MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Recently, I was invited to give a lecture about homeopathy for a large gathering of general practitioners (GPs). In the coffee break after my talk, I found myself chatting to a very friendly GP who explained: “I entirely agree with you that homeopathic remedies are pure placebos, but I nevertheless prescribe them regularly.” “Why would anyone do that?” I asked him. His answer was as frank as it was revealing.

Some of his patients, he explained, have symptoms for which he has tried every treatment possible without success. They typically have already seen every specialist in the book but none could help either. Alternatively they are patients who have nothing wrong with them but regularly consult him for trivial or self-limiting problems.

In either case, the patients come with the expectation of getting a prescription for some sort of medicine. The GP knows that it would be a hassle and most likely a waste of time to try and dissuade them. His waiting room is full, and he is facing the following choice:

  1. to spend valuable 15 minutes or so explaining why he should not prescribe any medication at all, or
  2. to write a prescription for a homeopathic placebo and get the consultation over with in two minutes.

Option number 1 would render the patient unhappy or even angry, and chances are that she would promptly see some irresponsible charlatan who puts her ‘through the mill’ at great expense and considerable risk. Option number 2 would free the GP quickly to help those patients who can be helped, make the patient happy, preserve a good therapeutic relationship between GP and the patient, save the GP’s nerves, let the patient benefit from a potentially powerful placebo-effect, and be furthermore safe as well as cheap.

I was not going to be beaten that easily though. “Basically” I told him “you are using homeopathy to quickly get rid of ‘heart sink’ patients!”

He agreed.

“And you find this alright?”

“No, but do you know a better solution?”

I explained that, by behaving in this way, the GP degrades himself to the level of a charlatan. “No”, he said “I am saving my patients from the many really dangerous charlatans that are out there.”

I explained that some of these patients might suffer from a serious condition which he had been able to diagnose. He countered that this has so far never happened because he is a well-trained and thorough physician.

I explained that his actions are ethically questionable. He laughed and said that, in his view, it was much more ethical to use his time and skills to the best advantage of those who truly need them. In his view, the more important ethical issue over-rides the relatively minor one.

I explained that, by implying that homeopathy is an effective treatment, he is perpetuating a myth which stands in the way of progress. He laughed again and answered that his foremost duty as a GP is not to generate progress on a theoretical level but to provide practical help for the maximum number of patients.

I explained that there cannot be many patients for whom no treatment existed that would be more helpful than a placebo, even if it only worked symptomatically. He looked at me with a pitiful smile and said my remark merely shows how long I am out of clinical medicine.

I explained that doctors as well as patients have to stop that awfully counter-productive culture of relying on prescriptions or ‘magic bullets’ for every ill. We must all learn that, in many cases, it is better to do nothing or rely on life-style changes; and we must get that message across to the public. He agreed, at least partly, but claimed this would require more that the 10 minutes he is allowed for each patient.

I explained….. well, actually, at this point, I had run out of arguments and was quite pleased when someone else started talking to me and this conversation had thus been terminated.

Since that day, I am wondering what other arguments exist. I would be delighted, if my readers could help me out.

34 Responses to Homeopathy as the treatment of choice for ‘heart sink’ patients?

  • It is not clear to me why I would want to seek the advice of a doctor knowing that they had maybe lied to the patient in front of me. Trust in what they have to say appears to me to be fundamental. If limited things can be done, I want to be told.

    When we have a medical profession that feels it can blithely mislead depending on the length of the queue in their waiting room, then it is no wonder the parents of that poor child with cancer feel their best bet is to flee to those who make false promises of miraculous or revolutionary cures.

  • I was going to write a long analysis of this guy’s comments, but in the end it boils down to this: he’s an overconfident (claims to never miss a trick) and arrogant (doctor always knows best) piece of (insert rude word here) of the sort that still infest many professions, including medicine.

    They kill patients with carelessness and cause far more distress than they relieve. Nurses despise them.

  • Sometimes ethics can be difficult particularly when it comes to what a practitioner believes based of their interpretation of the available evidence. As a case in point. I was traveling with a physician who was very excited about the acupuncture course she was taking. She will be treating patients who do not respond to other forms of treatment in her clinic once she is “certified. She has accepted the teaching of her instructor. She is further convinced because she had a long needle inserted into her leg and her tendonitis improved. From her point of view there is no problem with offering acupuncture.

    From my point of view acupuncture is actually a theatrical placebo. I have Dr. Novella and his group of bloggers and people like yourself an Simon Singh to thank for this perspective. However, when treating patients it would be unethical for me to use acupuncture as if it were something other than a placebo. To not tell that patient would for me be a violation of informed consent. I thus lose one modality of stimulating placebo effects. The deluded practitioner has no such problem.

    In the past my father who was a GP would sometimes resort to Vit B12 injections. He said that it might make a patient feel better and was not likely to do harm. That seems like the use of a placebo not unlike using homeopathy but does not appeal to invoking pseudoscience. We are not in a culture where patients with problems expect interventions. Doing the right thing ignores media driven expectations. Perhaps we should revisit the ethical limitations of the current standards for using placebos. That way we could help patients who would benefit from a dose of “Placebocin Forte” and be there for them if they need something more.

    I have found talking to CAM believers like talking to the wall. I will keep trying, especially socially, but for now there is another patient waiting.

  • Assuming that GPs who prescribe homeopathic remedies regularly to patients are in a tiny minority, I’d like to know what strategies the majority of GPs use when faced with heart sink patients. Surely they have a tried and tested solution?

    Meanwhile, could some sort of inadequacy be at the root of the problem with those GPs who resort to prescribing homeopathic remedies when a patient’s condition becomes too difficult for them to deal with?

    For example, it would appear that a close friend of Prince Charles, Dr Michael Dixon (OBE), was propelled towards the dubious placebo offerings of ‘integrated’ medicine when he found himself unable to cope with heart sink patients. Indeed, he admits that he uses it “for purely selfish reasons”:

    QUOTE
    “I got into the integrated approach for purely selfish reasons. I used to dread appointments with patients with conditions from back pain to allergies, where modern medicine has little to offer.”
    Ref: http://tinyurl.com/cpc5c5f

    It’s also interesting to note that Dr Dixon’s ‘College of Medicine’ colleague, Dr Peter Fisher (official homeopath to Her Majesty Queen Elizabeth II), confessed that it was “plain ambition” that got him into homeopathy. See between 6.20 mins and 9.08 mins in the following link. It shows him looking very uncomfortable during a tough interview with Prof. Richard Dawkins:
    http://www.youtube.com/watch?v=E0-NalmRSl8

    I wonder why the physicians in the two examples above aren’t recommending coping strategies (e.g. via explanatory leaflets or charitable groups) for their heart sink patients? After all, the UK General Medical Council demands that its members “must provide effective treatments based on the best available evidence”. IMO, that requirement doesn’t leave any room for a GP to prescribe a placebo/quack nostrum…

    QUOTE
    “…there is no such thing as a placebo responder (someone who always benefits from placebo) and a placebo non-responder (someone who never benefits from it). This unreliability makes it problematic to count on placebo effects in clinical practice.”
    Ref: http://web.archive.org/web/20100103080345/http:/www.arc.org.uk/news/arthritistoday/131_1.asp

  • You could have gone all Freudian ( the GP has repressed his anger at the patients who won’t take responsibility and demand that the GP cures them without any effort on their part, but he gives them treatment knowing it won’t work) but accusing someone of that doesn’t help.
    As a real question, how many heartsink patients does a typical GP see? This might be more common than anyone expects and I suspect that at least some of the GPs who see heartsink patients who don’t prescribe homeopathically, prescribe antidepressants. Not that I am justifying homeopathy, but …

  • Some of his patients, he explained, have symptoms for which he has tried every treatment possible without success.

    TEETH

    I explained that, by implying that homeopathy is an effective treatment, he is perpetuating a myth which stands in the way of progress.

    The fact that the patient is currently suffering from a condition for which there is no effective treatment doesn’t mean that this will always be the case. By endorsing homoeopathy he’s increasing the risk that the next time the patient is ill they will see a homoeopath rather than a doctor, and potentially miss out on timely diagnosis and effective treatment.

  • A clear case of treating the doctor, not the patient. The old adage of “just do do something-sit there!” seems anathema to this individual practitioner. Medicine is not always easy or clear cut, especially in general practice, but taking the easy way out and consciously lying to patients is a lazy and narcissistic way to practice.

  • Here’s an interesting case to compare the GP’s behaviour with: a fourteen-year-old girl goes to see her GP. Her problem: all her friends have bigger breasts and hers “won’t grow”. She feels insecure and is sometimes bullied. The GP comforts her, says there’s a solution and prescribes her a “brand new medicine which has just become available”. He takes ten pills from a glass jar on his desk, tells her to take one each day after breakfast and sends her home. The girl tries the pills and is quite enthusiastic: they taste great, there are no side-effects and boy, she sure feels her breasts are getting bigger!

    So what did the GP prescribe her?

    Breath mints.

    Sure, it’s a fictional story. It’s from “Dokter Tinus”, the Dutch version of “Doc Martin”. Still, I see many parallels. What the good doctor did, is give the girls placebos, just like the GP in your true story did. Of course the pills don’t make her breasts grow, but they do make her feel better and more confident. If giving patients homeopathic pills is ethically acceptable, then giving them breath mints disguised as revolutionary new remedies should be acceptable too. But in my view, a doctor who shies away from trying to convince his patients that they do not need any pills but should see a psychologist instead (for instance) is not a very good doctor.

  • “…chances are that she would promptly see some irresponsible charlatan who puts her ‘through the mill’ at great expense and considerable risk.”

    Yes, he did her a big favor. She remains under the care of a “responsible” charlatan.

    He also saved her from being put “through the mill” at great expense and considerable risk like the rest of his patients are. Indeed! Medical errors, bloopers and goof-ups are, after all, one of the leading causes of death each year here in the U.S. (400,000 – 800,000+ depending on who you believe) and likely in the U.K. as well. Not to mention the biggest expense at almost 3 trillion US dollars beating out The Pentagon/defense which is a mere 1.9 trillion dollars.

    EE, you should have thanked him!

  • Andy even tries to somehow link Ashya King to this blog post when the facts of this case have nothing whatsoever to do with homeopathy or CAM.

  • “But in my view, a doctor who shies away from trying to convince his patients that they do not need any pills but should see a psychologist instead (for instance) is not a very good doctor.”

    You may not need to say to go see a psy. You may just need to say “it will be okay, you are doing just fine”. With this point of view you are treating patient like kids that cannot handle themself alone (well in your exemple it’s a kid, but i will never bring my kid to a doctor because she don’t have enough breast… I will do the psy ! but with adult you can’t treat them like that). Accepting to give homeopathic pills as a GP to patient is breaking years of science and evidence, propagating myth and then give bad knowledge to people. It’s also dangerous because of the reasons evoked by Mojo.

  • Although I essentially disagree with the GP, I do sympathise with his position. Might we also extend this reasoning to the prescription of anti-depressants in (at least) mild to moderate depression (95% of depression cases), or any other psychiatric drug that purports to target an unproven and unlikely ‘chemical imbalance’?

    • No we might not.
      Comparing the prescription of a known, medicinally defined and prepared substance for an (at the time) established indication according to current knowledge and therapy recommendations cannot be compared to the prescription of a demonstrably and undoubtedly ineffective substance under the pretence of therapy.
      If I am not mistaken the question of SSRI’s effect clinical has not been concluded and it is likely that indications will remain albeit less wide ranging.
      That the said class of medicines may be proven less effective or even ineffective has nothing to do with the concept of using placebo outside consented clinical trials.
      Prescribing a placebo in this way involves dishonesty towards the patient. This can never be excused and can lead to deleterious consequences.
      It is not as difficult or time consuming as many think, to sit down with a patient and honestly explain that there are no treatment options left that you know of. You always have the option of helping the patient get a second opinion and you will both preserve your own dignity and your patients trust. Deceit will sooner or later lead to tragedy.

  • “When we have a medical profession that feels it can blithely mislead depending on the length of the queue in their waiting room, then it is no wonder the parents of that poor child with cancer feel their best bet is to flee to those who make false promises of miraculous or revolutionary cures.”

    “e’s an overconfident (claims to never miss a trick) and arrogant (doctor always knows best) piece of (insert rude word here) of the sort that still infest many professions, including medicine.

    They kill patients with carelessness and cause far more distress than they relieve. Nurses despise them.”

    “Meanwhile, could some sort of inadequacy be at the root of the problem with those GPs who resort to prescribing homeopathic remedies when a patient’s condition becomes too difficult for them to deal with?”

    “By endorsing homoeopathy he’s increasing the risk that the next time the patient is ill they will see a homoeopath rather than a doctor, and potentially miss out on timely diagnosis and effective treatment.”

    “A clear case of treating the doctor, not the patient. The old adage of “just do do something-sit there!” seems anathema to this individual practitioner. Medicine is not always easy or clear cut, especially in general practice, but taking the easy way out and consciously lying to patients is a lazy and narcissistic way to practice.”

    “But in my view, a doctor who shies away from trying to convince his patients that they do not need any pills but should see a psychologist instead (for instance) is not a very good doctor.”

    All the above comments just show what an arrogant, ignorant completely naive bunch of “experts” we have reading and commenting on this blog. I’m sure they would make much better doctors. Prof Ernst I really enjoyed reading that and thought it was one of your best. No bias, reasonable arguments from two points of view. More like it please.

  • Arrogant. “having or revealing an exaggerated sense of one’s own importance or abilities” I am not the one who feels they can criticise the working practice of the GP you spoke to. A very qualified medically trained individual. To question his working practice without having his level of qualifications or experience is definitely showing ones exaggerated sense of importance.

    Ignorant. “lacking knowledge or awareness in general” again questioning the work of a GP if you are not a GP shows you lack knowledge. I’m not talking about EBM but patient care and management.

    Naive. “showing a lack of experience, wisdom, or judgement.” See the two above.

  • Thanks Björn Geir, but I’m not convinced by this.

    Yes, anti-depressants are ‘known’, ‘medicinally defined’ and ‘prepared’ substances for an ‘established indication’, but so is homeopathy (I’m as critical of the British National Formulary on this issue as I’m am any homeopathic manual). And when you talk about ‘according to current knowledge’ and ‘therapy recommendations’, it is worth stating that current scientific knowledge has found no evidence (as far as I’m aware) of the serotonin (or any other biochemical) basis of depression, yet these medicines are marketed and prescribed as if there is (or will be). In fact current scientific knowledge undermines a simple serotonin model of depression, and stacks up in favour of these medications acting as an active placebo. When Kirsch et al. published their defining meta-analysis of anti-depressants in 2008, survey data suggested that almost half of GPs were reconsidering their prescribing practices (http://tinyurl.com/q9btsnu), yet anti-depressant prescribing continues to rise year on year. This suggests that many GPs continue to prescribe antidepressants under the ‘pretence of therapy’, even though they know the evidence-base doesn’t support this. More so, they are prescribing active medications with known side-effect profiles, whereas at least homeopathic remedies are empty. I may be wrong that the anti-depressant deception seems more harmful than the homeopathic deception (in the treatment of depression), but not for any of the arguments I’ve read here.

    Thanks for your time.

    • @Adzcliff

      anti-depressants are ‘known’, ‘medicinally defined’ and ‘prepared’ substances for an ‘established indication’, but so is homeopathy

      Bollocks! Homeopathic remedies do not contain ‘known’, ‘medicinally defined’ and ‘prepared’ substances for an ‘established indication’ As you well know, they contain nothing but wishful thinking embedded in sugar or shaken water.
      Homeopaths have not, for centuries, acted on current information and stopped prescribing remedies that are demonstrably empty.
      As far as SSRI’s I have been led to understand, they are not altogether useless but the indications are probably not as wide as previously believed. I may be misinformed, this is not my field of interest. That physicians are still prescribing them is not due to active placebo prescribing but to the normal inertia of changing knowledge. This is a matter of how fast information is distributed and consensus is accepted, not of physicians actively continuing to ignore facts as is the blatant case with homeopathy.

      • Thanks for this. I think you misunderstand me though. Science and the GP in question do ‘know’ homeopathy to be empty, as they are ‘medicinally defined’ as mainly sugar with no active pharmacological ingredient. The manuals also list indications.

        The evidence-base for antidepressants leads me to think they are not altogether useless for similar reasons that homeopathy isn’t altogether useless (albeit they are an active placebo as opposed to inert). When you consider that non-antidepressants (e.g. Atropine) with similar side-effect profiles perform similarly on measures of depressive outcomes, and selective serotonin inhibitors perform similarly to enhancers (e.g. tianeptine) and other neurotransmitter inhibitors, we have to question exactly how these drugs work and the assumed neural substrate of ‘depression’. If GPs felt compelled to change their practice following Kirsch et al. (2008) but never did, or did marginally in the opposite direction, this would suggest the problem is greater than the inertia of changing knowledge. There’s a problem here, and I see parallels with CAM.

  • I feel I can criticise the working practice of this GP as I happen to be one myself. I apologise for the typo in my above post . It should have read “just don’t do something-just sit there!” Honest conversations with patents can be therapeutic for both patient and doctor. A wink wink, nudge-nudge paternalistic type of practice drips with cynicism and is ethically wrong in my opinion.

    • Yes, an honest and forthright conversation with the patient is usually the best “placebo”. The doctor never has to “abandon” the patient even if he has no solutions at hand. I have often been in such a situation but I never tell the patient not to come back or knowingly give them useless advice.
      The apparently “heartsink” patients are often those who have a difficult life-situation, a conflict in marriage, finances or other problems that preclude progress. When the problem seems not to have a solution I usually start to dig more deeply into the patients life-situation. You see, even a surgeon has a holistic approach and sees the patient not as a bag of flesh and bones 😉 But I have never found it necessary to resort to deception. I found out a long time ago that being completely honest is the best way.
      Perhaps the biggest “epiphany” of my professional life was the case of an elderly lady I was, as a young general surgeon, trusted to diagnose for a severe, constant perianal pain. We went through everything and then some more. Nothing was found. Name a diagnostic modality or superexpert. We tried it all.
      I finally had to tell her we did not find any solution and had a good and thorough conversation with her about it. We decided to see each other in a month just to have some plan. She was somewhat better but still suffering.

      When she came for the appointment she was radiant. The pain had disappeared “magically”. She was a widow since a few years and had not yet finalised some financial arrangements after her husbands death. I had in our previous conversation suggested to her that there might be a psychological factor at play but we had not been able to define anything in that way. Maybe this was what helped her to sum up courage and have a lawyer help her finish this business. When this inner conflict of hers was solved, the pain disappeared. Pressing conflicts of this sort are surprisingly often the cause of mysterious and vague symptoms.

  • *Just don’t do something-sit there* 3rd time lucky 🙁

  • I wish I didn’t have first hand experience with doctors like this one.

    I have a rare disease that most doctors have never heard of. The first doctor I saw decided I was depressed. I was suffering from excruciating leg pain and was given magic oil to rub on my legs. I switched doctors many times, but was repeatedly mistreated. I ended up traveling to another county to see a doctor without access to my medical records in order to have my condition treated seriously. Long story, but I switched doctors about 8 times and lived with unbelieved debilitating pain for 4 years before receiving adequate tests revealing tumors, nerve compression & damage. I pay over $900 a month for health insurance, which made this whole ordeal even more disturbing. I also researched and found my condition within one year of the onset, but most of the doctors I saw refused to read the information I provided (published research). The eighth doctor I saw (fresh out of school) actually read my downloaded info, researched it and diagnosed me, but I shouldn’t have had to exhaust myself trying to find a doctor willing to investigate my problem.

    I visited online support groups and was disturbed by how common my experience seems to be, story after story of mistreatment. I was also shocked by the amount of quackery being discussed as if it were real medicine. I guess some people can’t afford to see multiple doctors before finding a good one. They are attracted to alternatives when the medical community lets them down. It is bad enough to have a painful condition, the grief is compounded when your doctor doesn’t believe you. The frustration is overwhelming when you know you are ill and your doctor thinks a placebo is the answer.

    Anyway, time and time again (on skeptic blogs & boards) the discussion “When is it ok to prescribe placebos?” comes up. I am surprised by people in the medical profession stating there are times when a placebo is appropriate. This topic really disturbs me due to my experience. It is more common than I ever would have believed. In my opinion, there is never an appropriate time for a medical doctor to prescribe placebos. I don’t care if only a small percentage of the cases are real diseases being brushed off as psychosomatic due to lack of knowledge, the damage is indefensible.

  • http://www.ncbi.nlm.nih.gov/pubmed

    Arnica montana has been widely used as a homeopathic remedy for the treatment of several inflammatory conditions in pain management and postoperative settings. This review gives an overview of the therapeutic use of Arnica montana in the above-mentioned fields also focusing on its mechanisms of action learned from animal models and in vitro studies. Arnica montana is more effective than placebo when used for the treatment of several conditions including post-traumatic and postoperative pain, edema, and ecchymosis. However, its dosages and preparations used have produced substantial differences in the clinical outcome. Cumulative evidence suggests that Arnica montana may represent a valid alternative to non-steroidal anti-inflammatory drugs, at least when treating some specific conditions.

  • Excrementum caninum

    Official denomination of proving material:
    Excrementum caninum
    Feces of a hybrid dog fed with cow’s paunch (mother: German shepherd, father: mix of Hungarian
    shepherd and setter)

    Guiding symptoms
    ‘Nidicolous’ child syndrome: children who don’t want to leave parents’ home, avoiding severance
    and remaining in close, ‘sticky’ relation with them (incestuous-symbiotic relationship)
    Dependency: no severance from dependent relationship (parents, profession, marriage partner,
    friends, children), consequences of abuse
    Repression: consequences of repressive education at school, in family etc.
    Inhibition: ‘Doesn- ‘t speak out’, smiling
    Language: children late in learning to speak
    Suicide: extreme feeling of futility and Depression with suicidality
    Unemployment: consequences of unemployment
    Turbidity of mind: unable to think clearly, is in a dazed state, forgetting things just said or thought
    Fear of illness
    Hemicrania
    Multiple allergies: hay fever and asthma, extreme itching in nose, running nose and sneezing fits,
    waking up by night from sneezing fits, tears watery, feeling as if sand was in eyes
    Painful hips: severe hip trouble such as arthrosis and very painful dislocation of hip
    People who cannot find place in life: uprooted, seeing no meaning in life, no profession, no partner
    Intestinal diseases: morbus Crohn, colitis ulcerosa
    Eating disorders
    Neurodermitis
    Chocolate/alcohol abuse

    • Brilliant! I love its circular reference: Eating disorders — the desire to ingest Excrementum caninum would be a strong indicator for this remedy. Those who claim that perpetual motion doesn’t exists have never studied the quackery of homeopathy.

      Increasing dilutions leads not to increasingly powerful solutions, it leads to increasingly crippling delusions. The only widespread disease for which homeopathy does not yet have a remedy is itself.

      • The only widespread disease for which homeopathy does not yet have a remedy is itself.

        I wouldn’t be so sure of that. At Helios you can order a remedy named Aqua Nova. The eminent inventors of that particular remedy wanted to produce it from the purest possible water so they put light to a mixture of oxygen and hydrogen. Luckily they survived the blast and lived to market the idea.
        As it is a remedy made out of purest water, diluted ad absurdum with… you guessed it, pure water, then it must be useful for conditions associated with or resulting from overindulgence in pure water like drowning, hyperhydration and homeopathic delusions…. right?

        The results of the provings conducted by internationally renowned experts on the matter, Misha Norland and Peter Fraser, are a “blast” to read 😀

        • I think the person at Materia Medica entry “03P 43 XX:XX NS” might be in need of professional help, rather than ascribing their gruesome fantasy to Aqua Nova.

          In the world of alt-med the following terms have alternative meaning: data; empirical; evidence; proof; efficacy; risk; science; normal; reason.

  • An alternative approach to ‘heart-sink’ patients: leave a bowl full of Percocet in the waiting room.

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