The idea of patient-centered care is fashionable -- and care is great, if you can't cure. But there's a whole spectrum in the wellbeing industry, from serious attempts to make people happier to the downright nuts. The problem is that caring for patients makes a very good bait, and the switch to a sales pitch for mumbo jumbo tends to follow not far behind.

I write from the perspective of someone who lives in a country that achieves health care for all its citizens at half the cost of the U.S. system, and gets better outcomes in life expectancy and infant mortality. The view from outside is that U.S. medicine rather resembles U.S. religion. It has been taken over by fundamentalists who are becoming very rich by persuading a gullible public to believe things that aren't true.

One of Freedman's problems is, I think, that he vastly overestimates the power of the placebo effect. It exists for sure, but in most cases, it seems to be small, erratic, and transient. Acupuncture is a good example. If you do a non-blind comparison of acupuncture with no acupuncture, there is in some trials (not all) a small advantage for the acupuncture group. But it is too small to be of much benefit to the patient.

By far the more important reason why ineffective voodoo like acupuncture appears to work is the "get better anyway" effect (known technically as regression to the mean). You take the needles or pills when you are at your worst, and the next day you feel better. It's natural to attribute the fact that you feel better to the needles or pills when all you are seeing are natural fluctuations in the condition. It's like saying echinacea will cure your cold in only seven days when otherwise it would have taken a week.

If the article itself was naïve and uncritical, the follow up was worse. It is rather surprising to me that a magazine like The Atlantic should think it worth printing an advertorial for Andrew Weil's business. Surely, though, Josephine Briggs, as director of an NIH institute, is more serious? Sadly, no. Her piece is a masterpiece of clutching at straws. The fact is that her institute has spent over $ 2 billion of US taxpayers' money and, for all that money it has produced not a single useful treatment. If I were a U.S. taxpayer, I'd be somewhat displeased by that.

Dean Ornish sounds more respectable. He bases his arguments on diet and lifestyle changes, which aren't alternative at all. He's done some research, too. The problem is that it's mostly preliminary and inconclusive research, on the basis of which he vastly exaggerates the strength of the evidence for what can be achieved by diet alone. It's classic bait and switch again. The respectable, if ill-founded, arguments get your foot in the door, and the switch to make-believe follows later.

This is all very sad for a country that realized quite early that the interests of patients were best served by using treatments that had been shown to work. The Flexner report of 1910 led the world in the rational education of physicians. But now even places like Yale and Harvard peddle snake oil to their students through their "integrative medicine" departments. The "integrative medicine" symposium held at Yale in 2008 boggled the mind. Dr. David Katz listed a lot of things he'd tried and which failed to work. His conclusion was not that they should be abandoned, but that we needed a "more fluid concept of evidence."

Senator Tom Harkin's promotion of NCCAM has done for the U.S. reputation in medicine what Dick Cheney did for the U.S. reputation in torture. It is hard to look at the USA from outside without thinking of the decline and fall of the Roman Empire. One had hoped that era was over with the election of Obama, but the hucksters won't give up without a fight. They are making too much money to do that.

The debate continues here.

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