Should we believe in the improbable, even when it shows to be so inconsistent?
We should not give up the scientific principles in our vision of the
world and – for us, physicians – the medical-scientific knowledge to
practice shamanism, divination, or start to believe in the implausible
only because people who deny those scientific principles claim to be
following an ancient tradition. Nothing in modern medicine should pivot
around orthodoxy, tradition, or authority. In a modern ICU (Intensive Care
Unit)only physiopatological and pharmacological bases have their place,
and it is by understanding their effects and limitation that we reach a
successful outcome. Which the methodology that China is using to fight the
SARS (Severe Acute Respiratory Syndrome)?
In this sense, I believe it is foolhardy to measure a medical
practice by the degree of patient “satisfaction” on the procedure itself.
Since Hippocrates bloodletting has been practice to eliminate the excesses
of the organism. The practice brought about spectacular results due to the
placebo effect. Patients believed that bad humors were being eliminated
from their bloodstream. Bloodletting is currently practiced in India by
medicine man in public settings, and patients feel greatly purified by the
procedure [1]. Here, in our country, we have seen the return of that
procedure by acupuncturists and practitioners of Chinese “Medicine”, who
claim to represent an alternative to scientific medicine, and who use
bloodletting to balance the “Chi” (chi energy). It is hard to defend this
primitive practice, however ancestral and supposedly beneficial to
patients prone to fantasy it may be.
To evaluate the subjective symptoms of a treatment whose “quality and
amount of evidence is not fully convincing” [2] only by the patient’s
response is unreasonable, especially when it comes to prove the
effectiveness of the treatment. The classical research investigating
placebo effects on cardiac surgery comes to mind. In a classical double-
blind study, bypass surgery using the mammary artery was evaluated against
mere skin incisions, showing the enormous potential for placebo effects in
surgery [3]. That is why the comparison between two drugs or treatments
has to be double blind, for the ease with which favorable results can be
induced. Cephalea, which is highly subjective and a symptom only, doesn’t
lend itself to the evaluation of effectiveness of an intervention in
twelve sections against none on the control group. The Hawthorne effect
should also be considered, since a weekly section of emotional
reinforcement for three months can lead the patient to believe that he or
she is being well cared for, and consequently, improving.
We cannot project a long-term economy [Fig. 2] if the event has not
been verified. How will be the migraine incidence in the future years in
this group? See, for instance, the spectacular promises of HRT, which
were based in large population samples and were shown later to be false.
Studies that consider only 255 patients (sample size in Table 2:
acupuncture = 136, control = 119) are not significant to determine
consequent medical practices.
The economy of visits after treatment (made 25% fewer visits to
general practitioners), is another interesting conclusion of the study,
considering that 12 more sections were spent on the treatment than on the
control group.
If we were to validate medical treatments by user satisfaction, we
would have to accept bloodletting, rhinoceros horn powder for impotence,
snake oil, and Naja snake blood as a “tonic” – all of them quackery but
satisfying to millions of users. This most certainly is not how clinicians
compromised with the truth treat their patients. We should expect a
demonstration of effectiveness before engage patients in a determined
treatment. There are many examples of this type of error in the history of
medicine to grant caution.
[2] Acupuncture for idiopathic headache (Cochrane Review)
Melchart D, Linde K, Fischer P, Berman B, White A, Vickers A, Allais G
The full text of the review is available in The Cochrane Library
(ISSN 1464-780X).
[3] Cobb LA, Thomas GI, Dillard DH, et al. An evaluation of internal
mammary artery ligation by a double-blind technique. N Engl J Med.
1959;260:1115-1118.
Rapid Response:
Should we believe in the improbable, even when it shows to be so inconsistent?
We should not give up the scientific principles in our vision of the
world and – for us, physicians – the medical-scientific knowledge to
practice shamanism, divination, or start to believe in the implausible
only because people who deny those scientific principles claim to be
following an ancient tradition. Nothing in modern medicine should pivot
around orthodoxy, tradition, or authority. In a modern ICU (Intensive Care
Unit)only physiopatological and pharmacological bases have their place,
and it is by understanding their effects and limitation that we reach a
successful outcome. Which the methodology that China is using to fight the
SARS (Severe Acute Respiratory Syndrome)?
In this sense, I believe it is foolhardy to measure a medical
practice by the degree of patient “satisfaction” on the procedure itself.
Since Hippocrates bloodletting has been practice to eliminate the excesses
of the organism. The practice brought about spectacular results due to the
placebo effect. Patients believed that bad humors were being eliminated
from their bloodstream. Bloodletting is currently practiced in India by
medicine man in public settings, and patients feel greatly purified by the
procedure [1]. Here, in our country, we have seen the return of that
procedure by acupuncturists and practitioners of Chinese “Medicine”, who
claim to represent an alternative to scientific medicine, and who use
bloodletting to balance the “Chi” (chi energy). It is hard to defend this
primitive practice, however ancestral and supposedly beneficial to
patients prone to fantasy it may be.
To evaluate the subjective symptoms of a treatment whose “quality and
amount of evidence is not fully convincing” [2] only by the patient’s
response is unreasonable, especially when it comes to prove the
effectiveness of the treatment. The classical research investigating
placebo effects on cardiac surgery comes to mind. In a classical double-
blind study, bypass surgery using the mammary artery was evaluated against
mere skin incisions, showing the enormous potential for placebo effects in
surgery [3]. That is why the comparison between two drugs or treatments
has to be double blind, for the ease with which favorable results can be
induced. Cephalea, which is highly subjective and a symptom only, doesn’t
lend itself to the evaluation of effectiveness of an intervention in
twelve sections against none on the control group. The Hawthorne effect
should also be considered, since a weekly section of emotional
reinforcement for three months can lead the patient to believe that he or
she is being well cared for, and consequently, improving.
We cannot project a long-term economy [Fig. 2] if the event has not
been verified. How will be the migraine incidence in the future years in
this group? See, for instance, the spectacular promises of HRT, which
were based in large population samples and were shown later to be false.
Studies that consider only 255 patients (sample size in Table 2:
acupuncture = 136, control = 119) are not significant to determine
consequent medical practices.
The economy of visits after treatment (made 25% fewer visits to
general practitioners), is another interesting conclusion of the study,
considering that 12 more sections were spent on the treatment than on the
control group.
If we were to validate medical treatments by user satisfaction, we
would have to accept bloodletting, rhinoceros horn powder for impotence,
snake oil, and Naja snake blood as a “tonic” – all of them quackery but
satisfying to millions of users. This most certainly is not how clinicians
compromised with the truth treat their patients. We should expect a
demonstration of effectiveness before engage patients in a determined
treatment. There are many examples of this type of error in the history of
medicine to grant caution.
[1] Bloodletting attracts daily patients in Índia
http://www.cnn.com/HEALTH/9806/27/india.bloodletting/
[2] Acupuncture for idiopathic headache (Cochrane Review)
Melchart D, Linde K, Fischer P, Berman B, White A, Vickers A, Allais G
The full text of the review is available in The Cochrane Library
(ISSN 1464-780X).
[3] Cobb LA, Thomas GI, Dillard DH, et al. An evaluation of internal
mammary artery ligation by a double-blind technique. N Engl J Med.
1959;260:1115-1118.
Competing interests:
None declared
Competing interests: No competing interests