Not feeling well, you decide to go to some sort of healthcare provider – be it a doctor, therapist, or voodoo witch doctor (depending on your preference).
You receive treatment.
Interestingly, you end up feeling better, either immediately, or after some time has passed.
Does this mean the treatment worked?
It sure seems so, especially if you experience immediate effects. You might be tempted to start telling people: “well it worked for me, so I know it works!”
But here’s the thing… that improvement could have been due to a number of other factors, and might have had nothing to do with the specific effects of that treatment.
This article will discuss some of these other factors. We’ll learn how we can be tricked – or how we trick ourselves – into thinking something works, when in fact it doesn’t!
And so begins a short series: “Why Science?”, beginning with an explanation of why we shouldn’t make important decisions based on anecdotes, testimonials, or coincidences. Why? Because we’re usually wrong.
- Logical Fallacies
– ‘False Cause’
- The ‘Natural History’ of Disease
– Some diseases just get better
– Some disease are ‘cyclical’
- The Placebo Effect
– What is it?
– How does it work?
– Spontaneous remission
- Something Else
– List of ‘other things’
- Symptoms improved, but the disease didn’t!
– Disease vs. Illness
- Nothing got better, we just think it did!
– Confirmation bias
– Cognitive dissonance
– Why science?
Logical Fallacies – namely ‘False Cause’
First and foremost, we have to recognize that we’re all capable of making mistakes in our thinking.
Philosophers have spent centuries pointing out our ‘logical fallacies‘ – when our reasoning seems to make perfect sense to us, but in fact, isn’t logical!
The most relevant ‘fallacy’ in this discussion is ‘false cause’.
- ‘False Cause‘ – when we think that just because two things happen together (or closely after one another), then one must have been the cause of the other.
But determining true ’cause and effect’ is way harder than that. There could have been a ton of different factors that caused those two things to happen closely together.
For example: – The more firefighters there are at a fire, the bigger the fire tends to be. (that’s a correlation) – Therefore, firefighters cause bigger fires. (that’s a cause – and in this case, it’s false!)
Correlation does not mean causation! There could be many other things that cause fires to become bigger, and when they are big, there are usually more firefighters there (we hope). But obviously firefighters don’t make the fire bigger!
When we receive treatment for an illness, and then feel better, we may ‘logically’ assume that the treatment worked. But as you can see, that logic is flawed. The treatment might have worked… or it might have been something entirely different! It could have been entirely coincidental, which happens much more often than people realize.
Get into the habit of asking yourself: “what else could it have been?”
Let’s discuss a few candidates.
The ‘Natural History’ of Disease
The ‘natural history’ of a disease refers to how it plays out on its own – how it starts, how it progresses, and how it ends if you don’t do anything about it 1.
- Some diseases just get better, end of story. For example, a cold or a flu. Whether you do anything about it or not, you’re probably going to get over it. And there usually aren’t any long term consequences or complications either. Many diseases follow this progression.
For example: If you have a common cold and you go to a doctor, they will probably just tell you to take some over-the-counter cold medications and rest. That will make you feel better and allow your immune system to fight off the cold virus (rest is probably the only thing that really helps). But whether you get this treatment or not, you will probably get better anyway.
- Some disease are ‘cyclical’, meaning they get worse or better temporarily, but always move back to an average severity. It’s known in statistics as “regression to the mean” 2. This is how a lot of chronic conditions behave. When it’s worse, people usually seek treatment… then it gets better. People might think this means the treatment worked, but it might have simply been the natural cycle of the disease.
For example: Low back pain is notorious for being ‘chronic’, coming and going even when there seems to be no aggravating factor. If you go and get treated every time your back ‘flares up’ (and of course, every time this happens, it ends up getting better, because that’s just how it goes), it won’t take long before you believe you absolutely need that treatment. This pattern can end up making the next factor – the placebo effect – much stronger.
The Placebo Effect
The placebo effect is something that comes with receiving any treatment – whether it works or not.
What is it?
- The Placebo Effect – The effect one experiences when receiving a treatment that they believe to be appropriate for the given illness.
Therefore, you could experience a ‘placebo effect’ from either a placebo (sugar pill with no medicine) or something that actually does treat the disease. It doesn’t matter, as long as it seems to be the right thing to do, you’ll probably feel better.
Why? How does it work?
The placebo effect has to do with the cultural tradition of being treated for an illness, and can be influenced by a ton of different factors 3, 4. Cultural tradition? Sounds pretty flaky, but the more ritualistic a treatment seems, the more powerful the placebo effect seems to be. Things that make the treatment more convincing – a confident practitioner, degrees and certificates on the walls, a good reputation, and even your own beliefs – can all make the effect more or less powerful. A lot of it has to do with reducing stress and anxiety.
For more on this interesting subject, read: ‘The Problem with Placebo‘
While the placebo effect can be very useful, perhaps even important, it can be achieved with just about any treatment (that you believe in) – and is an example of how you can feel much better even if the treatment itself has no specific effect on the disease.
It might have just been the placebo effect!
“Miracles”: (spontaneous remission, outliers, etc.)
Typically, only exceptional news is reported far and wide. You never hear the ‘usual’ story, or the ‘average’ case. You hear about the exceptions (which makes it seem like there are more than there really are).
- “Spontaneous Remission” – It’s obviously very difficult to do statistics on things that happen extremely rarely, but there are reports by oncologists (doctors specializing in cancer) that sometimes peoples cancer can simply “disappear” 5. It’s known as ‘spontaneous remission’, and it probably does have a real cause – but we just don’t understand it yet. (that’s why future research is so important!)
- Outliers – Sometimes, people just aren’t in the normal range 6. This happens with every statistic: you’ll always have a few points on your graph that are way off. Many times these are just mistakes, but they can be real too. Record setting star athletes are outliers in sports performance. Billionaires are outliers in financial success.
In 2006, a study was published in the medical journal Cancer that gave a good example of how outliers can exist in diseases 7. Researchers followed 2337 patients who had received treatment for ‘non-small cell lung cancer’ and recorded how long they survived. The average survival rate was about 5 months. However, 1.1% of them survived for 5 or more years!
Sometimes, miracles do happen. And sometimes, these miracles can happen when someone tries something new and/or different. Of course, these instances are always hyped up in the media as ‘miracle cures’, instead of being reported as what they probably are: coincidences. Until we have some good research, it is irresponsible to jump to conclusions like that. But hey, I guess it makes for a good news story right?
If you get better after a treatment, even if it’s not the natural history of a disease, or a placebo effect… maybe you’re just lucky?
Or (more likely), maybe it was something else…
When people are sick enough to seek healthcare, they usually don’t stop at just one thing. They usually take on a whole bunch of other healthy behaviours! If you are frustrated, even desperate, why wouldn’t you?
Here are some of those other things people may do (on top of receiving treatment):
- Take time off work / school.
- Drink less alcohol / smoke less.
- Rest more.
- Get attention from / spend more time with friends and family.
- Eat better.
- Get more sleep.
- Exercise appropriately.
- Reduce stress.
- Try other therapies / treatments at the same time.
Can you think of any more? There are a lot of them, all of which can have a powerful impact on your health. For many illnesses, a few of these changes may be all you need.
Symptoms improved, but the disease didn’t!
Some people disagree with this, but let’s talk about it anyway.
Just because signs and symptoms improve, doesn’t mean the underlying disease has gotten any better. Sure, many times, it probably does. But sometimes, it doesn’t.
It’s those ‘sometimes’ that worry us.
- Disease – best refers to an abnormal condition affecting an organism. This abnormal condition could be due to infection, degeneration of tissue, injury/trauma, toxic exposure, development of cancer, etc. This is what needs to be ‘cured’, especially if it’s life-threatening.
- Illness– best refers to the feelings that might come with having a disease. Feelings like pain, fatigue, weakness, discomfort, distress, confusion, dysfunction, etc. – the reasons people seek healthcare – and usually the way people measure their success with treatment.
– It’s very important to understand that feelings of illness can be vastly affected by many non-disease factors, such as expectations, beliefs, fears, feelings/moods, and culture. Being ill is a very personal experience, and can vary tremendously and be affected by very different things between people with the same ‘disease’.
Because of the many reasons discussed already, feelings of illness may genuinely improve, while the actual disease remains. Obviously, this can be dangerous for some diseases. This is why we need to be careful not to make any unsubstantiated claims about the effects of a treatment.
For more about this, read: Disease vs. Illness.
Nothing got better, we just think it did!
And finally, here are two more ways in which our thinking can fail us.
- Confirmation Bias – This is the tendency of people to look for information that confirms their pre-existing beliefs. Similarly, people tend to ignore or undermine the relevance of information that contradicts their beliefs. 12, 13
For example: You feel your knees are stiff. You do some reading on the internet about a nutritional supplement that is supposed to help with stiff joints. The reasoning of why it works makes so much sense that you are absolutely convinced that this is the real deal – so you buy some.
The next day, you notice you capable of doing things like walking to work a little faster, or picking things up off the floor that you usually avoid. Proof! It must have worked! Meanwhile, that same day, you noticed more pain than usual, and you avoided the stairs and didn’t bother going to the gym that day. But whatever, that’s pretty normal for you, so it’s probably not related. You’re just happy that those other things were a little better.
In this case, you are paying too much attention to the minor improvements, and not enough to the signs of no improvement. That’s an example of confirmation bias. Everyone does it.
- Cognitive Dissonance – Similarly, people experience “cognitive dissonance” when they have two competing ideas in their head. It’s an uncomfortable feeling that you might be wrong – and it’s far worse if you believed in the idea for a long time, or based a big part of your life on it. When hearing competing information, it may cause surprise, guilt, embarrassment, or anger. This usually causes people to justify or alter their beliefs to fit the new information, or they simply ignore it. 14
For example: Every time you get a cold, you always feel better with chicken soup. After a while, you start to believe in it very strongly. You decide to start a chicken soup company, and market it as a cure for the common cold.
Then, researchers publish studies that show that chicken soup has no effect on a common cold that’s any better than placebo. With such a big part of your life built around this belief, you feel very uncomfortable. But after some thought, you decide the placebo effect is under-rated, and then start marketing your chicken soup as “harnessing the power of placebo”!
Both confirmation bias and cognitive dissonance are biases we are all capable of. Because of these biases, it is easy to assume something works when in fact it didn’t even make you feel better!
Conclusion – Why Science?
When something seems to work, it could have been:
- the ‘Natural History’ of the disease,
- the ‘Placebo Effect’,
- a rare ‘miracle’,
- or something else you did caused the improvement.
Still, we could think something works when it actually doesn’t because of:
- logical fallacies,
- symptoms improving while the disease remains,
- or nothing got better at all, but we are biased to think it did.
Everyone has their own beliefs and biases. If anyone claims not to, don’t trust them.
The best we can do (which I strive for on this site) is to base our decisions and theories on the best evidence available. A part of most (if not all) training to become a healthcare practitioner involves learning what good evidence is. Still, healthcare practitioners fall victim to biases and logical fallacies all the time. So do I, and so do you.
But that’s okay! In fact, it should be expected.
This is why the scientific method exists.
Science isn’t some institution or authority, nor is it something nerds invented to make themselves feel cool for discovering things. Science is a method of testing things in a way that attempts to weed out our errors in thinking, and see if something truly works.
Thanks for reading!
Why do ineffective treatments seem helpful? A brief review. by Steve Hartman – an excellent article on the history of healthcare, and the many reasons why many unproven treatments seem helpful.
‘Why Bogus Therapies Seem to Work’ by Barry L. Beyerstein – this article is a fantastic reminder of why we should be humble in our claims as healthcare professionals, and constantly seek the best evidence available for choosing our treatments.