Placebos, Alternative Medicine and Scrutinizing Scientific Articles

A particular article in the New England Journal of Medicine has gotten the writers at Science-Based Medicine up in arms, spawning a series of critical articles of their own. Basically the original article demonstrates that a placebo, sham acupuncture and no treatment have an equally small effect on an asthma patient’s outcome compared to actual treatment, but that they can have a large psychological effect.

The problem is that their conclusion tries to push the idea that a patient subjectively feeling well is as or more important than their actual recovery; a dangerous perspective that props up alternative medicines that don’t actually accomplish anything besides a placebo effect, while putting patients at risk. From the “Spin City” article:

As I read the discussion of this paper, I could almost hear the cracking of bones as Kaptchuk went into major contortions to try to explain his negative result. Even though nowhere did the authors really explicitly state their real hypothesis, the design of the study made it painfully clear to anyone who understands clinical research that their hypothesis going in was that placebo responses would result in changes in objectively measured lung function in asthma. They were sorely disappointed, and the contortions of language that went into the discussion were plain to see. The authors implied that it might have been their use of a new, not really validated, patient-reported measure of asthma improvement. Or maybe, they argue, FEV1 isn’t a good measure of the severity of constriction of the airways in asthma, even though spirometry has been a reliable, well-validated test for asthma severity for decades. This is especially true in an academic medical center with a lot of pulmonary specialists. While spirometry can be unreliable in primary care settings and other settings where there isn’t a lot of experience performing it, such a description does not apply to Harvard-affiliated hospitals. At least I would hope not.

Overall, the spin on this study is not that placeboes don’t result in objectively measurable improvements, which is the correct conclusion. Rather, the spin is that subjective symptoms are as important or more important than objective measures; so let’s use placeboes.

All of this points to something important: even a peer-reviewed scientific article in a very important journal can be extremely misleading. Sadly, nowhere is safe enough for one’s critical-thinking-cap to be taken off. Analyzing and taking apart science articles is tough, and when I was in school and in lab I was repeatedly surprised by how my mentors could point out flaws in articles that I never would have thought of. Thinking takes practice :)  

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