Hey friend! So while I'm incredibly skeptical, I'm not strictly against alternative medicine, like you are. I saw you mention reiki, and thought you might geek out on this article like I did:
https://web.archive.org/web/20200308195914/https://www.theatlantic.com/magazine/archive/2020/04/reiki-cant-possibly-work-so-why-does-it/606808/
It's called "Reiki Can't Possibly Work. So Why Does It?" and I highly encourage reading the whole thing. It first of all thoroughly debunks a lot of the claims reiki practitioners make but it also details all of the studies that have proven its effectiveness and provides what I find a pretty compelling explanation: that much of modern western medicine is stressful and traumatizing. Of course laying in a quiet room with the lights dimmed while a kind person sits with you and wishes for you to be well is effective. It reduces stress and all of the negative biological processes it triggers, which promotes healing.
The article mentions that for years we didn't understand the mechanism by which acetaminophen worked - we just knew it did. I knew a man who was really into "chakra therapy" in the 90s where he had a set of colored sunglasses that, supposedly, would rebalance one's out-of-whack chakras through light therapy. He found that attending to his throat chakra, yellow, helped him sleep better. Years later, formal studies found that yellow lenses filter blue light and can help regulate circadian rhythms.
When I was really little, my uncle sold magnet therapy products (which claimed to promote circulation?? I think??). I had a huge meltdown at a family reunion and no one could get me to calm down. My uncle put a blanket full of magnets on top of me, and I immediately relaxed. Imagine my surprise hearing that story for the first time as an adult who now uses a weighted blanket for stress.
I agree that people need to be really careful about these practices, about getting scammed, and especially about herbal supplements that can have dangerous interactions. I also think there's an extent to which you can analyze the risks and benefits and say, "Okay, I have no idea why this works but it does and there's no major downsides."
Hey so I get a bit heated in this response but I want you to know that I approached this ask in good faith because I know you and I know that we have a lot of the same values and interests and this touched a nerve that was not at all your fault and once I get past the direct response to the article I think I come off a little less. Um. Like the aggression there is not directed at you, it's directed at the article and at one person mentioned in the article specifically who is part of why my reaction to the article is so not good. But I promise after the last bullet point I come off as less reactive, I think. (I'm also publishing this publicly because I think it may be helpful for people to see how CAM stuff often gets away with a veneer of skepticism-that-isn't-actually-skepticism - the article claims to be skeptical but then makes a ton of assumptions and cites some truly mind-bogglingly bad sources that a lot of people won't recognize as bad if they don't have a hair trigger trained by far too much time on the bad CAM parts of the internet).
I've actually read that article a few time times, and would like to do a quick rundown on why I find it unconvincing:
- She doesn't cite any decent studies on reiki; one that she does cite is just a self-reported questionnaire response from 23 people in 2002.
- While we don't know the exact mechanism of action for acetaminophen, we do know that it does work - it measurably reduces fever and in double blinded RCTs produces reproduceable results in reducing certain kinds of pain. The Science Based Medicine authors cited in the article who called for an end to studies on reiki did so both because there is no plausible mechanism of action for reiki (specifically as energy work, not as 'being in a room with a patient person who listens to you') and because there is no good evidence that it works. (And they wrote a follow-up to the Atlantic article; I like SBM but it's quite sneery, as are most of their write-ups of reiki). When Kisner asks "why should this be different?" when comparing reiki and acetaminophen, the answer is: because there is not only no plausible way that reiki *could* work, there is not any good evidence we have that it works better than placebo.
- "Various non-Western practices have become popular complements to conventional medicine in the past few decades, chief among them yoga, meditation, and acupuncture, all of which have been the subject of rigorous scientific studies that have established and explained their effectiveness." This one sentence needs probably twenty or so links in response, suffice it to say that western medicine has emphatically not established and explained the effectiveness of AT LEAST acupuncture and the casually credulous way Kisner accepts that acupuncture is effective (effective FOR WHAT?) throws some serious doubt on her ability to assess these kinds of things.
- The title of the article is "Reiki can't possibly work, so why does it?" and that's probably the Atlantic's fault more than Jordan Kisner's fault, but she doesn't ever demonstrate that it works. She says she got a buzzy feeling after her training, she says that patients at the VA were asking for reiki as treatment for pain and sleep disorders, she says that people remembered "healing touches" from parents and loved ones and that the same mechanism might be what makes reiki 'work.' She says that reiki "has been shown by various studies that pass evidentiary muster to help patients in a variety of ways when used as a complementary practice" and the two studies that she includes that weren't just a questionnaire were 1) a non-blinded study of heart rate variability post heart attack where the reiki arm involved continuous interaction with a trained nurse and the other two arms involved resting quietly or classical music (so relaxation as a result of additional focused attention by attentive medical professionals could account for this? Why was the control for this study not having a med student sit and hold the patient's hand?) and 2) a study of patients who sought out reiki who were surveyed after treatment and noted improvement on one of twenty mental or physical markers (this study is like, GOLD for an example of a bad study; no control, self-selected participants who believe in the efficacy of the intervention, exceptionally broad criteria for a positive result - I find it really really really challenging to grant any credence to someone who confidently cited this as an example of reiki "working")
- Near the end of the article she says "At the same time, this recalled the most cutting-edge, Harvard-stamped science I’d read in my research: Ted Kaptchuk’s finding that the placebo effect is a real, measurable, biological healing response to “an act of caring.” - if she read any of Ted Kaptchuk's research she didn't link to it; what she did link to was a 2018 New York Times profile of him and Kathryn Hall, researchers at Harvard's Placebo Studies and the Therapeutic Encounter program. Being any flavor of journalist and citing Ted Kaptchuk as your source for cutting-edge, institutionally-backed science is disqualifying.
I now need to do some yelling about Ted Kaptchuk.
For clarity: I have as much medical training as Kathryn Hall and Ted Kaptchuk, which is to say: None.
Hall is a microbiologist with a PhD in Public Health, so she at least a background in science. Kaptchuk is an acupuncturist with a BA in East Asian studies and a doctorate in Chinese medicine - notably NOT a medical degree; he was forced to stop calling himself a doctor and had papers retracted after enough people questioned whether the school he claimed he attended even existed and the documents he presented to claim that he was an "OMD" were conclusively translated and did not have any indication that the granted a medical degree of any kind - Science Based Medicine was involved in investigating this because they've been comprehensively anti-quack forever and Ted Kaptchuk has been a quack forever (after recieving confirmation from the government of Macau that Kaptchuk's alma mater was not a medical degree granting institution SBM STILL gave him the benefit of the doubt and had people translate his documentation for final confirmation).
He is also an author on of one of my most beloathed ever studies, which showed that sham acupuncture, placebo, and albuterol all produced the same effect on patient-reported well-being, coming to the conclusion that patient reports can be unreliable and that "placebo effects can be clinically meaningful and can rival the effects of active medication in patients with asthma." That fucking line, that stupid goddamned line, gets cited in every piece of woo bullshit about how acupuncture or chiropractic or some scam-ass diet all work, I've run into this study while looking through at least twenty bibliographies and it is one of the biggest, reddest flags that whoever is writing the paper you're reading is full up on some bullshit. Because, see, the paper found that "placebo effects can be clinically meaningful and can rival the effects of active medication in patients with asthma" in terms of *patient-reported* markers, but the fucking study found that only albuterol produced an actual effect in lung function. Here's the sentence BEFORE the one that gets cited all the time: "Although albuterol, but not the two placebo interventions, improved FEV1 [forced expiratory volume in one second - the measure for lung function used in the study and used to diagnose asthma] in these patients with asthma, albuterol provided no incremental benefit with respect to the self-reported outcomes." It doesn't matter if the patient *feels* better if they can't actually breathe! It doesn't fucking matter - feeling better but still having poor breathing leaves you more vulnerable to dying of a fucking asthma attack! I hate this goddamned study so fucking much and it's used all the time to claim that placebo can be just as effective as medicine for making people FEEL better but, like, they're still sick even if they feel better! I HAVE HAD PEOPLE CITE THIS STUPID FUCKING STUDY TO ME AS EVIDENCE THAT I DON'T CARE ENOUGH ABOUT TREATING MY FUCKING ASTHMA BECAUSE I DON'T GET ACUPUNCTURE TO TREAT MY FUCKING ASTHMA. If sham acupuncture makes you feel better when you've got the flu but doesn't lower your fever or make you less contagious, you shouldn't act like you don't have a fever or aren't contagious this study makes me INSANE.
Okay done yelling.
- I think this look at placebo in the midst of her article about reiki is really interesting because it's very common for CAM practitioners to claim that it's as effective as placebo - which just means that it's not effective. This is a great explanation from The Skeptic on why placebo isn't and can't be what Kaptchuk, Hall, and the like claim. It's also interesting to me that Kisner didn't choose to link to a 2011 New Yorker profile of Kaptchuk that is somewhat less rosy about his placebo studies and includes this absolutely crushing statement: "the placebo effect doesn’t appear to work with Alzheimer’s patients. Trivers suggests that this is because most people who have Alzheimer’s disease are unable to anticipate the future and are therefore unable to prepare for it."
But to the actual point of the ask: I honestly think it's fascinating how much CAM success probably rides on "well did you listen to the patient and pay attention to what was wrong with them and sympathize with them and help them lay out plan that made them feel like they had some agency in this exceptionally frustrating situation (chronic illness, newly diagnosed issue, totally undiagnosed issue) that they're dealing with?"
I know part of why people with chronic illnesses turn to CAM is because they're ignored and dismissed by allopathic practitioners who are largely looking for horses, not zebras - this is one of the reasons that I'm really big on reminding people that (at least in the US) DOs are fully licensed physicians who use a holistic and patient-centered approach so if you are someone with a chronic illness who has had trouble getting diagnosed or had trouble getting doctors to believe you, swapping your MD for a DO as a primary care physician might be really, really helpful to you.
But the flip side of that is that is that I worry deeply about the question of where harm starts; the example with your uncle is really great because you do have a solid instance of something working but for totally the wrong reason (pressure being the mechanism that actually helped, versus magnets being the reason given by the person who did the treatment). Some of this stuff has very little likelihood of causing direct harm, but has the distinct possibility of having indirect harms, which people in the anti-CAM space generally divide into two categories, treatment delay and unnecessary costs (opportunity costs, monetary costs, wasted effort, etc.)
I'm going to step outside of your specific example and look at magnet therapy generally, which really is a spectacular thing to focus on because it honestly doesn't have any direct harms; nobody is allergic to magnets, the kinds of magnets used aren't strong enough to interfere with medical devices, it's even safer than the whole "well herbalism is sometimes just a cup of tea" thing because there are "safe" teas that can do real harm to large populations! But simply being around magnets is not going to hurt anyone (unless they're swallowed; nobody swallow magnets please).
One of the things that I think goes under-discussed when talking about placebo and CAM is that the people trying the alternative solutions desperately WANT the alternative medicine to work (I suspect that this is why the self-selected study of reiki patients has such a significant finding). They are pulling for it; they may be looking at it as a last resort, or they may be hoping that it will work to avoid a treatment that is more frightening, expensive, or inaccessible. I think this actually contributes a lot to the delay of care that we see with CAM.
The absolute worst case harm I can imagine from magnetic therapy is delaying treatment. Let's suppose we've got a diabetic patient with gradually increasing peripheral neuropathy; they have reacted poorly to gabapentin in the past and are looking for something more natural, and they hear from their chiropractor that magnet therapy can be used to treat neuropathy. They buy some compression socks with "magnetic and earthing properties" and sleep in the socks. Whether through the compression controlling some edema or through the simple desire for the socks to work, they feel some relief from the nerve pain they were experiencing and decide that this is a success. The socks work! They continue wearing the socks with occasional pain, but less than before. However, because they are focused on the lack of pain, they don't notice that it's accompanied by increasing numbness. The numbness significantly increases their risk of injury to their feet, which significantly increases their risk of amputation.
It probably sounds like catastrophizing to say "using magnets could lead to amputation" but honestly I don't think it's that far out of the realm of possibility (every time I post on this topic I get flooded with the saddest stories in the world about people whose loved ones died because of delayed treatment for cancer or heart disease).
The second category of harm is cost, which is honestly pretty minimal with magnet therapy, as long as you aren't spending $1049 on a magnetic mat
or paying a chiropractor to give you magnetic treatments. For some other medically harmless treatments like reiki, cost is the thing that I worry about - while I was looking up information related to the article I found that people are charging anywhere from $60 to $225 a session, and selling multi-session packages for thousands of dollars - and if someone thinks that something works, even if it only works by being in a soothing space where someone cares about you - they'll pay for it.
I'm aware that all of this is also extra complicated because of the cost and lack of access to allopathic medicine - a chiropractor broke my spine because I could pay her $60 per appointment but I couldn't pay $125 to see an MD when I didn't have insurance. People who are sick are going to look for treatment; people who have been denied treatment or dismissed by doctors are going to look for alternative treatments.
But man, I really wish I'd spent that sixty bucks on half of a doctor's appointment because the chiropractor didn't know about the benign tumor that I had that weakened the structure of that particular bone when she did her adjustment; it also didn't make the pain go away, it made a different pain start and get worse because it turns out I was having debilitating muscle spasms that then had a bone injury added in on top.
(Chiropractic, for the record, goes with chelation therapy and many many many many cases of herbalism where it's NOT just cost or delay; people claim these treatments are harmless and they are not. They can do tremendous harm).
But yeah I'm not going to deny at all that all of this would be a hell of a lot better if people (especially marginalized people) didn't have to jump through hoops to prove to a doctor that something is wrong with them, and didn't have to do so in an appointment that attempts to cram whole person care down into fifteen minutes, and didn't have the possibility of bankrupting you. Interacting with allopathic medicine is a nightmare and I totally understand why people want to look outside of it for treatment.
I've just heard too many horror stories and seen too much predatory CAM to cut much of it any slack.
At the end of the SBM response to the Atlantic article, the author (I can't remember if it's Gorski or Novella) makes the point that reiki is a spiritual practice, and that we've known for a long time that spiritual practices can improve a person's well-being in a number of ways; they can reduce anxiety, they can provide community, they can give people a space to feel and express emotions that they certainly aren't going to be able to process in a doctor's office. Spiritual practices can be wonderful, and we know there are a lot of people who they can help. But they aren't medicine, and attempting to replace medicine with them (which I don't think that most reiki practitioners are trying to do, to be fair, but which Ted Kaptchuk DEFINITELY is in trying to 'harness the power of placebo') is a disservice to people who need an inhaler instead of acupuncture.
Also, and I know this was not your point but I have to bring it up because people ask about it whenever discussions of placebo come up:
The placebo effect is not treatment. The placebo effect, whether achieved through deception or when someone says loud and clear "this is a sugar pill" does not improve an illness, but it may improve how a patient *feels* about an illness. In some cases, this may as well be the same thing - if you're dealing with muscle pain because you're stressed and no matter what you do it doesn't go away because your shoulders are always up around your ears and you're grinding your teeth and you're sleeping poorly, then literally just talking to someone who is in an office and says "this is a sugar pill, go ahead and take it" may make your muscle pain feel better, but it isn't going to reduce your stress and it isn't going to last, and if your muscle pain is because you're feeling angina as a result of a partially blocked artery then it SURE AS FUCK is not going to make you better and may mask symptoms that were a warning sign of a much more serious problem. People who are sick deserve actual treatment, and placebo is not treatment, which is part of why Ted Kaptchuk makes me want to tear my hair out.
>didn't have to do so in an appointment that attempts to cram whole person care down into fifteen minutes Hol up, this because they charge more for a long appointment or because Americans don't have long appointments? I mean the price for long appointments is eye-watering but it's a cost that can be made legible without too much nastiness with patients being seen late or being subtly told to fuck off. It's still all very rushed obvs, but it's not like being disabled doesn't involve feeling guilty for wasting people's time sooooo
There is such a shortage of primary care providers that, unless you are dealing with some exceptional circumstances, PCP appointments are generally booked for 15 minutes; if an appointment runs long (due to being complicated or an emergency or something) the provider will have to make up time through the rest of the day.
This study includes information on visit length from four million patients visiting eight thousand doctors over one year with a median visit length of 18 minutes.
It also can take 38 days to get an appointment if you're a new patient to that practice.
seems like there's a bunch of pressures in the provision of healthcare that could be improved just by training more doctors
Yes but then we might have to pay doctors less, and that's unacceptable.
(Also because the Medicare budget process is insane, it would raise government expenditures even though it would save money on each visit.)
