I also recognise that for practising clinicians it might be one of the biggest challenges that evidence-based medicine presents – the need to put aside the very powerful experiences of seeing patients get better (for instance with antibiotics for sore throat or acupuncture for whiplash) and embed one’s professional judgement in the evidence.

It can also be very difficult to convey the evidence when speaking to individual patients with a problem. You can almost see them glazing over and I suspect they are thinking “Yes, it might not work in your trials but it might work for me, so what the hell – this sore throat/painful neck is killing me”.

I do take your point. You are quite right that there is a difference between deliberately promoting a placebo intervention as something efficacious, and being reluctantly cornered into it when under ill-informed pressure.

While some of my colleagues do not seem to resist casual antidepressant or antibiotic prescribing, I think even they do not prescribe them believing that they are placebos. To the contrary, experience has taught them that patients tend to get better after they are prescribed. This seems to be more powerful than any number of randomised controlled trials. I suspect similar experiential learning underlies many practitioners’ beliefs in acupuncture. So I doubt these practitioners are setting out to deceive their patients. They are deceiving themselves, and then honest with their patients about their beliefs.

I don’t have a problem with the BMJ group publishing appropriate scientific articles about acupuncture, but I share your concern that in a dedicated acupuncture journal, there may be a temptation for the boundaries of science and promotion to blur.

It will not provide any answers, particularly, but I would like to recommend Dr. David Eisenberg’s ‘Encounters With Qi: Exploring Chinese Medicine’ (W.W. Norton, 1995). He was one of the first medical doctors to study in China and has subsequently set up an institute at Harvard to study Asian medical traditions. His view of why acupuncture doesn’t work in the West, was fascinating. You might find it of some interest. Although, it sounds like you have many books you would like to read, but don’t get the chance to read.

Best wishes,

metap.

However, I do think that GPs are working to avoid prescribing antideps in these cases and antibiotics to sore throats. I am not aware of a vociferous and righteous lobby of GPs and patients who are demanding SSRIs or advocating antibiotics for sore throats in the face of the evidence. Or where unregulated practitioners can charge people for SSRIs or antibiotics.
And I am certainly not aware of the BMJ group setting up journals to publish the evidence (??promote the intervention) for interventions where the evidence is suggesting an absence of an effect. If you take my point.

I also worry that it is tempting to overstate the range of conditions (or the extent to which) a placebo effect may be helpful, in the attempt to find a respectable argument for CAM interventions generally.

These modest quibbles aside, it’s when the taxpayer foots the bill, it creeps into academia, or explanations are given that promote a misunderstanding of how the body works (scientific principles, or what constitutes scientific evidence) that I’m unhappy.

I must say that after reading the RCN’s current guide (herbs and other CAM) on CAM and the menopause I do find it distasteful that medical professionals promote acupuncture (and other bits of wishful thinking) to their patients within a CAM-based context (talking about qi and meridians as if they were true, for example), whilst riding roughshod over the evidence.

It’s a bit like antidepressants for patients with mild-moderate depression: no different from placebo, but they often get swallowed in this context. Personally I try to resist prescribing them in mild-moderate depression, but a lot of such prescribing seems to go on. Starting an antidepressant is often followed by improvement (probably placebo effect or regression to the mean) which is valued by patients and reinforces doctor’s prescribing behaviour, even though the improvement is not scientifically attributable to the drug. I think this might be worse than acupuncture actually, as it is probably associated with more risk of adverse effects, and is funded by the taxpayer.

It’s interesting to speculate on why many doctors get so hot-under-the-collar about the evidence base behind acupuncture but aren’t so vocal about other things we do that are likely to be working by placebo effect. Is it because acupuncture is so “foreign”, so “alternative”, so “not me”? Whereas we have all felt secretly complicit in breaking the holy vows of EBM when we relent and write that prescription for the antidepressant, or the antibiotic for the viral URTI, in the setting of demand from the patient?

Sigh.