BOOK REVIEW

Trick or Treatment: The Undeniable FactsAbout Alternative Medicine

By Simon Singh, PhD, and Edzard Ernst, MD

Publisher: W.W. Norton and Company

(500 Fifth Avenue, New York, NY 10110)

Website: www.wwnorton.com

2008; 342 pages

ISBN: 978-0-393-06661-6

Library of Congress Number: 2008019110

Reviewed by David Schwindt, MD

Edzard Ernst, known for his application of evidence-

based medicine (EBM) to the field of complementary

and alternative medicine (CAM), and Simon Singh, an ac-

complished science writer with a PhD in particle physics,

have paired up to coauthor a book that proposes to look to

EBM to sort out whether there is any value to acupuncture,

homeopathy, chiropractic medicine, and herbal medicine.

These subjects are dealt with in detail, followed by an ap-

pendix of (mostly negative) judgments on about 30 other

CAM modalities.

Evidence-Based Medicine

The authors start off with an impressive narrative on the

history of what became essential features of the clinical

trial. In order to emphasize the importance of blinding, they

tell the tale of how a blinded observer proved that it tastes

better to add milk to your tea before the hot water, instead of

after; and that a biologist could no longer tell whether ho-

meopathy stimulated an ex vivo immune response if he=she

were blinded to knowing who received placebo. There are

engaging stories about the importance of James Lind ran-

domly assigning sailors to different treatment groups for

scurvy, creating control groups to show the folly of blood-

letting and the virtue of hygiene; the use of placebo to

discredit a variety of healing fads; and the prospective

cohort study designed by Hill and Doll proving the link

between smoking and lung cancer. Finally, they offer up the

meta-analysis, inspired by the writings of Archie Cochrane,

as the ultimate exercise in EBM.

Dr Ernst has a long history of performing meta-analyses

on existing clinical trial data using the Jadad criteria to

assign value to each study. The Jadad score gives an as-

sessment of the ‘‘quality’’ of each individual study before

they are summarized in a meta-analysis. Quality is deter-

mined by whether or not there is an explicit discussion of

randomization and accounting for those who drop out from

the study; whether there is a blinded observer; whether the

patient is truly blinded to which treatment he=she is re-

ceiving; and whether there is a placebo control.

The Evidence for Acupuncture

The authors point out that the 1979 WHO consensus re-

port on acupuncture was a simple summary of all available

trials of acupuncture, without any assessment of the quality

of each trial submitted (the vast majority were simply case

series, without randomization, a control group, or use of

placebo). Similar critiques are applicable to the 1997 NIH

Consensus Statement on Acupuncture, although there were

preliminary discussions of what would come to be known as

‘‘quality’’ indicators. WHO reconvened in 2003 with an

attempt at looking at the quality of each trial, but the authors

are put off by the overall lack of ‘‘quality control’’ in this

publication, too. Ultimately, they offer the Cochrane Col-

laboration as the perfect machine to dissect the truth: using

the Jadad scoring system, low-quality trials are rejected and

high-quality trials are counted. They summarize the con-

clusions of the Cochrane Collaboration:

The Cochrane reviews suggest that there is no signifi-

cant evidence to show that acupuncture is an effective

treatment for . . . smoking addiction, cocaine depen-

dence, induction of labor, Bell’s palsy, asthma, stroke

rehabilitation . . . depression . . . carpal tunnel syndrome . . .rheumatoid arthritis, non-specific back pain, lateral elbow

pain, shoulder pain, morning sickness, period pains

(sic) . . . and whiplash.

The authors begrudgingly admit that there are some

positive trials for treating nausea=vomiting associated with

chemotherapy or anesthesia, and certain pain syndromes,

but dismiss these results as merely reflecting the placebo

effect; after all, most trials show minimal superiority over

sham acupuncture.

Editor’s Note: We welcome and encourage your Book Reviews. Please submit to our Managing Editor at rosalynr@aol.com

MEDICAL ACUPUNCTUREVolume 21, Number 4, 2009# Mary Ann Liebert, Inc.DOI: 10.1089=acu.2009.2003

283

The Quest for Placebo

The death knell for acupuncture, in the authors’ opinion,

has been the design and implementation of a telescoping

needle used for sham acupuncture in several clinical trials

that showed no superiority of real acupuncture over the

new placebo treatment. They reference large German trials,

in which acupuncture is minimally more effective than

sham, but both sham and real acupuncture groups did sig-

nificantly better than the third group, which received nei-

ther form of acupuncture in all of these trials. What is

obvious to any practicing medical acupuncturist, is that

there is quite a significant response to sham acupuncture in

these trials.

The Role of the Medical Acupuncturist

So, what can we, as practicing medical acupuncturists,

take away from the presented information, as well as the

authors’ conclusions?

� EBM and the Jadad scoring system are here to stay;

awareness of this can lead to designing trials that will

survive the scrutiny of peer review.� There is the need for better research into the basic

mechanisms of action of traditional, electric, laser, and

sham acupuncture. A novel approach would be to look

for the physiologic differences in those who do not

respond to acupuncture treatments (both real and cur-

rent definitions of sham acupuncture) in the hopes of

defining a meaningful placebo control.� The intent of using a placebo control has not been ac-

complished to date. (I find it fascinating and frustrating

that trials of mind-body medicine frequently show su-

periority over placebo. We cannot possibly be using the

appropriate placebo in acupuncture trials.)

Taking all this into account, only medical acupuncturists

can draw upon their clinical experience to ask the right

research questions (e.g., is acupuncture effective for low

back pain, and, is there a better placebo control to use than

the offerings we have had thus far?); design trials that will

withstand the rigor of peer review utilizing the best of EBM;

and, ultimately, legitimize acupuncture in both the medical

and managed care spheres of influence.

Trick or Treatment is an important example of what is out

there assigning value to what we do as medical acupunc-

turists, but it certainly is not a resource for a comprehensive

list of actual clinical trials on the subject. The same can be

said for the sections on homeopathy and chiropractic med-

icine. All 3 sections, however, have an in-depth discussion

of the history of each discipline. The review of herbal

medicine actually could serve as a handout to patients, but

the appendix is so cursory that the reader must take their

word for it that a certain modality is unproven and=or has no

biological plausibility.

Trick or Treatment does present a wonderful history of

the evolution of the clinical trial design, and of EBM itself.

It takes the reader on a memorable journey looking at the

work of pioneers from James Lind to John Snow, Florence

Nightingale to Ignaz Semmelweis, and follows the path

toward debunking bloodletting and other ‘‘heroic’’ medical

treatments. Their summary dismissals of acupuncture, chi-

ropractic medicine, and homeopathy are seen by the authors

as the logical extension of using EBM to debunk these

treatments. However, unlike the other examples used

throughout the book of quackery that has been abandoned

after being defrauded by the scientific method, these ther-

apies all endure. Why do humans continue for centuries to

submit themselves to acupuncture and herbal treatments,

homeopathy, and chiropractic manipulation? Although I

acknowledge the importance of using EBM to answer

clinical queries in the quest for truth, when it comes to the

specifics of acupuncture, we are asking the wrong research

question(s). However, after reading Trick or Treatment, I

did learn to make a better cup of tea!

David Schwindt, MD, DABMA

23 Clara Drive

Mystic, CT 06355

E-mail: schwindtmd@comcast.net

284 BOOK REVIEW