join them by re-addressing one of their favourite themes: their personal experience with homeopathy.
Most homeopathy-fans argue that the negative scientific evidence must be wrong because they have had positive experiences. Whenever I give a lecture, for instance, there will be at least one person in the audience who presents such an experience (and I too could contribute a few such stories from my own past). Such ‘case reports’ can, of course, be interesting, illuminating or leading to further research, but they can never be conclusive.
This concept is often profoundly confusing for patients and consumers. They tend to feel that I am doubting their words, but nothing could be further from the truth. Their experience is certainly true – what might be false is their interpretation of it. I think, I better explain this in more detail using a concrete, published example.
After the publication of our 2003 RCT of homeopathic Arnica which showed that two different potencies have effects that do not differ from those of placebo, I received lots of angry responses from people who told me that they had the opposite experience or observed positive outcomes on their pets. In my subsequent publication in the journal ‘Homeopathy‘ entitled ‘The benefits of Arnica: 16 case reports‘, I have tried my best to explain their experiences in the light of our finding that highly diluted homeopathic Arnica is a placebo:
Sixteen case reports of the apparent benefits of Arnica … raise several relevant points. Firstly, topical Arnica preparations are often wrongly equated with homeopathic Arnica, the subject of our trial. The former are herbal preparations (ie not homeopathically diluted), which have undisputed pharmacological activity. Taken orally they would even be toxic. Thus all Arnica for oral administration must be highly diluted and has therefore no pharmacological effects. The case reports show that many lay people seem to be unclear about the difference between herbal and homeopathic Arnica.
Secondly, if animals seem to respond to homeopathic Arnica, as claimed in several of the case reports, this is not necessarily a proof of its effectiveness. Animals are not immune to placebo effects. Think of Pavlov’s experiments and the fact that conditioning is clearly an element in the placebo response.
Thirdly, the natural history of the condition can mimic clinical improvement caused by therapy. Many of the 16 cases summarized can be explained through a placebo response or the natural history of disease or the combination of both phenomena…
Many of the letters I received were outspoken to say the least. The authors stated that they were ‘appalled’, ‘saddened and angry’ by our research. Others implied that I was paid by the pharmaceutical industry to abolish homeopathy in the UK. One person felt that ‘it is highly irresponsible to dismiss a natural healing remedy with no evidence at all’. I believe the case reports … convey an important message about the power of belief, anecdotes, placebos and expectation.
END OF QUOTE
The thing about case reports and personal experiences is quite simply this: they may seem almost overwhelmingly convincing, but they can NEVER serve as a proof that the treatment in question was effective. The reason for this fact could not be more simple. Any therapeutic response is due to a complex combination of factors: placebo effects, natural history of the condition, regression to the mean, etc.
See it this way: you wake up one morning with an enormous hangover. You try to identify the cause of it. Was it the beer you had in the pub? The wine you drank before you went out? Or the whiskey you consumed before you went to bed? Perhaps you think it was the Cognac you enjoyed at a friend’s house? Only one thing is for sure: it was not the glass of shaken water you drank during the night.
Lock 10 bright people into a room and tell them they will not be let out until they come up with the silliest idea in healthcare. It is not unlikely, I think, that they might come up with the concept of visceral osteopathy.
In case you wonder what visceral osteopathy (or visceral manipulation) is, one ‘expert’ explains it neatly: Visceral Osteopathy is an expansion of the general principles of osteopathy which includes a special understanding of the organs, blood vessels and nerves of the body (the viscera). Visceral Osteopathy relieves imbalances and restrictions in the interconnections between the motions of all the organs and structures of the body. Jean-Piere Barral RPT, DO built on the principles of Andrew Taylor Still DO and William Garner Sutherland DO, to create this method of detailed assessment and highly specific manipulation. Those who wish to practice Visceral Osteopathy train intensively through a series of post-graduate studies. The ability to address the specific visceral causes of somatic dysfunction allows the practitioner to address such conditions as gastroesophageal reflux disease (GERD), irritable bowel (IBS), and even infertility caused by mechanical restriction.
But, as I have pointed out many times before, the fact that a treatment is based on erroneous assumptions does not necessarily mean that it does not work. What we need to decide is evidence. And here we are lucky; a recent paper provides just that.
The purpose of this systematic review was to identify and critically appraise the scientific literature concerning the reliability of diagnosis and the clinical efficacy of techniques used in visceral osteopathy.
Only inter-rater reliability studies including at least two raters or the intra-rater reliability studies including at least two assessments by the same rater were included. For efficacy studies, only randomized-controlled-trials (RCT) or crossover studies on unhealthy subjects (any condition, duration and outcome) were included. Risk of bias was determined using a modified version of the quality appraisal tool for studies of diagnostic reliability (QAREL) in reliability studies. For the efficacy studies, the Cochrane risk of bias tool was used to assess their methodological design. Two authors performed data extraction and analysis.
Extensive searches located 8 reliability studies and 6 efficacy trials that could be included in this review. The analysis of reliability studies showed that the diagnostic techniques used in visceral osteopathy are unreliable. Regarding efficacy studies, the least biased study showed no significant difference for the main outcome. The main risks of bias found in the included studies were due to the absence of blinding of the examiners, an unsuitable statistical method or an absence of primary study outcome.
The authors (who by the way declared no conflicts of interest) concluded that the results of the systematic review lead us to conclude that well-conducted and sound evidence on the reliability and the efficacy of techniques in visceral osteopathy is absent.
It is hard not to appreciate the scientific rigor of this review or to agree with the conclusions drawn by the French authors.
But what consequences should we draw from all this?
The authors of this paper state that more and better research is needed. Somehow, I doubt this. Visceral osteopathy is not plausible and the best evidence available to date does not show it works. In my view, this means that we should declare it an obsolete aberration of medical history.
To this, the proponents of visceral osteopathy will probably say that they have tons of experience and have witnessed wonderful cures etc. This I do not doubt; however, the things they saw were not due to the effects of visceral osteopathy, they were due to chance, placebo, regression towards the mean, the natural history of the diseases treated etc., etc. And sometimes, experience is nothing more that the ability to repeat a mistake over and over again.
- If it looks like a placebo,
- if it behaves like a placebo,
- if it tests like a placebo,
IT MOST LIKELY IS A PLACEBO!!!
And what is wrong with a placebo, if it helps patients?
GIVE ME A BREAK!
WE HAVE ALREADY DISCUSSED THIS AD NAUSEAM. JUST READ SOME OF THE PREVIOUS POSTS ON THIS SUBJECT.
An article in the medical magazine ‘GP’ caught my eye. In it, a GP from Southampton argues that it is counter-productive for the NHS to ban ineffective treatments. Here are a few excerpts (my comments are inserted in brackets and are in bold print):
START OF QUOTES
NHS England’s recent decision requiring GPs stop prescribing a list of 18 medicines will reinforce the fears of many doctors that healthcare rationing is being introduced by the back door (all finite NHS resources need to be and always have been rationed). I would also argue that it is an illogical and ill-informed decision that will not achieve the professed aim of saving NHS resources (perhaps the decision is not purely based on the need to save money but also on a matter of principle and an attempt to make the NHS evidence-based?).
The decision to impose a blanket ban on these items will disproportionately affect those patients who currently receive free prescriptions: the young, the poor and the elderly (where is the evidence for this statement?). The conditions these patients are suffering from will persist (treating them with ineffective medications would also make them persist).
If in future these vulnerable patients want to continue with their medicines, they will be forced to pay for them. While wealthier patients will have the option to pay for their medications, those unable to do so will return to their GP for an alternative medication or procedure that has not been prohibited by NHS England’s recommendations. GPs will then find themselves prescribing other more costly medications. How this is helping NHS England to reduce prescribing costs is difficult to see (really? I don’t find it difficult to see that spending money on effective treatments is a better investment than wasting it on ineffective stuff)…
… ‘evidence-informed practice’… not only includes scientific research, but also evidence from clinical practice acquired over many years and endorsed by numerous clinicians. Yet this type of evidence, from the front line of medicine, is being dismissed as ‘unscientific’ or ‘anecdotal’ (no, it has never been considered to be evidence; remember: the plural of anecdote is anecdotes, not evidence)…
We all want the NHS to operate cost effectively… (as long as the NHS continues to pay for homeopathy?). Of course, treatments that have no good evidence of benefit to patients should be questioned (as long as the NHS continues to pay for homeopathy?)…
NHS England needs to conduct a review of how it evaluates treatments and take far more notice of the experiences of doctors and patients. Then perhaps we will see a more financially efficient health service, healthier patients and an end to the injustice of healthcare rationing (the author forgot to tell her readers that she is a homeopath – in fact, she did not even once use the word ‘homeopathy’ in her diatribe. Because of her extreme views, she has featured on this blog before. [“homeopathy can be helpful for pretty much any condition”] Dr Day also forgot to declare conflicts of interest in her most recent vituperation [easy mistake to make; I know I am being petty).
————————————————————————————————————————————
If I were a fan of homeopathy and a believer in the magical healing power of shaken water, I would be very worried. While homeopaths put forward such embarrassingly daft arguments, the future of homeopathy looks bleak indeed.
A cognitive bias known as the Dunning-Kruger Effect has, I think, considerable relevance in alternative medicine. The effect means that, the less you know, the less able you are to recognize how little you know, and the less likely you are to recognize your limitations. Consequently, your confidence in yourself is inflated and you believe you are more competent than your opponent. Expressed differently:
- Incompetence prevents the recognition of incompetence.
- Too stupid to doubt.
Even though the phenomenon of illusory superiority is today attributed to David Dunning and Justin Kruger, many others before them have alluded to the phenomenon:
The relevance of the Dunning Kruger Effect to alternative medicine seems obvious, I think. Here we are confronted with all sorts of practitioners who believe they know it all, can treat any condition, alleviate the ‘root cause’ of all ills, etc., etc. Many of my previous posts on this blog have dealt with aspects of this problem. And with unfailing regularity, the discussions brought some individuals badly affected by the Dunning-Kruger Effect to the fore. Typically, they go on and on and on… consumed by their inflated confidence and trapped by their incompetence to realise their incompetence. And typically, they find an audience who is gullible enough to applaud them.
They often remind me of a cartoon I once saw:
The little graph below explains it all quite neatly:
The novice lacks knowledge but, as he acquires a modicum of (pseudo-)knowledge, he gets a boost of confidence. An experienced person has enough knowledge to know that he knows very little; therefore his confidence is relatively low. When experience and knowledge combine to become wisdom, confidence grows and we might be talking to a real expert. Oddly, in terms of confidence, the novice can score higher than even the wisest expert.
To some extent, this simple graph even explains the popularity of many forms of quackery: they are being promoted by people who know very little but are bursting with confidence. And it is this high level of confidence that tends to impress the gullible public who then eagerly adopt the quackery.
Where the graph is somewhat misleading, I think, is where it might give the impression that there is an automatic and necessary transition from novice to expert (from left to right on the X-axis). In many individuals, this development does occur but, sadly, in many others it does not. The evangelical believers in alternative medicine, I fear, usually belong to the latter, sad category.
If I am correct, the Dunning Kruger Effect can therefore partly explain 1) the inflated confidence of proponents of alternative medicine, as well as 2) the current popularity of quackery.
This is a fascinating new review of upper neck manipulation. It raises many concerns that we, on this blog, have been struggling with for years. I take the liberty of quoting a few passages which I feel are important and encourage everyone to study the report in full:
The Minister of Health, Seniors and Active Living gave direction to the Health Professions Advisory Council (“the Council”) to undertake a review related to high neck manipulation.
Specifically, the Minister directed the Council to undertake:
1) A review of the status of the reserved act in other Canadian jurisdictions,
2) A literature review related to the benefits to patients and risks to patient safety associated with the procedure, and
3) A jurisprudence review or a review into the legal issues that have arisen in Canada with respect to the performance of the procedure that touch upon the risk of harm to a patient.
In addition, the Minister requested the Council to seek written input on the issue from:
- Manitoba Chiropractic Stroke Survivors
- Manitoba Chiropractic Association
- College of Physiotherapists of Manitoba
- Manitoba Naturopathic Association
- College of Physicians and Surgeons of Manitoba
- other relevant interested parties as determined by the Council
… The review indicated that further research is required to:
- strengthen evidence for the efficacy of cervical spinal manipulations (CSM) as a treatment for neck pain and headache, “as well as for other indications where evidence currently does not exist (i.e., upper back and should/arm pain, high blood pressure, etc.)”
- establish safety and efficacy of CSM in infants and children
- assess the risk versus benefit in consideration of using HVLA cervical spine manipulation, which also involve cost-benefit analyses that compare CSM to other standard treatments.
… the performance of “high neck manipulation” or cervical spine manipulation does present a risk of harm to patients. This risk of harm must be understood by both the patient and the practitioner.
Both the jurisprudence review and the research literature review point to the need for the following actions to mitigate the risk of harm associated with the performance of cervical spine manipulation:
- Action One: Ensure that the patient provides written informed consent prior to initiating treatment which includes a discussion about the risk associated with cervical spine manipulation.
- Action Two: Provide patients with information to assist in the early recognition of a serious adverse event.
During Voltaire’s time, this famous quote was largely correct. But today, things are very different, and I often think this ‘bon mot’ ought to be re-phrased into ‘The art of alternative medicine consists in amusing the patient, while medics cure the disease’.
To illustrate this point, I shall schematically outline the story of a patient seeking care from a range of clinicians. The story is invented but nevertheless based on many real experiences of a similar nature.
Tom is in his mid 50s, happily married, mildly over-weight and under plenty of stress. In addition to holding a demanding job, he has recently moved home and, as a consequence of lots of heavy lifting, his whole body aches. He had previous episodes of back trouble and re-starts the exercises a physio once taught him. A few days later, the back-pain has improved and most other pains have subsided as well. Yet a dull and nagging pain around his left shoulder and arm persists.
He is tempted to see his GP, but his wife is fiercely alternative. She was also the one who dissuaded Tom from taking Statins for his high cholesterol and put him on Garlic pills instead. Now she gives Tom a bottle of her Rescue Remedy, but after a week of taking it Tom’s condition is unchanged. His wife therefore persuades him to consult alternative practitioners for his ‘shoulder problem’. Thus he sees a succession of her favourite clinicians.
THE CHIROPRACTOR examines Tom’s spine and diagnoses subluxations to be the root cause of his problem. Tom thus receives a series of spinal manipulations and feels a little improved each time. But he is disappointed that the pain in the left shoulder and arm returns. His wife therefore makes another appointment for him.
THE ENERGY HEALER diagnoses a problem with Tom’s vital energy as the root cause of his persistent pain. Tom thus receives a series of healing sessions and feels a little improved each time. But he is disappointed that the pain in the left shoulder and arm returns. His wife therefore makes another appointment for him.
THE REFLEXOLOGIST examines Tom’s foot and diagnoses knots on the sole of his foot to cause energy blockages which are the root cause of his problem. Tom thus receives a series of most agreeable foot massages and feels a little improved each time. But he is disappointed that the pain in the left shoulder and arm returns. His wife therefore makes another appointment for him.
THE ACUPUNCTURIST examines Tom’s pulse and tongue and diagnoses a chi deficiency to be the root cause of his problem. Tom thus receives a series of acupuncture treatments and feels a little improved each time. But he is disappointed that the pain in the left shoulder and arm returns. His wife therefore makes another appointment for him.
THE NATUROPATH examines Tom and diagnoses some form of auto-intoxication as the root cause of his problem. Tom thus receives a full program of detox and feels a little improved each time. But he is disappointed that the pain in the left shoulder and arm returns. His wife therefore makes another appointment for him.
THE HOMEOPATH takes a long and detailed history and diagnoses a problem with Tom’s vital force to be the root cause of his pain. Tom thus receives a homeopathic remedy tailor-made for his needs and feels a little improved after taking it for a few days. But he is disappointed that the pain in the left shoulder and arm returns. His wife therefore tries to make another appointment for him.
But this time, Tom had enough. His pain has not really improved and he is increasingly feeling unwell.
At the risk of a marital dispute, he consults his GP. The doctor looks up Tom’s history, asks a few questions, conducts a brief physical examination, and arranges for Tom to see a specialist. A cardiologist diagnoses Tom to suffer from coronary heart disease due to a stenosis in one of his coronary arteries. She explains that Tom’s dull pain in the left shoulder and arm is a rather typical symptom of this condition.
Tom has to have a stent put into the affected coronary artery, receives several medications to lower his cholesterol and blood pressure, and is told to take up regular exercise, lose weight and make several other changes to his stressful life-style. Tom’s wife is told in no uncertain terms to stop dissuading her husband from taking his prescribed medicines, and the couple are both sent to see a dietician who offers advice and recommends a course on healthy cooking. Nobody leaves any doubt that not following this complex (holistic!) package of treatments and advice would be a serious risk to Tom’s life.
It has taken a while, but finally Tom is pain-free. More importantly, his prognosis has dramatically improved. The team who now look after him have no doubt that a major heart attack had been imminent, and Tom could easily have died had he continued to listen to the advice of multiple non-medically trained clinicians.
The root cause of his condition was misdiagnosed by all of them. In fact, the root cause was the atherosclerotic degeneration in his arteries. This may not be fully reversible, but even if the atherosclerotic process cannot be halted completely, it can be significantly slowed down such that he can live a full life.
My advice based on this invented and many real stories of a very similar nature is this:
- alternative practitioners are often good at pampering their patients;
- this may contribute to some perceived clinical improvements;
- in turn, this perceived benefit can motivate patients to continue their treatment despite residual symptoms;
- alternative practitioner’s claims about ‘root causes’ and holistic care are usually pure nonsense;
- their pampering may be agreeable, but it can undoubtedly cost lives.
