Evidence-based medicine (EBM) is a tool which enables health care professionals to optimize the chances for patients to be treated according to ethically, legally and medically accepted standards. Many proponents of alternative medicine used to reject the principles of EBM, not least because there is precious little good evidence from reliable clinical trials to support their treatments. In recent years, however, some alternative practitioners have stopped trying to swim against the tide.

They have discreetly changed their tune claiming that they do, in fact, practice EBM. Their argument usually holds that EBM represents much more than just data from clinical trials and that they actually do abide by the rules of EBM when treating their patients. The former claim is correct but the latter is not.

In order to explain why, we ought to first define our terminology. During recent years, several descriptions of EBM have become available. According to David Sackett,  who was part of the McMaster group that coined the term, EBM is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical experience with the best available external clinical evidence from systematic research”. As proposed by Sackett, the practice of  EBM rests on the following three pillars:

  • External Evidence– clinically relevant and reliable research mostly from clinical investigations into the efficacy and safety of therapeutic interventions – in other words clinical trials and systematic reviews. In a previous blog-post, I have elaborated on the question what evidence means.
  • Clinical Expertise– the ability to use clinical skills to identify each patient’s unique health state, diagnosis and risks as well as his/her chances to benefit from the available therapeutic options.
  • Patient Values– the individual preferences, concerns and expectations of the patient which are important in order to meet the patient’s needs.

So, how can a homeopath treating a patient with migraine, a chiropractor manipulating a child with asthma, or an acupuncturist needling a consumer for smoking cessation claim to practice EBM? The best available external evidence shows that neither of these therapies is effective. In fact, it even suggests that these options are ineffective for the above-named indications.

Using the first example of the homeopath, the scenario goes something like this: a homeopath believes in the ability of homeopathy and has the clinical expertise in it (he probably has clinical expertise in nothing else but homeopathy). His patient’s preference is very clearly with homeopathy (otherwise, she would not have consulted him). It follows that the homeopath does embrace two pillars of EBM. As to the third pillar – external evidence – he is adamant that clinical trials cannot do justice to something as holistic, subtle, individualized etc. Therefore he refuses to recognize the trial data as conclusive and rather trusts his experience which might be substantial.

I am sure that this line of arguing can convince some people; it certainly seems to appear compelling to those alternative practitioners who claim to practice EBM. However, I cannot agree with them.

The reason is simple: the practice of EBM must rest on three pillars, and each one of those three pillars is essential; we cannot just pick the ones we happen to like and drop the ones which we find award, we need them all.

We might be generous and grant that the homeopath’s pseudo-EBM argument outlined above suggests that his practice rests on two of the three pillars. However, the third one is absent and has been replaced by a bizarre imitation. To pretend that external evidence can be substituted by something else is erroneous and introduces double standards which are not acceptable – not because this would be against some bloodless principles of nit-picking academics, but because it would not be in the best interest of the patient. And, after all, the primary concern of EBM has to be the patient.

36 Responses to EBM and how it is abused in alternative medicine

  • I’d be interested to read your thoughts on what is asserted by some to be the SCAM equivalent of EBM: Cognition Based Medicine.

  • Professor Ernst surely osteopaths and chiropractors treating low back pain by utilising the treatment approaches recommeded by the NICE guidelines would be considered to be practicing EBM wouln’t they?

    • i did not write about this scenario; i wrote about alt med practitioners like chiropractors treating conditions for which there is no good or even negative evidence.

  • Professor Ernst, the specific examples that you quote are clearly not examples of EBM, I was pointing out however, that this is not universally true, and cases where alt med practitioners practice consistent with EBM can be found. Additionally there are numerous examples, where main stream medicine is practiced in a non-evidence based.

  • Dear professor Ernst, I do not have a problem understanding the gist of your post, and as I said I agree that the exaples that you state are relevant, however you also say:

    “……I am sure that this line of arguing can convince some people; it certainly seems to appear compelling to those alternative practitioners who claim to practice EBM. However, I cannot agree with them.”

    When maybe this only applies to some alternative practitioners who claim to practice EBM and not those working in the way that I have described and I thank you for clarifiying this point in your last post.

    • please do not quote me out of context; i made it perfectly clear from the start that i am writing about SOME and not ALL alt med practitioners:
      “Many proponents of alternative medicine used to reject the principles of EBM, not least because there is precious little good evidence from reliable clinical trials to support their treatments. In recent years, however, some alternative practitioners have stopped trying to swim against the tide.

      They have discretely changed their tune claiming that they do, in fact, practice EBM. Their argument usually holds that EBM represents much more than just data from clinical trials and that they actually do abide by the rules of EBM when treating their patients. The former claim is correct but the latter is not.”

  • Professor Ernst i apologize, because I thought that your post was implying that those alt med practitioners that prcatice EBM were doing so incorrectly when in fact you are in agreement that some do practice EBM correctly. as you pointed out there are some that do not.

  • Edzard Ernst is right to quote the seminal 1996 publication by David Sackett, [now Sir] Muir Gray et al “Evidence based medicine: what it is and what it isn’t”, however (and it suits his argument) he stops short of its full description of EBM by portraying this as 3 categorical “pillars” (a word not used in the 1996 article) comprising clinical expertise, patient’s preference, and external evidence,

    But what the article does go on to say (my capitalisation) is that:

    “Evidence based medicine is not “cookbook” medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients’ choice, it cannot result in slavish, cookbook approaches to individual patient care. External clinical evidence CAN INFORM, BUT CAN NEVER REPLACE, individual clinical expertise, and it is this expertise that decides WHETHER the external evidence applies to the individual patient AT ALL and, if so, how it should be integrated into a clinical decision. Similarly, any external guideline must be integrated with individual clinical expertise in deciding whether and how it matches the patient’s clinical state, predicament, and preferences, and thus WHETHER it should be applied. Clinicians who fear top down cookbooks will find the advocates of evidence based medicine joining them at the barricades.”

    It’s time for certain very senior scientists to re-read “Evidence based medicine: what it is and what it isn’t” in full before they demand the banning of (for example) NHS homeopathy. The 1996 article is conveniently available for all to see at

    I would propose that the categorical “3 pillar” Ernst vision of EBM is an unhelpful and irrational analogy. The totality of evidence (ie clinical expertise, patient’s preference and external evidence) needs to be looked at as a single entity, not 3, pillars, What matters is the effectiveness of the treatment supported by this pillar – does it work for the patient as it is integrated into his or her healthcare?

    John Cook

    • If alt med practitioners had undergone rigorous medical training and practice then I might be able to understand your point. Clinical expertise in this context means clinical medical expertise, it does not mean experience gained by treating patients using unproven and/or disproved techniques by a non-medical practitioner.

      Knowledge is justified true belief; one element of the justification component is a willingness to discard the belief if new evidence results in the truth component becoming false. Knowledge is the foundation stone of science: it enables science to be self-correcting and it enables knowledge to be built on top of existing knowledge in a trustworthy manner.

      Belief without truth, and without the element of justification mentioned above, is blind faith.

      It’s time for all alt med advocates to learn the difference between knowledge and blind faith.

      • Yes, you make a good point about medical practitioners who use complementary medicine having gone through rigorous medical training. Members of the Faculty of Homeopathy (whose members comprise qualified vets, doctors, dentists, podiatrists and other statutorily regulated healthcare professionals) do indeed so practise homeopathy, including NHS homeopathy, integrating homeopathic treatment into patients’ healthcare.

        • i am not sure what you are trying to say. is your point that it’s ok to use unproven treatments, make bogus claims etc., as long as one is regulated by statute?

          • I’ve looked hard at my comments and can’t find any evidence (RCT or otherwise!) I’ve said any of those things. I know this is your very own blog Edzard Ernst which gives you some poetic licence I suppose but …

          • JC: you looked so hard that you over-looked the question mark.

        • The Faculty of Homeopathy homepage states: “The Faculty of Homeopathy founded in 1844 provides internationally recognised training pathways in homeopathy for vets, doctors, dentists, podiatrists and other statutorily regulated healthcare professionals…. Members state homeopathy has increased their ability to care for their patients and broadened their knowledge of medicine and health.”

          No, its training has diluted the members’ knowledge of medicine and health, sometimes to the point of containing no active ingredient.

          I agree with the Chief Medical Officer that homeopathy is rubbish.

          Knowing that some vets still use homeopathy in animal husbandry makes me seriously question the quality of food for sale in the UK. This practice is absurd.

          John, I apologize for not being able to understand from your comment whether you are a supporter of homeopathy (and other alt med) or you think it’s time to lay it to rest.

    • The question “does it work for the patient” is a trick question here. Something does not “work” just because an individual patient happens to get better, because some patients just do get better even if they are “treated” (while being relieved of their money and a proper understanding of their condition specifically and of health generally) and, also, even if they are not. Similarly, sometimes the most effective treatment doesn’t “work.” Hence the need for evidence. This means ALL the evidence. For example, in the case of homeopathy, clinical studies do not show the results expected of an effective treatment. Worse, every dose-response curve ever constructed dramatically disconfirms the dilution premise of homeopathy which was never based on any evidence – or was even plausible – in the first place.

  • A parallel to what Professor Ernst so nicely describes here with respect to some forms of alt med has also occurred within some movements of professional psychology. Many practicing psychologists have been ambivalent (if not overtly hostile) toward scientifically-informed practice. They initially rejected evidence-based practice (EBP) as “paint-by-numbers” practice. But sensing that the movement was happening anyway, they decided to declare that they, too, practiced EBP. They did this by emphasizing clinical experience, and using that to trump scientific evidence (e.g., RCTs) with which they disagreed. In this way, psychoanalytic psychotherapy — to name just one example — could continue to be practiced for conditions for which there was no scientific evidence that it worked, and where there exists ample evidence for other interventions (e.g., cognitive behavior therapies, medications). They simply declare that their experience reveals its benefits; case closed. Even if we grant their sincerity, this approach completely misses the point of controlled clinical trials. Human cognition is subject to all manner of biases (e.g., the confirmation bias) that all but guarantees that we see what we want to see when we look at things non-systematically. So, the three pillars of EBP/EBM are not exactly equal. Scientific practice dictates that the best available scientific evidence is foundational. Clinician expertise involves how to apply that evidence in the individual case. It is not a get out of jail free card, allowing the practitioner to ignore scientific evidence in favor of uncontrolled anecdotal observations dressed up as “clinical experience.”

  • Evidence Based Medicine comes across, not just to me, as a 1990s fad, to some extent, that covers, at least in parts, what most sensible professionals would do anyway, not just in medicine. Besides, the principle of EBM goes back to the 19th Century, at least, from what I have read, so it is hardly new.

    For some reason, software engineers became rather intrigued by the EBM idea and endeavoured to apply it to some of their work, particularly the software and hardware connection between the pilot of an aircraft and the control surfaces engines, etc, of that aircraft. They failed, abysmally, but no aircraft were grounded as a result. I am not sure that such an approach can be fitted to software anyway; it is difficult to see how RCTs can be applied in that field. Much the same goes for engineering in general; how many Boeing 787 Dreamliners would be damaged or destroyed in RCTs and at what cost. That aircraft seriously stretches one of the principles of good engineering, which is to make only small changes at once and to leave a route of retreat in case there are problems, which is not easy in fields of endeavour such as aviation. The recent “fixes” for the battery fire problem are on a “best engineering judgement” basis from what I have read, which followed admissions that Boeing and the U.S. aviation authorities might never know what the actual cause of the battery fires was in the first place.

    From what I have researched about engineering and the evidence based approach, so far, it looks like ordinary engineering with the usual approach we take slightly adapted to fit the EBM structure, though engineering is far more pragmatic, as good medicine, is, or should be.

    Having an interest and sometime involvement with non-mainstream approaches to health, plus a few decades in the engineering profession, which includes a great deal of science, by default, I, long ago concluded that engineering pragmatism, as well as that of the technologies in general, is preferable to the “science and nothing else”, or even heavily science biased, approach by far. It makes more sense as the world as we find ourselves in is closer to technology than science and the way we have modified that world, constructed within it, definitely is; the technologies being arts that use science, not sciences in themselves. Also, the technologies have a far longer history, experience to go with that, and are more society oriented; “Engineer in Society” requirement is compulsory for a CEng, on top of a Masters Degree, or higher, let alone the experience, and science qualifications seem well short of an equivalent, though many commentators on CAM, as well as other matters, do not even seem to be able to manage the basics are far as science is concerned, let alone any extras.

    As far as health and medicine and health, generally, are concerned, I prefer Brian Haynes’ approach, probably because that too, is pragmatic, in addition to being well argued; “What kind of evidence is it that Evidence-Based Medicine advocates want health care providers to pay attention to? ( For example in the first paragraph:

    “Background: Evidence-Based Medicine (EBM) is based on the notion that clinicians, if they are to provide, and continue to provide, and continue to provide optimal care for their patients, need to know enough about applied research principles to detect studies published in the medical literature that are both scientifically strong and ready for clinical application. This opportunity for continuing to improve the quality of medical care stems from the huge ongoing public and private investment in biomedical and health research.

    The challenges in applying new knowledge, however, are considerable and EBM does not address them all.”

    I am well aware of applied research principles, in general, and, while having to be more careful when moving from my particular field to health matters, as far as applying EBM to matters in the so-labelled Complementary and Alternative Medicine field is concerned, there are certain types of experiments that are suspect, as well as at least one type that comes to mind which is a waste of time and effort, because the people involved in conducting them had between little idea and no idea, of what they were dealing with, at least potentially, or were completely lacking in knowledge in that field, certainly in terms of what actually underlies the process as to what they suppose underlies it.

    Part of the problem with such approaches as EMB and its non-medicine equivalents, is the vast amount of knowledge and experience required to properly assess the validity of the “evidence”, plus the time and effort consumed in doing so; hence the views of people like Dr Mahesh Jain ( I can empathise with that point of view as the constraints of time and funds on engineers determine how far we can go in terms of information gathering and assessment thereof, hence, frequently, if, in our view, something works, then it does, even if the science has not been done by then.

    On the other hand, as an article in “Cardio Brief” ( points out, quoting wordage from a Boston Globe article, “evidence based medicine is only as strong as the evidence that supports it. The stark reality is that evidence can be weak, biased, or even fraudulent.”

    In my profession we have trusted sources of information, many of which have been used on the basis of reputation in an appropriate field, peer recommendation, industry requirement and so on. The judgment on the trustworthiness of evidence is down to those with knowledge and experience of the field in question. That, in a sense, takes evidential, or whatever other approach is used, “back to square one”, as with any other field of knowledge or endeavour, only those with the requisite knowledge and experience are qualified to make judgements, which, as far as CAM and science, CAM and EBM, are concerned, rules out most of the usual commentators on such matters, though many seem to have a poor grasp of science, never mind CAM, and let alone both combined. There are faults, failings, anomalies in the CAM field, as there are in others, though not usually in quite the ways mainstreamers suppose they are, if at all.

    There is certainly a bias against CAM as there is against anything that is into “mainstream”, which, essentially, amounts to a situation that anything outside the knowledge, understanding, or comprehension, of scientistic materialists is not possible, implausible, rests on pseudoscience, magic, or something else. Hence, my delight, somewhat later in life, that I not only went past just science and on into engineering but even past that, though, no doubt, I am limited in some lifetime, or other.

    Equally, I have no illusions about the vein in which certain people will come back on this comment. I am already well aware that they “know” more and are bound to “right” in their views, opinions, “knowledge” than anyone who has a contrary view to theirs.

    • EBM must appear like a fad to all those who understand little about medicine and even less about science. they usually prefer intuition-based medicine or dogma-based medicine of the dark ages. health care has only started to make progress in the interest of patients when this line of thinking was abandonned about 150 years ago.

    • Richard, the article I’ve linked to is not intended as an insult — I wish I’d been aware of its salient points throughout my previous career in engineering.

  • Richard, I think you misunderstand the position of those who subscribe to EBM. It is not a matter of viewpoints and opinions. It is a matter of what the evidence says. Now I am not one of those who believes that only RCTs can be included as evidence. A broader interpretation is increasingly accepted these days. But that does not mean that RCTs can be discarded in favour of other evidence. Essentially the RCT tells us whether there is likely to be a genuine specific effect of a treatment. Whether that effect matters to the patient is another question, which might be answered by other types of evidence. The problem with most CAM is that RCTs almost always fail to detect any specific effect of the treatment. Hence, invoking other evidence is meaningless in such cases, as we have no effect whose clinical significance we can test. CAM supporters of course love to forget this principle, and rely on types of evidence that were never intended to test for specific effects.

    I have really re-stated Edzard’s post above, but I hope I have boiled it down to something helpful for you.

  • On submitting my post on 28th April I (like Richard King CEng) had no illusions about the vein in which certain people would come back), I would like to suggest:

    1. No more pillar talk, Lets look at the totality of evidence.

    2. No more hot air about evidence type A “trumping” evidence type B.

    3. No more statements like “homeopathy is rubbish”, “bogus claims etc”.

    4. Please re-read in full “Evidence based medicine: what it is and what it isn’t”, by David Sackett, [now Sir] Muir Gray et al at

    5. In the context of EBM and complementary medicine (in particular homeopathy) I suggest, as a good follow-up, reading the 2012 Doctoral Dissertation by James Andrew Turner “Evidence-based medicine, “placebos” and the homeopathy controversy” freely downloadable from

    6. Finally, I’ve been asked [naively? disingenuously?] in a posting if I think it’s time to lay homeopathy to rest. No I don’t.

    • I eagerly await to read the responses you get from writing to Professor Dame Sally Davies, the chief medical officer and Jeremy Hunt, the Health Secretary.

      If you convince them that homeopathy is efficacious then I sincerely hope that you would be willing to cure my debilitating chronic illness.

      Hey, I’d be an ideal test case for providing some evidence to convince them! My local outpatients clinic would be delighted to use the services of an effective practitioner.

      • Pete 628 said:

        I eagerly await to read the responses you get from writing to Professor Dame Sally Davies, the chief medical officer and Jeremy Hunt, the Health Secretary.

        That’s already been tried…

        First by farmer and homeopathy user Oliver Dowding: Reply to Professor Dame Sally Davies who says ‘Homeopathy is Rubbish’

        He got no reply, of course.

        And also by homeopath Lionel Milgrom to both Professor Dame Sally Davies (and her reply, but no reply, it seems, to his follow-up email) and to Hunt (who doesn’t seem to have replied): Scientist Dr. Lionel Milgrom Replies to Professor Dame Sally Davies

        Well worth reading to gain an understanding of the inner workings of the homeopathic mind and to see how science appears to be completely alien.

        • thank you for posting these links – they are well worth reading!

        • Thanks, Alan — very interesting links and I agree with your conclusion. In Carl Sagan’s book The Demon-Haunted World : Science as a Candle in the Dark (1995) he wrote

          “I worry that, especially as the Millennium edges nearer, pseudo-science and superstition will seem year by year more tempting, the siren song of unreason more sonorous and attractive.”

          The full quote is worth reading; it can be found by searching this webpage:

      • I’m sorry to hear about your debilitating chronic illness. If you wished to see a qualified medical doctor specialising in integrating homeopathy into healthcare, the website of the British Homeopathic Association, in addition to sections on research and NHS availability, has a search aid for Faculty of Homeopathy practitioners by post code – see

        • a bit of free advertising? it might not be all that effective on this particular blog.

        • John, I sincerely appreciate your reply. During the last three (coming up to four) decades I have seen a plethora of: MDs, NHS specialists in my condition, qualified medical doctors specialising in integrating CAM into healthcare, and sCAM practitioners. Note: I am not using sCAM as a derogatory term; I have tried many nutritional supplements and have paid for treatments with so many CAM practitioners that I’ve forgotten most of their names.

          My condition was in the top ten list of ailments that were claimed to be easily treatable by sCAM practitioners and many psychotherapists before the ASA clamped down on it. The ASA, Trading Standards, and the CMO haven’t clamped down on sCAM because a few skeptics have made a lot of noise, they have clamped down because the treatments have failed, abysmally, to work as claimed/advertised. Furthermore, many patients suffer serious financial difficulty down the line after being categorically told, during the initial (paid for) session, that the practitioner has a history of treating the illness — sCAM practitioners can/do produce a wad of client testimonials as evidence for efficacy. Desperate clients are obviously hooked during this first contact with the practitioner, which is why the ASA has a subset of codes that specifically address the advertising of services to vulnerable groups in society.

          Those who are pushing for sCAM to be funded by the NHS are seemingly very kind and supportive in their effort to alleviate patients from a financial burden that varies from uncomfortable to totally unaffordable. I would wholeheartedly support this effort if I could see robust evidence for efficacy. Overall, this gesture isn’t being kind and supportive; it is highly manipulative — cherry-picking trial data in order to gain funding for the sCAM industry. Yes, sCAM is first and foremost a multimillion pound/dollar industry that uses every trick in the book in order to protect itself from scientific scrutiny and increase its profits (business acumen 101).

          Since 1796 homeopathy has totally failed to produce both a plausible scientific hypothesis and the robust evidence for efficacy that is very reasonably required by the ASA. Its proponents refuse to subject themselves to even the minimal level of scientific scrutiny and critical thinking skills, indeed, the proponents keep crying out for the creation of alternative science to justify their trade.

          I assume sCAM proponents are also hoping to live in a world that uses their alternative science in the design and maintenance of such things as: aircraft, automobiles, bridges, nuclear power stations, the LHC, the Mars Rover, space telescopes, and the ultimate consumer device that demonstrates the difference between quantum quackery and solid scientific knowledge: the digital camera.

          I have yet to meet any proponent of sCAM who could can begin to explain how their camera actually works (film or digital). However, the many practitioners I’ve encountered have all explained to me, in-depth, the “Tooth fairy science” underlying their remedies/treatments. Harriet Hall, MD coined this very apt phrase:

          I would provide evidence to support what I’ve written, but for some unfathomable reason, my sCAM practitioners have not kept my records nor have they reported my negative outcomes to their regulators.

          • thank you for what i consider a most important contribution and perspective to this blog.

          • Dear Pete 628 I am sorry to hear now that your debilitating chronic illness has been with you for 30-40 years. I have also had the opportunity since my last posting to read some of your other contributions c/o Edzard Ernst’s blog, in particular that at your last visit to a homeopathic practitioner – “I didn’t take any of the remedies I was given on each monthly visit (for 10 months) yet was told categorically by the homeopath which previous remedy was causing my current symptoms!”

            It’s not clear whether or not Pete 628’s homeopathic encounters have been with qualified medical doctors (members of the Faculty of Homeopathy) or whether these are the CAM practitioners whose names he’s ‘forgotten’. And there goes that word ‘categorically’ again. See my ‘posts’ above about ‘pillars’.
            The important point though is that Pete 628 still has a debilitating chronic illness 4 decades later which unfortunately it seems has not been “cured” by “mainstream”, “CAM”, or “sCAM” (the last of which I take to mean “supplements and complementary and alternative medicine” in a “non derogatory” sense). The medical practice of integrative homeopathy does not offer panaceas but many with chronic illnesses have found themselves helped by homeopathy and the totality of evidence supports this (no “trumping” please”). I can’t drag Pete 628 to see a medically qualified homeopath and it may be even if I did, his predisposition to treat healthcare consultations as controlled trials (not exactly randomised and not exactly blinded but there we are) would stand in the way of his being helped. However maybe not – many of homeopathy’s most ardent supporters started off as homeopathy’s most sceptical opponents.

            I’m grateful to Edzard Ernst for not moderating out my ‘free advertising’ of the British Homeopathic Association. Whether or not this advertising is ‘effective’, it is good value! The post code search aid for medically qualified practitioners remains available to Pete 628 and others.

            There is no fundamental or rational conflict between support of medical homeopathy and a quest for better healthcare. Our comprehensive National Health Service (and medicine in general) is about adding years to life and life to years. Homeopathy helps with that and at the same time let’s boldly go with Carl Sagan in the pursuit of knowledge.

          • don’t you find it a bit tasteless to continue advertising quackery in the face of pete’s story?

  • The ability of CAM advocates to cherry pick their definitions is as pervasive as their selection of evidence. Their rhetorical arguments in the comments above are only necessary because of the very lack of quality evidence in support of their interventions.

    We have to accept that the CAM community will wrongly appropriate any scientific concept either through ignorance or as a marketing gimmick. This makes Ernst’s clear and careful explanations of the correct definition of EBM extremely valuable.

  • There is issue of the mainstream medics with proper medical education who are using “alternative” methods together with the evidence based ones. Even if they have made information about it public, their patients usually apply to them with the hope to be treated and not treated by any specific method. These medics have clinical skills and expertise, most likely their expertise in the conventional medicine is much higher that in the “alternative”, but nevertheless they are also using alternative methods. Take a thing called osteoreflexotherapy (I suppose it should be called intraosseal stimulation) which is still very popular in my country. It was invented 1956, but became really popular in 1956. One might think that injecting NaCl solution in the bones sound scientific, however list of indications clearly do not, because it is applied for very broad range of conditions everything from lower back pains to myopia to psoriasis to alcohol abuse. So patient with no access to the internet comes to the doctor to treat his diabetic foot. He does not care how. Maybe his endocrinologist and/or GP had told him to lose weight, but he failed, and now real (apparently) doctor suggests that he should try Osteoreflexotherapy which is recommended as monotherapy. Hopefully patient will not drop his diabetes meds (but he may), lose some weight (unlikely) and find good shoemaker (not an easy task), and the procedures will not end in massive infection and amputation, however bad things may happen, and just because patient who does not need to know about EBM, is subjected to the system where regulators believe that doctor will make his best judgement (Yes, the doctor who had come to the conclusion that diabetic foot can be treated by injection NaCl in the bones).

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