MD, PhD, FMedSci, FSB, FRCP, FRCPEd

According to a recent comment by Dr Larry Dossey, sceptics are afflicted by “randomania,” “statisticalitis,” “coincidentitis,” or “ODD” (Obsessive Debunking Disorder). I thought his opinion was hilariously funny; it shows that this prominent apologist of alternative medicine who claims that he is deeply rooted in the scientific world has, in fact, understood next to nothing about the scientific method. Like all quacks who have run out of rational arguments, he resorts to primitive ad hominem attacks in order to defend his bizarre notions. It also suggests that he could do with a little scepticism himself, perhaps.

In case anyone wonders how the long-obsolete notions of vitalism, which Dossey promotes, not just survive but are becoming again wide-spread, they only need to look into the best-selling books of Dossey and other vitalists. And it is not just lay people, the target audience of such books, who are taken by such nonsense. Health care professionals are by no means immune to these remnants from the prescientific era.

A recent survey is a good case in point. It was aimed at exploring US student pharmacists’ attitudes toward complementary and alternative medicine (CAM) and examine factors shaping students’ attitudes. In total, 887 student pharmacists in 10 U.S. colleges/schools of pharmacy took part. Student pharmacists’ attitudes regarding CAM were quantified using the attitudes toward CAM scale (15 items), attitudes toward specific CAM therapies (13 items), influence of factors (e.g., coursework, personal experience) on attitudes (18 items), and demographic characteristics (15 items).

The results show a mean (±SD) score on the attitudes toward CAM scale of 52.57 ± 7.65 (of a possible 75; higher score indicated more favorable attitudes). There were strong indications that students agreed with the concepts of vitalism. When asked about specific CAMs, many students revealed positive views even on the least plausible and least evidence-based modalities like homeopathy or Reiki.

Unsurprisingly, students agreed that a patient’s health beliefs should be integrated in the patient care process and that knowledge about CAM would be required in future pharmacy practice. Scores on the attitudes toward CAM scale varied by gender, race/ethnicity, type of institution, previous CAM coursework, and previous CAM use. Personal experience, pharmacy education, and family background were important factors shaping students’ attitudes.

The authors concluded: Student pharmacists hold generally favorable views of CAM, and both personal and educational factors shape their views. These results provide insight into factors shaping future pharmacists’ perceptions of CAM. Additional research is needed to examine how attitudes influence future pharmacists’ confidence and willingness to talk to patients about CAM.

I find the overwhelmingly positive views of pharmacists on even over quackery quite troubling. One of the few critical pharmacists shares my worries and commented that this survey on CAM attitudes paints a concerning portrait of American pharmacy students. However, limitations in the survey process may have created biases that could have exaggerated the overall perspective presented. More concerning than the results themselves are the researchers’ interpretation of this data: Critical and negative perspectives on CAM seem to be viewed as problematic, rather than positive examples of good critical thinking.

One lesson from surveys like these is they illustrate the educational goals of CAM proponents. Just like “integrative” medicine that is making its ways into academic hospital settings, CAM education on campus is another tactic that is being used by proponents to shape health professional attitudes and perspectives early in their careers. The objective is obvious: normalize pseudoscience with students, and watch it become embedded into pharmacy practice.

Is this going to change? Unless there is a deliberate and explicit attempt to call out and push back against the degradation of academic and scientific standards created by existing forms of CAM education and “integrative medicine” programs, we should expect to see a growing normalizing of pseudoscience in health professions like pharmacy.

I have criticised pharmacists’ attitude and behaviour towards alternative medicine more often than I care to remember. I even contributed an entire series of articles (around 10; I forgot the precise number) to THE PHARMACEUTICAL JOURNAL in an attempt to stimulate their abilities to think critically about alternative medicine. Pharmacists could certainly do with a high dose of “randomania,” “statisticalitis,” “coincidentitis,” or “ODD” (Obsessive Debunking Disorder). In particular, pharmacists who sell bogus remedies, i.e. virtually all retail pharmacists, need to remember that

  • they are breaking their own ethical code
  • they are putting profit before responsible health care
  • by selling bogus products, they give credibility to quackery
  • they are risking their reputation as professionals who provide evidence-based advice to the public
  • they might seriously endanger the health of many of their customers

In discussions about these issues, pharmacists usually defend themselves and argue that

  • those working in retail chains cannot do anything about this situation; head office decides what is sold on their premises and what not
  • many medicinal products we sell are as bogus as the alternative medicines in question
  • other health care professions are also not perfect, blameless or free of fault and error
  • many pharmacists, particularly those not working in retail, are aware of this lamentable situation but cannot do anything about it
  • retail pharmacists are both shopkeepers and health care professionals and are trying their very best to cope with this difficult dual role
  • we usually appreciate your work and critical comments but, in this case, you are talking nonsense

I do not agree with any of these arguments. Of course, each single individual pharmacist is fairly powerless when it comes to changing the system (but nobody forces anyone to work in a chain that breaks the ethical code of their profession). Yet pharmacists have their professional organisations, and it is up to each individual pharmacist to exert influence, if necessary pressure, via their professional bodies and representatives, such that eventually the system changes. In all this distasteful mess, only one thing seems certain: without a groundswell of opinion from pharmacists, nothing will happen simply because too many pharmacists are doing very nicely with fooling their customers into buying expensive rubbish.

And when eventually something does happen, it will almost certainly be a slow and long process until quackery has been fully expelled from retail pharmacies. My big concern is not so much the slowness of the process but the fact that, currently, I see virtually no groundswell of opinion that might produce anything. For the foreseeable future pharmacists seem to have decided to be content with a role as shopkeepers who do not sufficiently care about healthcare-ethics to change the status quo.

32 Responses to Pharmacists should finally get their act together…or lose credibility

  • I have the same complaint about doctors and hospitals. Even those who contribute to science blogs often fail to do anything in their own professional groups to combat the creeping woo. Where is the annual meeting of Physicians Against Creeping Crap (or whatever catchy name they can come up with)? Blogs are not enough. Professional organizations need to mobilize and work actively to instill good science at every level of training and practice.

  • Dr Ernst is unfortunately correct. For years there has been intermittent discussion on the ethics of selling products that don’t work in community pharmacies and none of the representative bodies appears to want to rock the boat by taking up the challenge in a meaningful way. I’m in favour of revoking product licences for items without evidence of efficacy. Continuing availability of products masquerading as medicines potentially denies the public access to effective treatment, both for minor conditions and through delayed referral for more serious ones.

    • @Cathy

      The RPS is, at least, clear on nonsense like homeopathy, but I’m not sure how that influences individual members.

      I entirely agree that product licences should be revoked if there is no good evidence. However, in the UK, homeopathic authorisations and registrations are embedded in EU Directives and it’s going to be difficult to change that.

      What would help is for the MHRA to finally scrap PLR products. These are 40-year-old anachronisms, allowing sugar pills to make therapeutic claims without a jot of evidence. These products sit on every pharmacist’s shelves. The MHRA said it was minded to scrap these in 2011, but has since retreated from that view – under pressure from the homeopathic industry, I suspect.

  • RPS is professional body but not all pharmacists are members so RPS can only give guidance. MHRA product licences give a perception of respectability and efficacy to products that have one and I could envisage companies using that argument to support stocking these products. Normal requirements for evidence of efficacy for issue of medicinal product licence were lowered for inclusion of homeopathic products I seem to recall from reading the directive a while ago.

    It would be for the General Pharmacuetical Council to decide if a pharmacist was in breach of required professional standards by recommending or selling a homeopathic product, but the fact that they all have product licences suggests to me it would be an interesting discussion.

    I think that you are probably right about the lack of action to revoke licences.

    • Cathy Cooke said:

      RPS is professional body but not all pharmacists are members so RPS can only give guidance.

      Yes, not all pharmacists are members (any idea the percentage?), but that does not stop them giving instructions to their members.

      It’s not so much that efficacy requirements were lowered for homeopathic products – they are completely non-existent!

      There would certainly appear to be no appetite at the GPhC to deal with the problem, but we’re doing what we can to make them take notice…

  • I am a student of pharmacy and I can assure you that here at the University of Sydney we are under no pretense that any kind of pseudoscientific CAM has any place in modern healthcare (with the possible philosophical exception of terminal and palliative cases, but even then…).
    I agree that by providing the ‘option’ of CAM, pharmacists implicitly endorse them, which is why I, and I hope most of my cohort, oppose them. Here it’s made clear to us that these products are not efficacious, and the good lecturers will point out how immoral it is to provide them. Unfortunately, after decades of opposition from the medical community on subjects of how useful we are as a profession and our role in healthcare (I would point out that without pharmacists, the entire medical industry would fall – what can you do without drugs?), combined with the lack of care seen in most patients for what we have to say, pharmacists tend to become weary and disenfranchised, realising it is easier to make money (a lot of money can be made from CAM with very little effort) than to provide evidence based medicine.
    If you seriously ask any decent pharmacist about these products, they will be open about how absolutely absurd they are. No pharmacist in their right mind would stand behind homeopathy or Reiki. I am ashamed that so many of our American cousins felt that way.

    • thank you!
      if it is as you say, why are bogus medicines and gadgets for sale in pharmacies? even Australian pharmacies!

      • Money!
        Sadly, it is always the answer. I was warned by one of my professors that it’s only a matter of time before disillusionment sets in and one realises that trading integrity for money is not so bad after all. Promise I won’t though 🙂
        Another common one I’ve started to hear more recently is the ‘patient choice’ argument, or the idea that patients want it, so it should be provided for them (which is absurd). I’ve even heard it argued that it’s better that someone buy homeopathy or whatever from a pharmacist so they can warn patients about the dangers of the CAM mentality and to ensure it’s only ever used in conjunction with real medicine.
        It’s my opinion that it’s not a treatment choice if it’s not an actual treatment (i.e. all of CAM).
        I heard a nice analogy about this – it’s akin to asking a builder to build you a house, and them offering you the choice of jelly or bricks as materials for the house, purely because they feel people should be given the choice, even if one is ill-advised.

      • I’d also note that the situation here is different to the UK. We have a few different paths to market for a preparation, and our Therapeutic Goods Administration (MHRA/FDA equivalent) does not give AUSTR licensing, the minimum for an actual medicine to be sold, to homeopathics or the rest of CAM. It instead gives AUSTL licences, which are easily obtained (five minutes and one or two forms) and easily revoked, and do not require actual evidence. This might be a purely academic difference, since both systems allow sale in Australia, but it does not necessarily have the same implied support as does other countries’ systems, at least in the eyes of the industry.

  • In response to Alan Henness’s comment, the RPS is quite clear in it’s guidance in Medicines, Ethics and Practice:
    ‘Given the lack of clinical and scientific evidence to support homeopathy, the RPS does not endorse homeopathy as a form of treatment.’

    A pharmacist has a duty to provide up-to-date evidence-based advice to comply with regulatory standards of the GPhC.

    As I noted previously, it is unfortunate that homeopathic preparations have medicinal product licences giving them the appearance of medicinal authenticity.

  • even though the vast majority of readers [even pharmacists] seem to have appreciated this post, it seems to have upset 2 or 3 pharmacists who claim to be on the side of reason – at least they have initiated a rather fierce exchange on twitter over it. sadly I could not persuade them to comment on this blog where, I think, such a discussion belongs – 140 characters are often insufficient to have a meaningful discussion.
    if I understand their comments correctly, they thought I was rude, needlessly insulted an entire profession, “pissed off” people who had been ‘on my side’, and failed to recognise that lots of pharmacists were doing their best to fight woo in their ranks. when I asked them to point out were my post was factually wrong, no answer was provided. so I would like to invite them and anyone else to tell me what exactly my errors were. furthermore, I want to state a few things more clearly than I perhaps did in the above post:
    – I did only mean to implicate those retail pharmacists of quackery who sell homeopathic preparations and other woo pretending they are effective health care.
    – I did assume that this was the vast majority of retail pharmacists [I admit I have no stats except this one: I never went into a pharmacy without being overwhelmed by the woo on sale] but I would be more than happy to learn otherwise provided someone is able to give me hard data.
    – I currently live in France [where the pharmacies are ‘something else’] and did certainly mean my post to be not aimed specifically at the UK but wanted to express a concern of global relevance.
    – I cannot accept that those pharmacists who do not work in retail can entirely wash their hands of this issue: the problem can only exist, if it is being tolerated by pharmacists generally.
    – I am not normally rude and do not want to offend people, but I do sometimes take the liberty to give back in the same coinage as I am given.
    – I fail to see any change at all during the last two decades indicating that the woo in pharmacies is getting less; if anything, my impression is that it is getting worse.

  • Guidance has been issued by the RPS and the PSNI about homeopathy. But it’s just that – guidance. And the regulator of professional standards is deliberately soft-touch to rely on an individual pharmacist’s judgment.

    But here’s the thing. The RPSGB (which was both the RPS and the regulator’s forerunner) did have a vote on this. A motion was tabled in, I believe, 2009, saying pharmacists shouldn’t support homeopathy. The vote failed – almost totally opposed by the local representatives.

    I’ve spoken to pharmacists extensively, and actually the arguments I encounter are different to Prof. Ernst’s. They often include statements along the lines of ‘I know it’s junk but if it makes the patient happy, it can’t be that bad’. Essentially the pharmacist assesses the patient as having a self-limiting, relatively harmless condition, so will sell them sugar pills to keep them sweet. They see this as good patient care. Patient choice is a powerful argument. Not one I subscribe to, but a powerful one. Today customers vote with their feet, and this vote is not on who is right on scientific grounds, but who makes them happy. Of course, you only have to look at antibiotic resistance, caused in part by giving out antibiotics for colds like they’re Smarties, to see the overall fallacy. You create a sense of false faith in junk.

    As an interesting aside, my pharmacy school arranged a series of lecturers by, well, quacks. It sounds like the start of a bad joke: a homeopath, crystal healer, herbalist and acupuncture therapist walk into a pharmacy school.

    Here’s the good bit. The students destroyed them. I remember one particularly fierce exchange when the herbalist proclaimed mint has been used as a cure for thousands of years, and some young, 20-year-old epidemiology fan asked why, then, disease rates only started freefalling in the past 100 years or so.

    I am almost certain that the lecturer who arranged this series (Dr Colin Wright) did so for this very reason. In which case, bravo, sir. A lesson well remembered.

  • I think the problem is that these ‘alternative’ products have been around for so long and, as I keep repeating and don’t apologise for, they have medicinal product licences. This is a barrier to removing them.

    I think we should also recognise the difference between a pharmacist actively promoting a CAM and responding to a question about the use of one with the lack of evidence to support its use. In the UK I would expect the latter scenario to be more common.

    Let us not forget that in the UK a substantial proportion of pharmacies are owned by chains where,nowadays, the pharmacist cannot control what is stocked, whereas in other European countries it is common for pharmacies to be individually owned so that the pharmacist has direct control on items stocked. I would expect to see a difference.

    Chris is right about consumer choice as that’s the approach now rather than paternalism. But it needs to be informed choice and, actually, that’s the advantage of having a pharmacist available to give evidence-based advice. I recall from my community pharmacy days people bringing in all sorts of products purchased from ‘health stores’ to ask my opinion, often sent in by the store staff. Removing products from pharmacies won’t make them go away.

    • I thought all the grandfathered in homeopathics (‘Product Licencing Rules’?) were not being renewed after June 2013 and they would have to apply for proper registration?

      • Joel

        Yes, the MHRA stated that that was what they wanted to do (in January 2011), and encouraged homeopathy manufacturers to move their products to the HR and NR schemes. However, I asked a few months ago about this and was told that this had been dropped. I assume it was pressure from manufacturers: even though the MHRA was minded to allow them to do it for free, it would still cause them a lot of work and I assume they were quite happy making lots of claims that they would not be able to do it they only had an HR registration or even an NR authorisation. See our last newsletter for more details: Obeying the rules – The Nightingale Collaboration

          • Entirely coincidentally (maybe), the MHRA published a new document on their website today: Guidance on the transfer of certain Product Licences of Right (PLRs) to homeopathic marketing authorisations under the National Rules Scheme or to registration certificates under the Simplified Registration Scheme.

            This encourages homeopathy manufacturers to transfer PLR products to either the HR on NR schemes. Unfortunately, they do not give a deadline, but this surely demonstrates that the MHRA wants to finally abolish the 40-year anachronism of PLRs.

            Also unfortunately, the MHRA say they will do this for free (for the time being at least), so that the manufacturers will not have the burden of the usual fees they would have to pay for HR or NR applications.

            In some ways this is good: any PLR products that transfer to the HR scheme will not be allowed indications and will all have to have the following text on the product:

            Homeopathic medicinal product without approved therapeutic indications

            Products that become NR products will be allowed indications if the manufacturer can provide evidence for therapeutic use…no wait! No evidence at all is required: they just have to show that it’s been used for whatever condition by homeopaths in the past. However, this means they are brought under control to some extent and are more tightly controlled in terms of advertising. At least NR products have to carry the wording:

            ‘A homeopathic medicinal product used within the homeopathic tradition for the relief of or treatment of…

            with the list of conditions it can ‘treat’ as permitted by the product’s Public Assessment Report.

            Hardly ideal and unwitting members of the public will still be misled into thinking these homeopathic products are real medicines, but at least a step in the right direction.

            Hopefully, the MHRA will at some time in the future scrap PLRs completely and – again hopefully – many PLR products will finally be consigned to history.

  • Pr Ernst, I live in France too and work in a pharmacy (as a préparatrice), and I agreed with most of your post thinking about France.
    Could you please explicit this : you write “I currently live in France [where the pharmacies are ‘something else’] and did certainly mean my post to be not aimed specifically at the UK but wanted to express a concern of global relevance.”

    What do you mean by ‘something else’ ? That french pharmacies ‘really’ don’t sell bogus treatments (because I think they do) ? That they provide a good advice ?
    As pharmacies are really different in UK, I think I understand what you mean by ‘something else’, still here in France many pharmacies struggle to survive and develop important ‘alternative sales’, like aromatherapy (that I love, but in its form ‘aromatic care’), Fleurs de Bach, expensive alimentary supplements, etc…

    • by “something else”, I meant to express that French pharmacies are proactive on selling unproven treatments. I see this each time I visit one: the pharmacist regularly advises customers to buy this or that remedy for which the evidence is negative; example: a homeopathic treatment to prevent sea-sickness.

  • Thank you for this answer. It confirms my view of french pharmacies : being “proactive” is called “le conseil” (advice), and is essential in french pharmacies (I mean : if you want to work there, you’ better be very good in conseil).

    So, just to keep this straight : the french model, in your view, could be even worse that, say, the UK model ?

    I’m asking that because in France you have the protection of pharmacist’s monopoly (only pharmacists can sell medicines) and to have medications sold in supermarkets is often presented as the end of the pharmacist’s advice (as something bad, of course). Add to that, that most of the time a “préparateur” (like me) is selling medicines (instead of a pharmacist), and you have a completely schizofrenic situation in France, in my point of view.

    I would really appreciate your point of view.

  • My local pharmacy not only sells but advertises some worrying stuff – they have a video advertising screen above the counter, so alongside all the advice on health care, stopping smoking etc you can watch adverts for weight-loss products that remove ‘toxins’ (whatever they are). Makes me very reluctant to ask the pharmacist for real advice – this despite having had thoughtful, careful advice from there in the past – she rang the inhaler manufacturer, then called me back detailing their research findings, couldn’t have been more conscientious – but her bosses are selling this nonsense literally over her head!

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