Whinge moan

November 22nd, 2008 by Ben Goldacre in bad science, evidence, irrationality research | 40 Comments »

Here is my slightly shite backup column. Apologies. I do, however, have something amazing up my sleeve for the next couple of days.

Ben Goldacre
The Guardian
Saturday November 22 2008

I have a cold (and they’re worse than you remember when you’re well). Throughout the nation, homeopaths and self-declared nutrition therapists are celebrating. More importantly, I know that there is almost nothing I can do, except sit it out, and wait. Vitamin C will shave a few hours off it, at high doses, like 7g a day, which I can happily live without.

Although literally anything I try will appear, to me, to work: because unless I’m seroconverting with HIV (not that I’m prone to hypochondria) I will get better anyway. This is the natural history of the illness, and it’s true with most things. When your back pain is at its worst and you visit your doctor – or your friendly local spoonbender – it’s bound to get better, because these things come in cycles, or as statisticians say, they “regress to the mean”. You can look at regression to the mean mathematically, if you like. On Bruce Forsyth’s Play Your Cards Right, when Brucey puts a three on the board, the audience all shout: “Higher!” because they know the odds are that the next card is going to be higher than a three. “Do you want to go higher or lower than a jack? Higher?” “Lower!”

So I could take homeopathy. Or I could, equally stupidly, harass my GP for antibiotics, even though they are ineffective in treating a viral cold.

In one study, prescribing antibiotics rather than giving advice on self-management for sore throat resulted in an increased overall workload through repeat attendance. If a GP prescribed antibiotics for sore throat to 100 fewer patients each year, they calculated: 33 fewer would believe that antibiotics were effective, 25 fewer would intend to consult with the problem in the future, and 10 fewer would come back within the next year.

If you were an alternative therapist, or a drug salesman, you could turn those figures on their head and use them as a blueprint to drum up more trade: because we are all prone to see patterns where there is none, and more than that, to believing that our actions have results. This was demonstrated in a chilling experiment several decades ago. Subjects were recruited to play the role of a teacher trying to make a child arrive on time for school at 8.30am. They sat at a computer, on which it appeared that each day, for 15 consecutive days, a child would arrive at some time between 8.20 and 8.40.

Since this was a psychology experiment, the subjects were lied to: they did not know that the arrival times were entirely random, and predetermined before the experiment began.

Nevertheless, participants thoughtfully deployed punishments for lateness, and rewards for punctuality.

When they were asked at the end to rate their strategy, 70% concluded that reprimand was more effective than reward in producing punctuality from the child. It’s a touching testament to their own beliefs about the world.

These people were convinced that their actions had an impact on the punctuality of the child, even though the arrival time was entirely random. The joy is, you have no way of knowing how many areas of your life this experiment might be relevant to. Now I’m going to dangle some goat entrails around my neck and get chanting.

• Please send your bad science to bad.science@guardian.co.uk

Hemilä H, Chalker E, Treacy B, Douglas B. Vitamin C for preventing and treating the common cold. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD000980. DOI: 10.1002/14651858.CD000980.pub3.

Specious learning about reward and punishment. Journal of Personality and Social Psychology, 48, 1377-1386. Schkade, DA, & Johnson, EJ 1989.

Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997;315: 350-2.


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40 Responses



  1. paulhutton said,

    November 22, 2008 at 5:38 am

    That wasn’t a shite column! I, too, have a cold / flu and it’s good to be reminded that it will pass.

    The main feature of my man-flu is a very sore, swollen and infected set of tonsils. I have to confess that I’ve taken to gargling with vodka instead of consulting with my GP. I’m sure there’s no evidence to support this approach however the side-effects of vodka-gargling are always welcome…

    Do you have a reference for that psychology study by the way?

    Cheers
    Paul

  2. omar said,

    November 22, 2008 at 8:24 am

    this was no shite post at all. I think the main feature of a sick person is that he will try each and every medicine/entrails to try and cure his disease, even if he normally doesn’t care about living healthy. Deep down, there is something we could learn from being sick..

  3. Peter Young said,

    November 22, 2008 at 8:47 am

    The Lateness experiment.
    This is mentioned in Chapter 2 of
    Thomas Gilovich (1991) How we know what isn’t so, Simon & Schuster, (page 27). The reference that Gilovich gives is:
    P E Schaffner (1985) Specious learning about reward and punishment. Journal of Personality and Social Psychology, 48, 1377–86

  4. Seahorse said,

    November 22, 2008 at 8:50 am

    I agree. No shite.

    Even if you’re seroconverting you should get better nowadays, shouldn’t you, Ben? Assuming you have access to a properly funded health service.

    Would be great if you routinely put references on this website.

    …A fan

  5. jodyaberdein said,

    November 22, 2008 at 9:50 am

    I went out to Boots yesterday to get some lemsip for my very own cold. I can get paracetamol from the ward, but it was the ephedrine I wanted. The sales assistant very smoothly placed a free packet of vitamin C next to my nice shiny over-priced lemsip. Which I thought was nice of him. He was somewhat surprised when I told him no thanks as it didn’t really work.

    Jody

  6. CDavis said,

    November 22, 2008 at 10:28 am

    The high regard in which bloody Lemsip is held has long been a mystery to me.

    While I agree that nothing can be done for the cold itself, I don’t believe that I’m under any obligation to feel the discomfort and misery. I employ such analgesia as is necessary to blot out the sensation, and promote sleep. Honi soit qui mal y pense.

  7. Waider said,

    November 22, 2008 at 10:58 am

    In similar condition this week; I’ve had a persistent recurring incidence of sore throat followed by stuffy head, all lasting a few days, for the last several years, and was sufficiently annoyed at its recurrence this time around to go visit the local GP for advice. And advice he gave:

    “Is your bedroom warm enough?”
    “uh, I guess so”
    “Could you sit stark naked on the end of the bed reading a book at 3am?”
    “heh. no, probably not at this time of the year.”
    “your bedroom isn’t warm enough.”

    He then proceeded to explain the nasal cavity, the various things that drain into it especially in cold environments where more fluid is produced, and the fact that at night it drains whatever it’s collected down the back of your throat; the collected fluid tends to irritate the throat. I’m probably not doing his explanation justice, but the general gist was that no, you don’t have an infection (he did a throat & nose inspection to be sure), just a cold bedroom.

    All in all, a reassuringly informative and quack-free encounter, and while I felt a little guilty taking up his time with such a trivial issue, I’m now just a little bit more educated than I was before.

    On a side note, I think the fact that the body persistently seems to put generators of acidic substances in close proximity to acid-sensitive tissues to be an excellent counterargument against the Intelligent part of Intelligent Design.

  8. BobP said,

    November 22, 2008 at 12:54 pm

    Common colds do not “regress to the mean”. You deserve to be standardly deviated for at least another week.

  9. David Mingay said,

    November 22, 2008 at 1:37 pm

    Far from shite – very useful, in fact. I used it to introduce my Year 9 English students to the analysis of media texts (we have Saturday school at my current establishment). They quickly came to the conclusion that its tone was “intellectual” and “sarcastic”. So, thank you.

  10. Bogusman said,

    November 22, 2008 at 1:41 pm

    I have long sworn by whisky, honey and lemon in hot water at bedtime for all colds and sore throats. Doesn’t cure them, just makes me happier about having them.

  11. kim said,

    November 22, 2008 at 2:10 pm

    Is there anyone here who can comment on the advice from Waider’s doctor? It’s not something I’ve ever heard before, except from older members of one’s family who always go on about wrapping up warm etc. I mean, leaving your central heating on at night sounds like it ought to be the wrong thing to do…

  12. BobP said,

    November 22, 2008 at 3:16 pm

    muscleman – try “buttercup” syrup, benylin, olbas oil etc. Many of these contain wholesome herbal extracts which will also put hair on your chest.

  13. katy6 said,

    November 22, 2008 at 3:58 pm

    muscleman:

    Actually ibuprofen is a very effective fever reducer. I actually found it better than paracetamol (or acetaminophen as they call it here in the States) for my kids when they were little. Although I only gave it to them for fevers over 101 F (38 C), so that might have made a difference.

    I agree with Bogusman about the medicinal qualities of whisky. Except leave out the lemon, honey and hot water. Save them for a cup of tea in the morning.

  14. emen said,

    November 22, 2008 at 5:19 pm

    Muscleman, of course you can buy decongestant tablets without paracetamol! Try your supermarket’s own “decongestant” tablets (phenylephrine or pseudoephedrine). Or nasal sprays.

    Ben, although you have said before that you are getting bored of talking about homeopathy, I’m always glad when you mention it. Yes, homeopathic remedies are still popular for colds and flu

    www.nationalnutrition.ca/detail.aspx?ID=1421

    www.iherb.com/ProductsList.aspx?c=1&cid=483&gclid=COyhspuCiZcCFUsa3godsiqqDA

    www.londonmoms.ca/Vbulletin/showthread.php?t=9549

    Coryzalia and Oscillococcinum are both rated with five stars, and mummy notices little nose being less runny after just two doses.

    I also have a cold right now, and I’m not using anything homeopathic – but I have tried them in the past. (One gets so fed up with homeopaths asking “But have you actually TRIED homeopathy, or are you just attacking us…? You don’t have to BELIEVE in it, just try it ONCE.”)
    I tried both Coryzalia and Oscillococcinum, also the Dutch favourite called Nysileen. I gave them both two goes. I guess nobody here will be especially surprised that they didn’t do anything at all. Nysileen drops are fascinating, you count the drops, keep the water in your mouth for a few seconds and I got quite excited about the ritual, but it had no effect nonetheless.

    What’s interesting is that you are saying, they (as anything) SHOULD have made me feel better because if you take them at your worst, you are about to get better anyway, and that’s how they manage to recruit the fans. However, the leaflets with these homeopathic remedies suggest you start taking them at the first signs of a cold or flu and then they will prevent it from developing into a proper illness. Which is what I did, and of course, I always ended up with a proper cold. So I’m just puzzled by how highly rated these products seem to be with people who buy them.

    Oh, the fun bit is that Oscillococcinum is supposed to be also suitable for PREVENTING flu, just take one tube of sugar pills a week and you are protected – how on earth that is compatible with the principle of homeopathy, I have no idea, but a lot of people swear by it.

    Fruit tea with honey or chicken soup have a better chance of making me feel better than this rubbish. But at least now I can tell homeopaths, yes, I have tried them, and they didn’t work, so there!

  15. zooloo said,

    November 22, 2008 at 10:16 pm

    @emen

    My brother get gout and uses a homoeopathic remedy to prevent it and he swears it works… if he “catches it in time”.

    Ditto for cold cures I suppose.

  16. Dudley said,

    November 23, 2008 at 1:06 pm

    Erm… is nobody saying “Get well soon” because that would be a betrayal of your strict scientific rationality?

  17. elfy said,

    November 23, 2008 at 2:12 pm

    @emen: one possibility is the people taking homeopathic cures aren’t great at knowing when they have ‘the first signs of cold or flu’, and when they’re just generally a bit under the weather.

    Right now, I have a dry throat and stuffy nose. It’s probably something to do with the alcohol I drank last night, the cold weather, and my relative lack of sleep lately. But it could plausibly be thought to be the beginning stages of an infection. If I feel like this, say, 10 times a year, take a homeopathic remedy everytime – just to be on the safe side – and only one of them turns out to be an infection, then even a totally ineffective remedy will look pretty powerful.

  18. emen said,

    November 23, 2008 at 2:38 pm

    Elfy

    “If I feel like this, say, 10 times a year, take a homeopathic remedy everytime – just to be on the safe side – and only one of them turns out to be an infection, then even a totally ineffective remedy will look pretty powerful.”

    Exactly. If it’s homeopathic, it’s harmless, so they think they might as well start to take it really “in time”.

    Oh, yes, Ben, get well soon!

  19. Mojo said,

    November 23, 2008 at 3:33 pm

    @Elfy:

    “But it could plausibly be thought to be the beginning stages of an infection. If I feel like this, say, 10 times a year, take a homeopathic remedy everytime – just to be on the safe side – and only one of them turns out to be an infection, then even a totally ineffective remedy will look pretty powerful.”

    If you feel like this 20 times a year and only one of them turns out to be a cold, you have statistical significance.

  20. bigjohn756 said,

    November 23, 2008 at 9:52 pm

    I like to take a LOT of vitamin C when I have a cold or the flu. I enjoy taking my vitamin C as orange juice diluted with lots of vodka. The vodka ensures that I don’t get too much vitamin C at once. I seem to require several applications of this medicine before the symptoms just don’t seem to bother me much anymore….

  21. Kapitano said,

    November 23, 2008 at 10:18 pm

    A possible experiment:

    Select 100 believers in homeopathic medicine. Explain to them that you’re going to infect them with a cold, and one half will receive conventional medicine, the other half homeopathic. At the end, they state which group they think they were in.

    As is traditional, they’ll all actually receive the same treatment – it doesn’t matter what the treatment is.

    I predict that those who recover quickly will guess they’re in the “homeopathic” group, and those still sniffing after two week will be convinced they’re being given “orthodox” (ineffective, unnatural, harmful etc.) treatment.

  22. Squander Two said,

    November 24, 2008 at 11:00 am

    I used to suffer really badly from colds: I got more of them than your average person and each one would last weeks. Then my step-mother explained to me that the human immune system is really quite clever and heats us up to kill infection, makes us cough to keep infection out of our lungs, makes our eyes and nose stream to flush infection out, and makes us dead sleepy so we go to bed to recover properly, while we humans cunningly take pills to lower our temperature, stop us coughing, dry out our eyes and nose, and wake us up so we can get on with working and knackering ourselves, and then wonder why this damn cold is dragging on so long. I thought she sounded like she had a point, so, ever since, I’ve tried treating my colds with absolutely nothing whatsoever. It is by far the best treatment I’ve ever had. I recommend it to everyone.

  23. smithers said,

    November 24, 2008 at 12:37 pm

    Why so hard on yourself Ben? Personally I think you deserve a gold star for doing anything when suffering with a bout of man-flu.

  24. banshee said,

    November 24, 2008 at 7:47 pm

    Fascinating discussion – and a reminder of why the Common Cold Research Unit in Salisbury no longer publishes – nothing worked!

    Interesting that the Cochrane Collaboration gives a thumbs up to Vitamin C to reduce cold frequency in those people who are physically stressed – “n six trials with participants exposed to short periods of extreme physical or cold stress or both (including marathon runners and skiers) vitamin C reduced the common cold risk by half.”

    I’m also suffering a cold – and self medicating with Magners Cider although contemplating a combination cold product (my fave is Night/Day Nurse).

    All the non-steroidal anti-inflammatories, aspirin and paracetamol reduce fever – as well as reucing aches and pains (which is a boon in flu!).

    Just a quick note – pharmacies are less eager to sell pseudoephedrine products – especially single agent products – as the MHRA have deemed that unscrupulous folk can make illicit drugs from them!

  25. kim said,

    November 25, 2008 at 2:45 pm

    SquanderTwo – what you say seems to make sense, yet I wonder if it’s true. While it seems logical that a fever is your body’s way of fighting infection, doctors will always tell you to try to lower your temperature if you have a fever, usually with paracetamol or (in children) Calpol. I assume there is actually a medical reason for this, rather than just that doctors are in thrall to pharmaceutical companies.

    It’s at times like these when we need a doctor to explain it to us. If only there were one on this site…

  26. warhelmet said,

    November 26, 2008 at 2:35 pm

    Nothing works faster than Anadin. That’s why I take nothing…

  27. Robert Carnegie said,

    November 27, 2008 at 12:29 am

    Do you prepare your backup column in advance to use when you do have a cold? Or is it a less stressful number not requiring research? Good luck getting well. I think I may have the cold too, having previously imagined that cycling in rather chilly weather, deep breathing especially, could be giving me transient symptoms without the actual lurgy. Oh well. Lousy weather and the bus to work tomorrow anyway.

    And meanwhile, further alarming and questionable advice about colds. (Once a correspondent to the Guardian’s “Notes and Queries” explained with superficial sanity that fax machines, the thing of the day, had the practical drawback that the secret GCHQ office received a copy of everything sent by any fax machine in the country. So much paper…) Heating your bedroom is a nice idea, don’t use central heating, a little electric heater and enough ventilation so you don’t suffocate. I can’t sit naked and read in my bedroom at 3 am because the light’s off. But paracetamol makes the cold longer? Nasty thought there. It does, however, make it more bearable. Perhaps that’s the problem, dose yourself and go to work and get stressed, or don’t dose and spend the day watching TV from your bed, much healthier. Regardless, as this article explains, you -will- get better, unless it’s bird flu after all. Drugging up to -feel- better seem completely reasonable to me, and doesn’t it stand to reason that if you pharmacise your closed sinuses open again, they’re less likely to go nastier still? Maybe not?

  28. Alison Jane said,

    November 27, 2008 at 10:35 am

    This study from Cardiff University says Mum was right:
    www.timesonline.co.uk/tol/news/uk/article589905.ece

  29. Dr* T said,

    November 27, 2008 at 10:46 am

    Hi Alison – did you look at the protocol?

    “Half of the participants immersed their feet in bowls of ice-cold water for 20 minutes. The others sat with their feet in empty bowls”

    I think this is an attempt at placebo. I haven’t read the original paper, but the report doesn’t fill me with confidence.

  30. Alison Jane said,

    November 27, 2008 at 11:11 am

    Well they describe the empty bowls as a control procedure. More problematic maybe is that there were only 180 people – so a pretty small study to draw sweeping conclusions from.

    “Claire Johnson and Ronald Eccles, Acute cooling of the feet and the onset of common cold symptoms Fam. Pract., December 2005; 22: 608 – 613.”

  31. Andrew_F said,

    November 27, 2008 at 11:26 am

    Those results seem to suggest that between 10 and 35 people would conclude doctors are useless.

  32. Dr* T said,

    November 27, 2008 at 11:41 am

    Regardless of dubious methodology (and that control is nonsensical, please) it doesn’t do anything that the Times article says it does. My mother never warned me about putting my feet in ice cold water. The article talks about wrapping up warm to prevent colds, which has not been investigated in this research.

    Seems like Cardiff trying to fluff up their PR rating and nothing more.

  33. Andy Dingley said,

    December 1, 2008 at 12:09 pm

    Here’s a new one for megadose VitC. Seems that it cures posion ivy rash too (recently added to the wiki article on “Urushiol-induced_contact_dermatitis”), “Powdered vitamin C mixed with water to form a paste and applied to poison ivy or oak will usually effect a cure in 24 hours when adequate vitamin C is also taken by mouth.”

    Frederick Robert Klenner, B.S., M.S., M.D., F.C.C.P., A.A.F.P. (Spring 1974). “Significance of High Daily Intake of Ascorbic Acid in Preventive Medicine”. Journal of the International Academy of Preventive Medicine, Spring 1974, Volume 1, Number 1, pp. 45-69.

    www.seanet.com/~alexs/ascorbate/197x/klenner-fr-j_int_assn_prev_med-1974-v1-n1-p45.htm

    Funniest of all though has to be this (ibid.), “Lightning victims can also be saved. I have done it.”

  34. dmcclure said,

    December 1, 2008 at 1:56 pm

    Please correct me if I’m wrong – fever and the raised temperature and sweating that accompanies it are a necessary part of cold elimination and it is this sweating/heat which partly gets rid of the cold.

  35. Numbat said,

    December 5, 2008 at 9:23 am

    Sorry – don’t know what happened there but here’s the rest. P less than 0.01. Would you reject the results on the basis that there are only 180 subjects?

    I’m a vet and probably about to astound you with my ignorance. We are the ‘poor relations’ of the the medics and our clinical trails are always small. I’ve always consoled myself by saying that it’s difficult to achieve a statistically significant result with a small sample size.If, therefore there is such a result then there must have been a large difference in outcome between the two groups and I can trust the results. If this isn’t true I’m going to give up on ‘evidence-based veterinary medicine’ and become a homeopath.

  36. richard_cockshott said,

    December 10, 2008 at 4:00 pm

    in response to nubat, as i understand it the question is does the study have sufficient power to answer the question? Yes a small study may have sufficient power to significantly demonstrate a profound difference in outcomes. i’ll be honest i’ve not looked at the study but i suspect the difference demonstrated is unlikely to be profound. One statistical way to look at this, I think, is to look at the confidence intervals, around the results: broad confidence intervals shows the power of the study likely to be insufficient. I’m sure someone better at statistics will correct me but a good starter for understanding clinical trials is Tricia Greenhalgh, “How to read a paper: the basics of evidence based medicine”

  37. Mark Wainwright said,

    December 16, 2008 at 11:19 am

    “70% concluded that reprimand was more effective than reward in producing punctuality from the child. It’s a touching testament to their own beliefs about the world.”

    It isn’t though; it’s good old regression to the mean. If you punish a late child, the punishment will seem to work when it regresses to an earlier time. If you reward an early child, the reward will seem to have been counterproductive when it regresses to a later time.

    This is a very generally applicable lesson in why praising and rewarding children (and adults) is a better idea than experience suggests, and punishing and censuring them a worse one.

  38. garrog said,

    January 12, 2009 at 1:17 pm

    As a GP I often prescribe antibiotics to whinging patients, and I’ve often wondered if I am doing the right thing!
    Am I treating an illness, such as a virus, or am I managing a clinical problem? Let’s take the ” managing a clinical problem” scenario a little more seriously, as follows:
    Patients sometimes get a pneumonia and die from viral respiratory tract illnesses; they often find access to healthcare tricky and after an initial visit, can be reassurred by the advice ” take a few paracetamol and drink lots of hot fruit drinks and go and wait at home till it gets better”, and they sometimes get very ill as a result. very occassionally that is. If this happens on my watch, then I get a complaint. I don’t like getting complaints.
    So, what I would like to know, Ben, is what the science of this “clinical management” scenario is. How many 80 year old LOL ( little old ladies) with a cold, if left alone, will get a pneumonia? and how many will not, if given an antibiotic? with the proviso that they don’t have access to medical intervention in the meanwhile ( its a bank holiday weekend and the Out of hours service is crap at seeing people with viruses).

  39. gothgirl said,

    October 17, 2009 at 8:57 pm

    This is an issue which is particularly bothering me at the moment. As a science teacher I often pick out examples of bad science from the media to engage my class in discussion and debate, and highlight the importance of proper data collection and handling.

    However, my school is currently experiencing a lot of staff absence (which is perfectly expected given the time of year and the fact we have daily contact with 1000 students who are coughing and sneezing their germs all over us). However, a directive from the school assures us that it is nothing a little vitamin C won’t cure, and has procured a supply of high strength pills, at school (and thus taxpayer) expense, for us all to take to prevent colds and even swine flu.

    Far be it from me to point out the problem with this plan, but the fact that my disease prevention plan (having the children sneeze into tissues and wash their hands occasionally) was rubbished as being ‘impractical’ has me particularly riled. I can only hope that there is a placebo benefit from this regimen.

    What is the world coming to when science teachers don’t know a baseless marketing ploy when they see one.

  40. NickInHamburg said,

    November 25, 2009 at 12:36 pm

    A good few years ago now I was suffering a bad cold (no, I don’t think it was the flu) and I tried taking Boots “Vitamin C with Bioflavaniods” … merely because I believed that it would help my body in fighting the cold and might have shortened the suffereing by a little.

    The recommended doseage was 1-a-day, and I took 2.

    I was VERY surprised when within about 15 minutes the symptons all but vanished and I was feeling hugely better … about 2 hours later the effects wore off and I was feeling very rough again … so I took another 2 tablets .. and the symptoms were gone again.

    I would like to point out that I did check the effect of taking such a high dose of Vit-C and over the short term my understanding was that if you take too much Vit-C the biggest effect to worry about is the laxative effect :O) … over the long term there are other problems … but I only had the cold for about a week (I guess it didn’t reduce the actual length of the cold any)

    Unfortunately, the year later Boots were nolonger doing the tablets, and the standard Vit-C without the Bioflavaniods just didn’t work the same, so I was back to suffering along like everyone else.

    Gothgirl, you have it right, a few years ago I was working backstage for a play when I went down with the Flu 2 days before curtain-up and I was the only person who could run the sound-desk … a friend told me that if I felt up to actually doing it, so long as I coughed into a hanky, rather than spreading my joy around ;O), then no-one else would get it … sure enough it was spot on advice … on-one else did get ill.

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