practice building and the placebo effect

[Guest guest]

Many, if not most, in the field are focused on practice-building as

their main activity other than practice. that is sadly the case if one

wants to make a living primarily from practice. Others like myself are

focused on outcomes of education and practice. What is effective?

What is valid? We often have debated the value of clinical anecdotes on

this list as it this issue drives right to the heart of the validity of

what we do. Anecdotes must have value if experience is a meaningful

attribute of a practitioner. Because experience is the sum total of

conclusions drawn from one's anecdotes. And the so-called medical

literature of TCM, more than anything else, is a series of anecdotes

that have stood the test of time. So at least some anecdotal

observations must be correct. Of course this is the case as all

science begins from such observation. However another dictum of

science is that many conclusions about the natural world drawn by

laypeople based solely upon anecdotal observation are just plain wrong

(the sun does not rise and set, etc). So what makes an anecdote more

or less valid?

 

Well, it occurred to me that in modern practice, we introduce a very

large independent variable into our experiences. And that variable is

practice building. Practice building is selling, pure and simple. And

it often involves making claims, subtle or otherwise, that range from

ignorant to deceptive to outlandish. By the time most folks show up in

your office, they are what is called a highly self-selected group.

They have either bought your claims or other similar claims found on

the internet or in magazines. They are not a random group of patients.

In ancient times, the docs were dealing with true random groups, thus

their collected anecdotes might truly reflect a valid statistical

sample. The same is true of case based research in other fields, like

WM or psych, where the hard sell is not part of the dr/pt interaction.

But the fact that modern practices are almost exclusively filled with

either self-selected patients or those milking the insurance system

questions any validity of anecdotes from one's private practice. Since

most conditions respond to the placebo effect, a successful hard sell

of acupuncture is almost a guarantee of some short term results. That

is why I demand laboratory proof of changes in diseases like hep C,

SLE, cancer, cardio. In the absence of such proof, we have absolutely

nothing to show for ourselves.

 

The fact that our self-selected patients report satisfaction with

treatment is meaningless to our critics for the reasons expressed

above. It is also a caution to mavericks in the field who believe they

have had a personal revelation about TCM as a result of their

" experience " . I am very skeptical of anyone who makes such claims

without either having studied chinese language (not fluency, just

study) and premodern texts as well as modern research and/or spent time

in a chinese hospital. That is what will teach you what the classical

and modern consensus on treatment are. Then when you have exhausted

those avenues, strike out on your own and show us your stuff. Anything

else borders on malpractice based upon fantasy under the guise of

experience.

 

I see about 70 patients per week as a clinical supervisor. I assess

every single case and diagnose and guide acupuncture treatment for all

70. Plus I write most of the herbal formulas for such patients. Since

I don't do any selling and have nothing to lose, I always put my cards

on the table with patients - real likelihood of cure, etc.. I think

this minimizes placebo effects due to overblown claims, faith, charisma

or enthusiasm and increases the validity of my experience. While I

think we should maximize the placebo effect from good rapport and hope,

etc., I draw the line at deception (it is also illegal, like giving

sugar pills and claiming they are active meds). I also think we must

also maximize the specific effects of our treatments and I think the

" hard sell " actually detracts from ever discovering what the active

meds are. And in the long run, this results in harm to patients as the

placebo effect is typically short lived for organic and structural

complaints and medicine based solely upon nonspecific functional

effects is no medicine at all and will ultimately be abandoned by the

public. So for those who think case based research is the salvation of

TCM, think again. It is already dismissed as invalid in fields like

ours. So its randomized comparative and double blind placebo all the

way.

 

Lets stop debating how we should best do research. Only standard forms

of research will be accepted. While acupuncture may have a lot to lose

when studied in this format, we have nothing to fear from the study of

herbology this way. We will invariably prove much efficacy as long as

we attend to issues like bian zheng and proper dosage. This is another

reason to separate the fields, esp. for research purposes. We don't

need the hands of herb researchers bound by acupuncturists who are

scared what such research will reveal about that modality. While

standard practice is combined therapy, cost effectiveness and the

scientific method demand separate studies. I know Misha is involved

with expanding the herb dept at the Society for Acupuncture Research.

I would encourage such a development to study the use of herbs and

supplements without acupuncture and design separate studies for

acupuncture. Acupuncture needs to be studied like physical therapy or

surgery, not like drugs. Research designed for substances will never

work on acupuncture and the inclusion of acupuncture in such studies

will just diminish the positive effects of such studies and call into

question their validity.

 

 

 

 

Chinese Herbs

 

 

FAX:

 

 

[Guest guest]

 

 

Excellent points all.

 

Bob

[Guest guest]

In a message dated 9/3/04 3:48:42 PM, writes:

 

 

> " By the time most folks show up in

> your office, they are what is called a highly self-selected group. 

> They have either bought your claims or other similar claims found on

> the internet or in magazines.  They are not a random group of patients. "

>

Over 1/2 of my patients are referred by physicians who have tried everything

else. How does that fit in? Now, remember that they have believed each and

every thing they have tried was going to work. Acupuncture, herbs, homeopathics

and nutrition do the job. Which one? How about all together? Is that not also a

possibility? Looking at the patient as a whole?

 

" Since

I don't do any selling and have nothing to lose, I always put my cards

on the table with patients - real likelihood of cure, etc..  I think

this minimizes placebo effects due to overblown claims, faith, charisma

or enthusiasm and increases the validity of my experience. "

 

It is my contentioin that the opposite is true, in that you are so sure of

your capability that you can predict how a persons body will react to the point

of telling them whether you will be able to help them without at least tryng

to do so and working off of that information instead. More information is

received from the response of a patient to what you have done than they give

you,

most times. Your self-limitation on your choices regarding patient care may

help you in understanding to some extent the genesis of the disorder from your

perspective, but we all choose the limits we practice under (with some choices

being made by the state we practice in, or the facility), and to consider

useless others for not meeting the limitations you choose may not be the best

way

to facilitate discussion. We do need to develop a format of record keeping

that is inclusive, but can be scrutinized in different ways to show specific

actions of stimulous and materials.

DAVE

 

 

 

[Guest guest]

, acuman1@a... wrote:

>

 

> Over 1/2 of my patients are referred by physicians who have tried everything

> else. How does that fit in?

 

that is clearly a different scenario and would tend to greatly mitigate the

fefect I have

described.

 

Now, remember that they have believed each and

> every thing they have tried was going to work.

 

 

But they typically did not have to sell that to the patient. I think the sales

pitch magnifies

the placebo effect exponentially beyond variable like the dr.'s tacit beliefs

and a good dr/

pt rapport.

 

Acupuncture, herbs, homeopathics

> and nutrition do the job. Which one? How about all together? Is that not also

a

> possibility? Looking at the patient as a whole?

 

Using multiple modalities is not the same thing as looking at the patient as a

whole. To

solely practice TCM herbology or homeopathy or acupuncture, you must look at the

patient as a whole. Adding modalities does not make things more holistic and in

fact is

often an attempt to cover one's butt when one knows nothing well.

 

>

> It is my contentioin that the opposite is true, in that you are so sure of

> your capability that you can predict how a persons body will react to the

point

> of telling them whether you will be able to help them without at least tryng

> to do so and working off of that information instead.

 

 

But one's assuredness may be largely due to erroneous conclusions drawn from

observations of placebo effects in one's practice over the years. Perhaps not

in your

referral based practice (and I assume you are NOT talking about workers comp or

PI

referrals because my topic is whether we have any anecdotal proof that TCM works

for

chronic internal diseases). that is why in the absence of objective proof of

curing an

organic illness, it all pretty much a variation on he said, she said. If one

" cures " PMS, a

highly fluctuating self limited disorder that often disappears for years with no

explanation,

what does that mean? If one sees fibroids shrink or bleeding time decrease or

such

things, that is proof. If one is confident from past experience that one can

cure PMS most

of the time, you are probably right. But if one thinks they typically help in

hep C cases just

cause a few people reported less fatigue while receiving weekly treatment but

were never

followed up or lab tested, that is disingenuous to say the least.

 

Basically, if what you do works only for you because of your faith, charisma,

etc. but

cannot be conveyed to others objectively, I consider that the placebo effect.

And while it

certainly has its place and must be harnessed and explored, I will just

reiterate that a

medicine that is shown to be largely rooted in placebo will not be taken

seriously in the

long run. WM will just develop their own placebo methods that work just as well

and

abandon all that TCM jargon they hate so much. It is thus vital that we

demonstrate the

viability of each of our modalities independently and stop pretending they were

ever part

of a " system " of medicine. All such multi-modality studies will ever yield is

cogent

critiques that all the observed effects could be explained by placebo. I

understand your

political goals with presenting OM as a complete independent system that belongs

to our

field and includes by default massage, acupuncture, etc. But I genuinely think

this is not

only historically inaccurate but also does not serve the public good.

 

 

[Guest guest]

In a message dated 9/4/04 4:45:22 PM, writes:

 

 

> All such multi-modality studies will ever yield is cogent

> critiques that all the observed effects could be explained by placebo.  I

> understand your

> political goals with presenting OM as a complete independent system that

> belongs to our

> field and includes by default massage, acupuncture, etc.  But I genuinely

> think this is not

> only historically inaccurate but also does not serve the public good.

>

I use multiple modalities because I look at nutrition, physical injury,

stress, at other factors as intrinsic to the case, along with lifestyle.

Hopefully,

a good doctor in any field does the same, and to be truthful, research is not

done on any field of medicine but usually on mere modalities to see thier

utility. This has always been the ethical dilemma for good doctors. Does

witholding treatment you know to be useful for a patient in the name of helping

scads

of other patients because other doctors may believe in your findings justify

what you have done (or not done) to help the patient?

 

Perhaps that is what the difference is between a doctor and a researcher. I

just saw the movie " Windtalker " , where a man is given charge of a Navaho code

radio guy and basically told to kill him if he is likely to be captured so the

code is not broken. The ethical dilemma of his regarding his order to kill a

fellow Marine, who have a different view on warfare than normal troops, in

order to ostensibly save a lot of Marines is what the movie is about.

 

In the case of Western medicine, which uses many toxic materials and

dangerous proceedures, this sort of thing may be justified better to save more

people

from the medicine itself. However, to do this to my patients to prove a point

(research) is difficult for me, and I support a search for a better way to

prove that what do is not placebo.

At this point, I tell patients I specialize in spontaneous remission. They go

everywhere else first to no effect and thier forms of placebo that they

strongly believe in have not worked, but they believe so strongly in what I am

doing to them even though they have never considered it before, that they

improve

lastingly. I can't really teach what it is I do, because it is the result of

over 25 years of clinical experience, combined with self experimentation for

another 10.

Perhaps I can see where I might do research with patients who have agreed to

have research done on them in a facility that has that focus, but I do feel

that in my private practice, that I have an ethical need to do what I have found

is best for my patients, who have put their trust in me to do so.

I understand where the research angle is coming from, but hope a more

comprehensive style of research cmes down the pike someday.

David Molony