MD, PhD, FMedSci, FSB, FRCP, FRCPEd

charlatan

In Europe, we have chiropractors, homeopaths, naturopaths and anthroposophical physicians who recommend to their patients not to vaccinate their children. In the US, they have all this plus some of the clergy to jeopardize herd immunity.

An outbreak of measles infections has been reported in Tarrant County, Texas, US where at least 21 people have been affected this month at the Eagle Mountain International Church. The ministers of this church have been critical of vaccination and advised to use alternative treatments. Several more cases of infections with fever and rash have been noted, but so far remain unconfirmed.

Before the measles vaccine was introduced in 1963, between 3 million and 4 million people in the U.S. were infected each year, 48,000 of them needed hospitalisation and 400 to 500 died. Another 1,000 developed chronic disabilities. In the US measles were considered eradicated in 2000, but outbreaks continue because of imported infections brought back by travellers from areas where measles remains common.

The Texas outbreak was caused by a non-vaccinated visitor who had been infected in Indonesia and then returned to expose unvaccinated church members, staff and children in a day-care centre. In the wider community, more than 98 per cent of kids are immunized and less than 1 per cent are exempt. But the congregation of unvaccinated people allowed the disease to catch hold. Church leaders, including Kenneth Copeland and his daughter, Terri Pearsons, senior pastor at Eagle Mountain, have advocated faith-healing and questioned vaccines in the past.

And what can faith-healing achieve? Where is the evidence that it prevents or cures infections or any other diseases? You probably guessed: there is none.

What is a competent homeopath? This intriguing question was addressed in a recent article by researchers from the Department of Public Health, School of Health and Related Research, University of Sheffield, UK, and the Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway. Non-homeopaths would probably argue that either a clinician is competent or he/she is a homeopath; being a competent homeopath seems like a contradiction in terms. So, is is interesting to see what these authors had to say on the subject.

They started by pointing out that homeopathy is unregulated in most European countries, it is therefore not clear, in their view, what it means to be a “competent homeopath”. To clarify this issue, they decided to conduct a small survey investigating homeopathy-educators’ views on what a “competent homeopath” might be and what homeopaths might require in their education. They did a qualitative study based on grounded theory methodology involving telephone interviews with 17 homeopathy-educators from different schools in 10 European countries. The main questions asked were “What do you think is necessary in order to educate and train a competent homeopath?” and “How would you define a competent homeopath?

The results indicate that the homeopathy-educators defined a “competent homeopath” as a professional who, through his/her knowledge and skills together with an awareness of his/her bounds of competence, is able to help his/her patients in the best way possible. This is achieved through the processes of study and self-development, and is supported by a set of basic resources. Becoming and being a “competent homeopath” is underpinned by a set of basic attitudes. These attitudes include course providers and teachers being student-centred, and students and homeopaths being patient-centred. Openness on the part of students is important to learn and develop themselves, on the part of homeopaths when treating patients, and for teachers when working with students. Practitioners have a responsibility towards their patients and themselves, course providers and teachers have responsibility for providing students with effective and appropriate teaching and learning opportunities, and students have responsibility for their own learning and development (in order to avoid confusion or misinterpretation, I have copied this section almost verbatim from the abstract).

The authors consider that, according to homeopathy-educators’ understanding, basic resources and processes contribute to the development of a competent homeopath, who possesses certain knowledge and skills, all underpinned by a set of basic attitudes. And they conclude that this study proposes a substantive theory to answer what homeopathy educators believe a competent homeopath is and what it takes to be educated and trained to become one. The model suggests that certain basic resources and educational and self-developmental processes contribute to developing knowledge and skills necessary to be competent homeopaths. It also pinpoints underlying attitudes needed in the education as well as the clinical practice of competent homeopaths.

I find two things particularly striking in this text which I have copied almost unchanged from the abstract of the original paper (the full text is hardly more illuminating).

Firstly, these statements tell me virtually nothing that is specific to homeopathy. In my view, they are merely a bonanza of platitudes without much real meaning. We could substitute almost any other health care profession for “homeopath”, and the text would still be applicable in a very general and politically correct sort of way. I see nothing here that is specific to homeopathy.

Secondly, according to the findings of this survey, a “competent homeopath” does not seem to have much need for evidence. With virtually every other health care profession I know, one would expect a very strong emphasis on the need for the competent clinician to abide by the rules of evidence-based medicine. Not so in homeopathy!

Why? The answer seems obvious: if a clinician practices evidence-based medicine, he/she cannot possibly practice homeopathy – the evidence shows that homeopathy is a placebo-therapy. So, here we have it: a competent homeopath has to be a contradiction in terms because either someone practices homeopathy or he/she practices evidence-based medicine. Doing both at the same time is simply not possible.

Sorry, but I am fighting a spell of depression today.

Why? I came across this website which lists the 10 top blogs on alternative medicine. To be precise, here is what they say about their hit-list: this list includes the top 10 alternative medicine bloggers on Twitter, ranked by Klout score. Using Cision’s media database, we compiled the list based on Cision’s proprietary research, with results limited to bloggers who dedicate significant coverage to alternative medicine and therapies…

And here are the glorious top ten:

Andrew WeilDr. Andrew Weil’s Daily Health Tips

Joy McCarthyJoyous Health Blog

Johanna BjörkGoodlifer

Stacey ChillemiStay Healthy and Cure Your Conditions Naturally

Eric GreyDeepest Health

Kristi ShmyrPrana Holistic Blog

Cathy WongAlternative Medicine Blog

Renee CanadaHartford Healthy Living Examiner

Dee BraunNatural Holistic Health Blog

Geo EspinosaDr. Geo’s Natural Health Blog

All of these sites are promotional and lack even the slightest hint of critical evaluation. All of them sell or advertise products and are thus out to make money. All of them are full of quackery, in my view. Some of the most popular bloggers are world-famous quacks!

What about impartial information for the public? What about critical review of the evidence? What about a degree of balance? What about guiding consumers to make responsible, evidence-based decisions? What about preventing harm? What about using scarce resources wisely?

I don’t see any of this on any of the sites.

You see, now I have depressed you too!

Quick, buy some herbal, natural, holistic and integrative anti-depressant! As it happens, I have some for sale….

Even after all these years of full-time research into alternative medicine and uncounted exchanges with enthusiasts involved in this sector, I find the logic that is often applied in this field bewildering and the unproductiveness of the dialogue disturbing.

To explain what I mean, it be might best to publish a (fictitious, perhaps slightly exaggerated) debate between a critical thinker or scientist (S) and an uncritical proponent (P) of one particular form of alternative medicine.

P: Did you see this interesting study demonstrating that treatment X is now widely accepted, even by highly critical GPs at the cutting edge of health care?

S: This was a survey, not a ‘study’, and I never found the average GP “highly critical”. Surveys of this nature are fairly useless and they “demonstrate” nothing of real value.

P: Whatever, but it showed that GPs accept treatment X. This can only mean that they realise how safe and effective it is.

S: Not necessarily, GPs might just give in to consumer demand, or the sample was cleverly selected, or the question was asked in a leading manner, etc.

P: Hardly, because there is plenty of good evidence for treatment X.

S: Really? Show me.

P: There is this study here which proves that treatment X works and is risk-free.

S: The study was far too small to demonstrate safety, and it is wide open to multiple sources of bias. Therefore it does not conclusively show efficacy either.

P: You just say this because you don’t like its result! You have a closed mind!

In any case, it was merely an example! There are plenty more positive studies; do your research properly before you talk such nonsense.

S: I did do some research and I found a recent, high quality systematic review that arrived at a negative conclusion about the value of treatment X.

P: That review was done by sceptics who clearly have an axe to grind. It is based on studies which do not account for the intrinsic subtleties of treatment X. Therefore they are unfair tests of treatment X. These trials don’t really count at all. Every insider knows that! The fact that you cite it merely confirms that you do not understand what you are talking about.

S: It seems to me, that you like scientific evidence only when it confirms your belief. This, I am afraid, is what quacks tend to do!

P: I strongly object to being insulted in this way.

S: I did not insult you, I merely made a statement of fact.

P: If you like facts, you have to see that one needs to have sufficient expertise in treatment X in order to apply it properly and effectively. This important fact is neglected in all of those trials that report negative results; and that’s why they are negative. Simple! I really don’t understand why you are too stupid to understand this. Such studies do not show that treatment X is ineffective, but they demonstrate that the investigators were incompetent or hired with the remit to discredit treatment X.

S: I would have thought they are negative because they minimised bias and the danger of generating a false positive result.

P: No, by minimising bias, as you put it, these trials eliminated the factors that are important elements of treatment X.

S: Such as the placebo-effect?

P: That’s what you call it because you irrationally believe in reductionist science.

S: Science requires no belief, I think you are the believer here.

P: The fact is that scientists of your ilk negate all factors related to human interactions. Patients are no machines, you know, they need compassion; we clinicians know that because we work at the coal face of health care. Scientists in their ivory towers have no idea about patient care and just want science for science sake. This is not how you help patients. Show some compassion man!

S: I do know about the importance of compassion and care, but here we are discussing an entirely different topic, namely tests the efficacy or effectiveness of treatments, not patient-care. Let’s focus on one issue at a time.

P: You cannot separate things in this way. We have to take a holistic view. Patients are whole individuals, and you cannot do them justice by running artificial experiments. Every patient is different; clinical trials fail to account for this fact and are therefore fairly irrelevant to us and to our patients. Real life is very different from your imagined little experiments, you know.

S: These are platitudes that are nonsensical in this context and do not contribute anything meaningful to the present discussion. You do not seem to understand the methodology or purpose of a clinical trial.

P: That is typical! Whenever you run out of arguments, you try to change the subject or throw a few insults at me.

S: Not at all, I thought we were talking about clinical trials evaluating the effectiveness of treatment X.

P: That’s right; and they do show that it is effective, provided you consider those which are truly well-done by experts who know about treatment X and believe in it.

S: Not true. Only if you cherry-pick the data will you be able to produce an overall positive result for treatment X.

P: In any case, the real world results of clinical practice show very clearly that it works. It would not have survived for so long, if it didn’t. Nobody can deny that, and nobody should claim that silly little trials done in artificial circumstances are more meaningful than a wealth of experience.

S: Experience has little to do with reliable evidence.

P: To deny the value of experience is just stupid and clearly puts you in the wrong. I have shown you plenty of reliable evidence but you just ignore everything I say that does not go along with your narrow-minded notions about science; science is not the only way of knowing or comprehending things! Stop being obsessed with science.

S: No, you show me rubbish data and have little understanding of science, I am afraid.

P: Here we go again! I have had about enough of that and your blinkered arguments. We are going in circles because you are ignorant and arrogant. I have tried my best to show you the light, but your mind is closed. I offer true insight and you pay me back with insults. You and your cronies are in the pocket of BIG PHARMA. You are cynical, heartless and not interested in the wellbeing of patients. Next you will tell me to vaccinate my kids!

S: I think this is a waste of time.

P: Precisely! Everyone who has followed this debate will see very clearly that you are obsessed with reductionist science and incapable of considering the suffering of whole individuals. You want to deny patients a treatment that  really helps them simply because you do not understand how treatment X works. Shame on you!!!

Fairly early on during my time at Exeter, I had felt that it would be relevant, interesting and important to familiarise general practitioners with alternative medicine. At the time, we decided that we would start to run regular courses specifically for these health care professionals. Back in the mid 1990s, this was a remarkable thing to do, so much so that we even published our experience after the first such event. Recently I came across the article that resulted from this endeavour; here is an except from the abstract:

The delegates started with a positive but questioning attitude toward complementary medicine (CM) and acknowledged that they gained useful information, leading to increased confidence in discussing CM with patients. The course to a large extent met their needs and expectations. Benefits and draw-backs of integrating CM within general practice were explored. The main advantage of CM, apart from the potential intrinsic value of the techniques themselves, was identified as the time to establish a good therapeutic relationship with the patient. The particular concerns about CM that were expressed by the doctors included poor dialogue with CM practitioners, doubts about competence, and lack of readily identifiable and recognized qualifications. The risk of holding out unrealistic hope of cure was their greatest concern, however, especially if patients were thereby denied an effective orthodox treatment.

What strikes me as particularly remarkable is the fact that, even then, so many doubts were voiced by our GPs about alternative practitioners, their therapeutic claims and their doubtful medical competence. It was then that it occured to me for the first time that these therapists might systematically misinform their patients. This suspicion was strengthened on numerous occasions in the years to come; but it was not until much later that we decided to look into this subject (which is rather difficult to research) more systematically. What we found shocked us. Here are the conclusions of some of our investigations:

The most popular websites on complementary and alternative medicine for cancer offer information of extremely variable quality. Many endorse unproven therapies and some are outright dangerous. The link to the article is here.

Some complementary and alternative medicine (CAM) providers have a negative attitude towards immunisation and means of changing this should be considered. The link is here.

Advice about herbal medicine is readily available over the Internet. The advice offered is misleading at best and dangerous at worst. Potential Internet users should be made aware of these problems and ways of minimizing the risk should be found. The link is here.

The majority of chiropractors and their associations in the English-speaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue. The link is here.

In another study, we found that advice given by alternative practitioners to diabetic patients had the potential to kill them. A similarly scary conclusion emerged when we evaluated the advice chiropractors provide to asthma patients. Other research found that anthroposophic doctors often advise against measles vaccinations and are thus causing measles outbreaks.

The totality of this evidence, I believe, begs the question: DO ALTERNATIVE PRACTITIONERS SYSTEMATICALLY MISINFORM THEIR PATIENTS? I look forward to a lively discussion of it.

On the last day of the year, is time to contemplate the achievements and failures of the past 12 months and think about the future. For me, it is also the moment to once again place my tongue in my cheek, empathise with my opponents and think of what they might hope for in the coming year.

Here is a brief yet somewhat ambitious expose of what I came up with: the charlatan’s wish list for 2013.

1 Let the Daily Mail and similar publications continue to promote uncritical thinking and bogus claims for alternative medicine.

2 Make sure that politicians remain blissfully ignorant of all matters related to science.

3 Let the anecdote continue to reign over evidence, for instance, in the popular press.

4 Regulate alternative practitioners such that they benefit from the added status without any obligation to abide by the generally accepted rules of evidence-based practice.

5 Prevent the closure of more homeopathic hospitals.

6 Ensure that the public continues to be mislead about nonsensical scams such as “integrated medicine”.

7 Increase the influence of Prince Charles in the realm of health care.

8 Give Royal status to the ‘College of Medicine’.

9 Appoint Dr Michael Dixon, chair of the ‘NHS-Alliance’ and the above-named “college”, as advisor to the government.

10 Introduce more post-modern thinking into health care; after all, there is more than one way of knowing!

11 Defame all those terrible sceptics who always doubt our claims.

12 Cherish double standards in medicine; they are essential for our survival!

13 Make sure researchers of alternative medicine use science not for testing but for proving the value of alternative therapies.

14 Continue to allow promotion of alternative medicine to masquerade as research.

15 Ensure that all our celebrity clients tell every journalist how young they look thanks to alternative medicine.

16 Let ‘Duchy’s Original detox Tincture’ become a financial success – Charles needs the added income for promoting quackery.

17 Open more woo-institutes in academia to spread the gospel of belief-based medicine.

18 Prevent anyone from finding out that many of us break even the most fundamental rules of medical ethics in our daily practice.

I am aware that the list is probably not nearly complete, and I invite everyone to add items of importance. Happy New Year!

 

 

In these austere and difficult times, it must be my duty, I think, to alert my fellow citizens to a possible source of additional income which almost anyone can plug into: become a charlatan, and chances are that your economic hardship is a memory from the past. To achieve this aim, I [with my tongue firmly lodged in my cheek] suggest a fairly straight forward step by step approach.

1. Find an attractive therapy and give it a fantastic name

Did I just say “straight forward”? Well, the first step isn’t that easy, after all. Most of the really loony ideas turn out to be taken: ear candles, homeopathy, aura massage, energy healing, urine-therapy, chiropractic etc. As a true charlatan, you want your very own quackery. So you will have to think of a new concept.

Something truly ‘far out’ would be ideal, like claiming the ear is a map of the human body which allows you to treat all diseases by doing something odd on specific areas of the ear – oops, this territory is already occupied by the ear acupuncture brigade. How about postulating that you have super-natural powers which enable you to send ‘healing energy’ into patients’ bodies so that they can repair themselves? No good either: Reiki-healers might accuse you of plagiarism.

But you get the gist, I am sure, and will be able to invent something. When you do, give it a memorable name, the name can make or break your new venture.

2. Invent a fascinating history

Having identified your treatment and a fantastic name for it, you now need a good story to explain how it all came about. This task is not all that tough and might even turn out to be fun; you could think of something touching like you cured your moribund little sister at the age of 6 with your intervention, or you received the inspiration in your dreams from an old aunt who had just died, or perhaps you want to create some religious connection [have you ever visited Lourdes?]. There are no limits to your imagination; just make sure the story is gripping – one day, they might make a movie of it.

3. Add a dash of pseudo-science

Like it or not, but we live in an age where we cannot entirely exclude science from our considerations. At the very minimum, I recommend a little smattering of sciency terminology. As you don’t want to be found out, select something that only few experts understand; quantum physics, entanglement, chaos-theory and Nano-technology are all excellent options.

It might also look more convincing to hint at the notion that top scientists adore your concepts, or that whole teams from universities in distant places are working on the underlying mechanisms, or that the Nobel committee has recently been alerted etc. If at all possible, add a bit of high tech to your new invention; some shiny new apparatus with flashing lights and digital displays might be just the ticket. The apparatus can be otherwise empty – as long as it looks impressive, all is fine.

4. Do not forget a dose of ancient wisdom

With all this science – sorry, pseudo-science – you must not forget to remain firmly grounded in tradition. Your treatment ought to be based on ancient wisdom which you have rediscovered, modified and perfected. I recommend mentioning that some of the oldest cultures of the planet have already been aware of the main pillars on which your invention today proudly stands. Anything that is that old has stood the test of time which is to say, your treatment is both effective and safe.

5. Claim to have a panacea

To maximise your income, you want to have as many customers as possible. It would therefore be unwise to focus your endeavours on just one or two conditions. Commercially, it is much better to affirm in no uncertain terms that your treatment is a cure for everything, a panacea. Do not worry about the implausibility of such a claim. In the realm of quackery, it is perfectly acceptable, even common behaviour to be outlandish.

6. Deal with the ‘evidence-problem’ and the nasty sceptics

It is depressing, I know, but even the most exceptionally gifted charlatan is bound to attract doubters. Sceptics will sooner or later ask you for evidence; in fact, they are obsessed by it. But do not panic – this is by no means as threatening as it appears. The obvious solution is to provide testimonial after testimonial.

You need a website where satisfied customers report impressive stories how your treatment saved their lives. In case you do not know such customers, invent them; in the realm of quackery, there is a time-honoured tradition of writing your own testimonials. Nobody will be able to tell!

7. Demonstrate that you master the fine art of cheating with statistics

Some of the sceptics might not be impressed, and when they start criticising your ‘evidence’, you might need to go the extra mile. Providing statistics is a very good way of keeping them at bay, at least for a while. The general consensus amongst charlatans is that about 70% of their patients experience remarkable benefit from whatever placebo they throw at them. So, my advice is to do a little better and cite a case series of at least 5000 patients of whom 76.5 % showed significant improvements.

What? You don’t have such case series? Don’t be daft, be inventive!

8. Score points with Big Pharma

You must be aware who your (future) customers are (will be): they are affluent, had a decent education (evidently without much success), and are middle-aged, gullible and deeply alternative. Think of Prince Charles! Once you have empathised with this mind-set, it is obvious that you can profitably plug into the persecution complex which haunts these people.

An easy way of achieving this is to claim that Big Pharma has got wind of your innovation, is positively frightened of losing millions, and is thus doing all they can to supress it. Not only will this give you street cred with the lunatic fringe of society, it also provides a perfect explanation why your ground-breaking discovery has not been published it the top journals of medicine: the editors are all in the pocket of Big Pharma, of course.

9. Ask for money, much money

I have left the most important bit for the end; remember: your aim is to get rich! So, charge high fees, even extravagantly high ones. If your treatment is a product that you can sell (e.g. via the internet, to escape the regulators), sell it dearly; if it is a hands-on therapy, charge heavy consultation fees and claim exclusivity; if it is a teachable technique, start training other therapists at high fees and ask a franchise-cut of their future earnings.

Over-charging is your best chance of getting famous – or have you ever heard of a charlatan famous for being reasonably priced?  It will also get rid of the riff-raff you don’t want to see in your surgery. Poor people might be even ill! No, you don’t want them; you want the ‘worried rich and well’ who can afford to see a real doctor when things should go wrong. But most importantly, high fees will do a lot of good to your bank account.

 

Now you are all set. However, to prevent you from stumbling at the first hurdle, here are some handy answers to the questions you inevitably will receive from sceptics, this nasty breed that is never happy. The answers are not designed to convince them but, if voiced in public, they will ensure that the general opinion is on your side – and that’s what is paramount in the realm of quackery.

Q: Your treatment can cause considerable harm; do you find that responsible?

A: Harm? Do you know what you are talking about? Obviously not! Every year, hundreds of thousands die because of the medicine they received from mainstream doctors. This is what I call harm!

Q: Experts say that your treatment is not biologically plausible, what is your response?

A: There are many things science does not yet understand and many things that it will never understand. In any case, there are other ways of knowing, and science is but one of them.

Q: Where are the controlled trials to back up your claim?

A: Clinical trials are of very limited value; they are far too small, frequently biased and never depict the real life situation. This is why many experts now argue for better ways of showing the value of medical interventions.

Q: Professor Ernst recently said that your therapy is unproven, is that true?

A: This man cannot be trusted; he is in the pocket of the pharmaceutical industry! He would say that, wouldn’t he?

Anyway, did you know that only 15% of conventional therapies actually are evidence-based?

Q: Why is your treatment so expensive?

A: Years of training, a full research programme, constant audits, compliance with regulations, and a large team of co-workers – do you think that all of this comes free? Personally, I would treat all my patients for free (and often do so) but I have responsibilities to others, you know.

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