MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

doctors

Guest post by Richard Rawlins MB BS MBA FRCS

Doctors who are registered medical practitioners (RMPs) must comply with the standards of practice set down by the General Medical Council. ‘Homeopathy’ is a specific system of medical care, devised by Dr Samuel Hahnemann in the nineteenth century, and comprises two distinct dimensions: (i) the establishment of a constructive therapeutic relationship between an empathic homeopath and a patient. This may provide benefit due to the non-specific effects of condolence, counselling, and care – and should be a component of the practice of all doctors in any event; (ii) the homeopathically prepared (HP) remedies that are generally prescribed. To avoid confusion, these two dimensions should not be conflated.

HP remedies may be obtained over the counter, prescribed by lay homeopaths and even given out by dentists and nurses on the grounds that “30C homeopathic arnica helps bruising”. The US Federal Trades Commission has stated that “The Commission will carefully scrutinize the net impression of OTC homeopathic advertising or other marketing employing disclosures to ensure that it adequately conveys the extremely limited nature of the health claim being asserted…accordingly, unqualified disease claims made for homeopathic drugs must be substantiated by competent and reliable scientific evidence.” (FTC Policy statement 2017).

Special focus should be brought to bear on the ethical, intellectual and professional obligations of those doctors registered as medical practitioners by the GMC and practicing homeopathy in the UK. Some homeopaths may intend taking advantage of gullible and vulnerable patients. Here I take it that those practitioners who prescribe homeopathic remedies sincerely do believe they have worthwhile effects, but I contend such practice generally fails to comply with ethical and professional standards as set down by the GMC. That is to be deprecated.

Systems to regulate medical practice in the British Isles have been devised since the middle ages. In 1518, Thomas Linacre founded the College of Physicians – based on systems he had seen in Europe. From 1704, the Society of Apothecaries licensed its members to prescribe and dispense medicines, and developed the profession of general practice. In order to protect the public from charlatans, quacks and fraudsters more effectively, the Medical Act of 1858 established formal statutory regulation of doctors by the General Medical Council. Registrants who are not deemed fit to practice may be struck off the register. They can still practice, but not as registered medical practitioners. They can still use the title ‘doctor’ (as can anyone), but not for fraudulent purposes.

Dr Samuel Hahnemann qualified in Saxony in 1781 and was a good doctor, but he became disillusioned with many of the practices and practitioners of his day. He wrote about his fellow doctors: “Precious and fragile human life, so easily destroyed, was frequently placed in jeopardy at the hands of these perverted people, especially since bleedings, emetics, purges, blistering plaster, fontanels, setons, caustics and cauterisations were used.” In 1796 he wrote to a friend, “I renounced the practice of medicine that I might no longer incur the risk of doing injury, and I engaged in chemistry exclusively and in literary occupations.”

Hahnemann went on to develop his own alternative system of health care, which he styled ‘Homoeopathy’. Published as the Organon of the Healing Arts in 1810, Hahnemann set out an idiosyncratic medical system based on identifying ‘remedies’ which in large doses, could produce symptoms comparable to those suffered by the patient. The remedies he prescribed were prepared with serial dilutions so that no active principle remained. Today’s homeopaths hold that a remedy’s ‘vital force’, ‘healing energy’ or ‘memory’ provides therapeutic benefit. That may be the case, but the consensus of informed scientific and medical opinion is that any effects of ‘homeopathy’ are as a result of contextual placebo effects. The remedies themselves cannot and do not have any effect. England’s Chief Medical Officer has described homeopathy’s principles as ‘rubbish’. The government’s Chief Scientific Adviser, Sir Mark Walport has said he would tell ministers, “My view, scientifically, is absolutely clear: homeopathy is nonsense. The most it can have is a placebo effect.” Simon Stevens, CEO of the NHS, when interviewed on Radio 4 said he agrees with Sir Mark – yet failed to explain why he had not included homeopathic remedies in the 2017 list of NHS proscribed medicines. That stance is being reviewed.

The GMC states, “Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and make sure your practice meets the standards expected.” Those standards are set down in the GMC’s Good Medical Practice which advises, “Serious or persistent failure to follow this guidance will put your registration at risk.” The GMC standards are coherent with those of the American Medical Association’s Principles of Medical Ethics (2016).

In précis, the most relevant and important GMC standards are:

  • Make the care of your patient your first concern.
  • Give patients the information they want or need in a way they can understand.
  • Be honest and open and act with integrity.
  • Never abuse your patients’ trust in you or the public’s trust in the profession.
  • You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.
  • You must  prescribe drugs or treatment only when you are satisfied that the drugs or treatment serve the patient’s needs.                                                                                                                                             
  • You must provide effective treatments based on the best available evidence.
  • You must be satisfied that you have consent or other valid authority before you carry out any examination, investigation or provide treatment.
  • You must make good use of the resources available to you.

I contend that medical practitioners who prescribe homeopathic remedies regularly fail to meet these standards. They know perfectly well that the best available evidence indicates no support for the assertion that homeopathic remedies ‘serve the patient’s needs’, except as placebos; that the treatments have no specific effects; that the remedies are placebos; and that resources are wasted by expenditure on these ineffective remedies. Medical homeopaths invariably do not give patients this information; they fail to obtain properly informed consent; they do not justify their decisions and actions rationally; and they may be obtaining financial advantage by misrepresentation to insurance companies or the NHS. This is an abuse of the public’s trust in the medical profession.

The issue of informed consent is particularly important. GMC guidance states that, “The doctor uses specialist knowledge and experience and clinical judgement, and the patient’s views and understanding of their condition, to identify which investigations or treatments are likely to result in overall benefit for the patient. The doctor explains the options to the patient, setting out the potential benefits, risks, burdens and side effects of each option, including the option to have no treatment. The doctor may recommend a particular option which they believe to be best for the patient, but they must not put pressure on the patient to accept their advice. …Before accepting a patient’s consent, you must consider whether they have been given the information they want or need, and how well they understand the details and implications of what is proposed. This is more important than how their consent is expressed or recorded.”

The GMC states that, “in order to have effective discussions with patients about risk, you must identify the adverse outcomes that may result from the proposed options… risks can take a number of forms, but will usually be: side effects; complications; failure of an intervention to achieve the desired aim.” The risk of wasting money on ineffective remedies, whether NHS or private, and of delaying treatment known to be effective should also be discussed.

Homeopaths acknowledge that after ministration of remedies, some patients experience ‘aggravations’ – a worsening of symptoms, but they advise this is evidence that the remedy is ‘working’. Medical consensus is more likely to suggest ‘aggravations’ are evidence of an underlying psychological component to the patient’s condition. Suggestions that remedies themselves have any effect, good or bad, is misrepresentation and may be fraud. Offering patients sugar pills with a claim the pills have therapeutic effects means lying to them, and is an abuse of trust.

Homeopaths’ system of diagnosis and prescription of remedies requires them to have beliefs for which there is no plausible evidence base. The Oxford Dictionary defines ‘belief’ as “assent to a proposition, statement or fact, especially on the grounds of testimony or authority, or in the absence of proof or conclusive evidence.” It might be acceptable to practice ‘homeopathy’ as a counselling modality, providing the practitioner complies with the GMC standard that, “You must not express your personal beliefs to patients in ways that exploit their vulnerability or are likely to cause them distress.”

Homeopaths are invariably non-compliant in obtaining fully informed consent. Such a failing is an abuse of patients’ trust in the medical profession. Doctors might be determined to be unfit to practice unless they clearly justify their prescriptions, and identify the evidence that supports them. All these issues should also be explored during the doctor’s annual appraisal, without which a registered medical practitioner will not be licensed to practice. Even registration without a licence requires compliance with the standards. Appraisal can be carried out by non-homeopaths, as the issue is not the assessment of the standard of ‘homeopathic practice’, but compliance with GMC standards of good medical practice.

If a medical homeopath wishes to be GMC compliant, they must properly inform patients about contentious issues. I suggest that consent should be obtained along the lines: “I propose prescribing you a remedy comprising sugar pills impregnated with a solution which has been diluted to such an extent that a sphere of water the size of the Earth’s average radius to the Sun would probably contain no more than one molecule of the original substance. Nevertheless, my clinical experience suggests to me that this remedy will improve your condition. You need to understand that colleagues who practise conventional evidence-based scientific medicine regard my belief as implausible and the methods I use as ‘alternative.’ I believe the remedy will help you, but I have no evidence accepted by the majority of doctors that the intervention I propose will achieve the desired effects. I do not believe that taking a homeopathic remedy will delay any other treatment which might reasonably help your condition and I invite you to take this remedy with understanding of the issues I have outlined.” A copy of the consent should be placed in the patient’s records.

Those who defend the right of registered medical practitioners to prescribe HP remedies do so with arguments fatally holed by a myriad of logical fallacies. Some arguments are (with fallacies in parenthesis):

  • “Homeopathy has been used for over two hundred years” (appeal to tradition and argument from ignorance);
  • “It has become very popular and is what patients want (appeal to popularity);
  • “Homeopathy has the capacity to help patients” (red herring, because present consideration is about the value of HP remedies, not relationships);
  • “Remedies are cheap” (red herring);
  • “Homeopathy does not do any harm” (irrelevant and a red herring);
  • “Pharmaceuticals have side effects” (tu quoque and red herring);
  • “The Royal Family use it” (appeal to irrelevant authority);
  • “The remedies enhance the doctor/patient relationship (straw man);
  • “Science does not know everything” (red herring and false dichotomy);
  • “Those who oppose us don’t understand homeopathy” (argumentum ad hominem and ‘poisoning the well’);
  • “I have the evidence of patients’ anecdotes and testimonials” (pseudoscience, confirmation bias and cherry picking);
  • “Homeopathic doctors are caring people” (red herring and straw man);
  • “I’ve got much evidence of  patients taking remedies and getting better” (post hoc ergo propter hoc – ‘after this, therefore because of this’ – confusion of coincidence with causation).

The latter most perverse fallacy is the foundation of homeopathic practice, based on identifying a remedy whereby ‘like cures like’ – a principle based on post hoc fallacy for which there is no scientifically credible evidence.

Unless and until medical homeopaths understand the intellectual environment in which they practice, are prepared to properly inform their patients, and obtain consent for treatment having done so, they should not prescribe homeopathic remedies. Fortunately, there is no evidence that patients who are prescribed HP remedies by empathic GMC registered homeopaths have any different outcomes from those prescribed pure sugar pills – even if they are told they are placebos. However, trust in the medical profession can only be maintained if deceptive practices are set aside and full explanations for proposed interventions are offered. Given the scientific consensus, patients have to face up to the fact that to the highest degree of probability, HP remedies have no value. Regrettably, too many patients and even homeopaths are in denial. Medical homeopaths should continue to serve their patients with care, compassion and intellectual honesty, but if they are to comply with the standards required for GMC registration, they should not prescribe homeopathically prepared remedies.

Dr Gabriella Day is a GP in England who describes herself and her beliefs as follows: “I began training in homeopathy as it is clear that for many conditions conventional treatment options are not effective and can have unwanted side effects. It seemed to me that there must be another way to help people suffering from symptoms such as these… I believe in whole person medicine. No illness exists in isolation. The human body is immensely sophisticated and complicated and we do not understand it fully. Therefore the illness cannot be separated from the person suffering the disease. This may be as simple as stress impairing the immune system to far more complex interactions. Homeopathic treatment seeks to match the underlying disturbance in the system and stimulate the body to correct itself.”

I do not know Dr Day, but she caught my attention recently when she published an article in THE HIPPOCRATIC POST (I had never heard of this publication before!). It is, I think, sufficiently noteworthy to show you some excerpts (the references [in square brackets] were added by me, and they refer to my comments below):

START OF QUOTES

…Homeopathy can be helpful for pretty much any condition [1], whether as the main treatment [1], as a complement to a conventional treatment [2] to speed up the healing process [1], or to lessen the side-effects of a pharmacological medication [1]. It can be helpful in the treatment of emotional problems [1], physical problems [1] and for multi-morbidity patients [1]. I find it an invaluable tool in my GP’s toolbox and regularly see the benefits of homeopathy in the patients I treat [3]…

There are many conditions for which I have found homeopathy to be effective [1]… There are, however, a multitude of symptomatic treatments available to suppress symptoms, both on prescription and over-the-counter. Most symptoms experienced by patients in this context result from the body’s attempt to eliminate the infection. Our immune systems have spent thousands of years refining this response; therefore it seems counter-intuitive to suppress it [4].
For these types of acute conditions homeopathy can work with the body to support it [1]. For instance, homeopathic Arsenicum album (arsenic) is a classic remedy for diarrhoea and vomiting that can be taken alongside essential oral rehydration [1]. And in influenza I’ve found Eupatorium perfoliatum (ague or feverwort) to be very helpful if the patient is suffering with bony pain [3].
…Unless it is clinically imperative for a pharmacological intervention, I will always consider homeopathy first [5] and have successfully prescribed the homeopathic remedy Nux vomica (strychnine) for women suffering from morning sickness [5]. Problems associated with breastfeeding such as mastitis have also responded well to the classic remedies Belladonna (deadly nightshade) and Phytolacca (pokeweed), while I have found Urtica urens (dog nettle) effective in switching off the milk supply to prevent engorgement when the mother stops breastfeeding [3].
…“heart sink” patients are clearly suffering from pain and discomfort, which is blighting their lives. This is understandably frustrating for them, for they know full well something is awry but there is no medical evidence for this… Homeopathy affords me another approach in trying to help these patients [1,3]. It doesn’t work for them all, but I’m frequently surprised at how many it does help [3].

Positive side-effects

The beauty of homeopathy is that it combines mental and emotional symptoms with physical symptoms [3]. When the right remedy is found it appears to stimulate the body to recognise how it is being dysfunctional and corrects this, with no suppression, just a correction of the underlying disturbance [3]. Thus homeopathy not only eliminates unwanted symptoms [1], it dramatically improves a patient’s overall well-being [1].
…homeopathy… enables me to reduce the number of painkillers and other drugs I’m prescribing [1,3]. This is particularly true for older multi-morbidity, polypharmacy patients [1] who are often taking huge amounts of medication.
Contrary to what most homeopaths will tell you, I believe homeopathic treatment does have side-effects – positive side-effects! [1] It fosters an enhanced doctor patient relationship [1]. The process of eliciting the relevant information to select a remedy enables me to better understand the patient’s condition and helps me to get to know them better [3]. And the patient, seeing that the doctor is interested in the idiosyncrasies and detail of their disease, finds themselves heard and understood [3]. In short, since training in homeopathy I enjoy my job as a GP and my relationship with patients so much more [3].
Dr Gabriella Day BSc, MBBS, MRCP, DCH, MRCGP, MFHom

END OF QUOTES

MY COMMENTS:

  1. statement without good evidence,
  2. Hahnemann was vehemently against combining homeopathy with other treatments and called clinicians who disregarded this ‘traitors’,
  3. statement of belief,
  4. wrong assumption,
  5. questionable ethics.

I have recently attempted to slip into the brain of lay-homeopaths and shown how illogical, misguided and wrong the arguments of such enthusiasts really are. Surely, the logic of a doctor homeopath must be better, I then thought. Once you have studied medicine, you have learnt an awful lot of things about the body, disease, therapy, etc., etc., I felt.

Judging from the above article, I might have been wrong.

Alternative medicine suffers from what might be called ‘survey overload’: there are far too much such investigations and most of them are of deplorably poor quality producing nothing of value except some promotion for alternative medicine. Yet, every now and then, one finds a paper that is worth reading, and I am happy to say that this survey (even though it has several methodological shortcomings) belongs in this category.

This cross-sectional assessment of the views of general practitioners towards chiropractors and osteopaths was funded by the Department of Chiropractic at Macquarie University. It was designed as a quantitative descriptive study using an anonymous online survey that included closed and open-ended questions with opportunities provided for free text. The target population was Australian general practitioners. Inclusion criteria included current medical registration, membership of the Royal Australian College of General Practitioners and currently practicing as a general practitioner in Australia. The data being reported here were collected between May and December, 2014.

There were 630 respondents to the online survey during this period representing a response rate of 2.6 %. Results were not uniform for the two professions. More general practitioners believed chiropractic education was not evidence-based compared to osteopathic education (70 % and 50 % respectively), while the scope of practice was viewed as similar for both professions. A majority of general practitioners had never referred a patient to either profession (chiropractic: 60 %; osteopathy: 66 %) and indicated that they would not want to co-manage patients with either profession. Approximately two-thirds of general practitioners were not interested in learning more about their education (chiropractors: 68 %; osteopaths: 63 %).

The authors concluded that this study provides an indication of the current views of Australian general practitioners towards chiropractors and osteopaths. The findings suggest that attitudes may have become less favourable with a growing intolerance towards both professions. If confirmed, this has the potential to impact health service provision. The results from this cross-sectional study suggest that obtaining representative general practitioner views using online surveys is difficult and another approach is needed to supplement or replace the current recruitment strategy.

The authors do not speculate on the reasons why the attitudes of general practitioners towards chiropractic and osteopathy might have become more critical. Therefore I decided to offer a few possibilities here. The more negative views could be due to:

  • better education of general practitioners,
  • tightening of healthcare budgets,
  • recent ‘bad press’ and loss of reputation (for instance, the BCA’s libel action against Simon Singh),
  • the work of sceptics in informing the public about the numerous bogus claims made by osteopaths and chiropractors,
  • the plethora of overtly bogus claims which nevertheless continue to be made by these practitioners on a daily basis,
  • a more general realisation that these therapies can cause very serious harm,
  • a mixture of the above factors.

Whatever the reasons are, the finding that there now seems to be a growing scepticism (in Australia, but hopefully elsewhere as well) about the value of chiropractic and osteopathy is something that cheers me up no end.

WARNING: THIS POST IS NOT ABOUT ALTERNATIVE MEDICINE

My first ever scientific paper, a spin-off from my MD thesis, was published exactly 40 years ago. Since then, I have written many more articles. Readers of this blog might think that they are all on alternative medicine, but that is not the case. My most cited paper is (I think) one which combined my research in haemorheology with that in epidemiology. Yet, I would not consider it to be my most important article.

So, what is my most important publication?

It is one that relates to the history of medicine.

How come?

In 1990, I was appointed as chair of Rehabilitation Medicine at the University of Vienna. On the occasion of the official opening of the new 2000-bed university hospital in Vienna, I was asked to say a few words and thought that a review of the history of my department might be a fitting subject. But I was wrong. What I discovered while researching it turned out to be totally unfitting for the event; in fact, it contributed to my decision to leave Vienna in 1993. I did, however, summarize my findings in an article – and it is this paper that I consider my most important publication. Here is its abstract:

Misguided by the notion that the decline of the German race would be prevented by purifying “Aryan blood” and eliminating foreign, particularly Jewish, influences, the Nazis evicted all Jews from universities within their growing empire during the Third Reich. The Medical Faculty of Vienna suffered more than any other European faculty from “race hygiene.” Within weeks of the Nazi annexation of Austria in 1938, 153 of the Faculty’s 197 members were dismissed. By far the most frequent reason for dismissal was Jewish origin. Most victims managed to emigrate, many died in concentration camps, and others committed suicide. The “cleansing” process encountered little resistance, and the vacant posts were quickly filled with persons known not for their medical expertise but for their political trustworthiness. It was in this climate that medical atrocities could be committed. After the collapse of the Third Reich, most members of the Faculty were burdened with a Nazi past. Most remained in office, and those who had to leave were reinstituted swiftly. The Jews evicted in 1938 were discouraged from returning. These events have significantly–and with long-lasting effects–damaged the quality of a once-leading medical school. This story needs to be told to honor its victims and to fortify us so that history does not repeat itself.

As I pointed out in my memoir, it “was not published until 1995, by which time I was no longer at the University of Vienna but had left Austria and gone joyfully back to the U.K. to take up my post at the University of Exeter. When the paper was published, it had a considerable impact and important consequences. On the one hand, I received a torrent of hate-mail and threats, and was even accused by the more sensationalistic elements of the Austrian press of having stolen considerable amounts of money from my department at the University of Vienna – an entirely fabricated story, of course, and so ridiculous that I couldn’t even take it seriously enough to instigate legal action.”

So, what else happened as a consequence of the paper?

The answer is ‘lots’.

The Nazi-dean of the medical faculty in 1938, Eduard Pernkopf,  became the author of one of the world’s best anatomical atlas. Here is a short excerpt from a website on Pernkopf and his work which outlines some of the consequences of my paper:

START OF QUOTE

Following Dr. Edzard Ernst’s, revelations in the Annals of Internal Medicine (1995) about the source of Pernkopf’s “models,” Yad Vashem (the Holocaust Authority in Israel) requested that the Universities of Vienna and Insbruck conduct an independent inquiry to determine who the subjects in Pernkopf’s Atlas were and how they died. The request from Yad Vashem was initially denied; but the issue did not end. The following year, a letter by Dr. Seidelman and Dr. Howard Israel, an oral surgeon at Columbia University published in JAMA (November, 1996) in which they stated: “The abuses of medicine perpetrated during the Hitler regime pervaded the entire medical profession of the Third Reich including the academic elite. One legacy of the tragic era endures today through the continued publication of a critically acclaimed atlas, Pernkopf Anatomy…” Their letter prompted a report by the New York Times (1996).

In 1997, Alfred Ebenbauer, the rector of the University of Vienna, wrote to JAMA indicating that an investigation had been initiated and that preliminary findings indicated that the anatomy department had indeed, routinely received corpses of executed persons, among them renowned dissidents, and “brain preparations derived from children under the euthanasia program in psychiatric institutes were still stored there…” For the first time, he acknowledged publicly systematic suppression and even denial of the university’s Nazi past and its failure to conduct relevant investigations. Ebenbauer explained that this attitude had changed because of ‘‘increasing pressure from abroad’’ and a new political atmosphere in Austria (Ethics and Access…Pernkopf atlas, Bulletin of the Medical Library Association 2001; Hildebrandt, 2006).

Penkopf_Atlas Human Anatomy_neck-shoulderThe final report of University of Vienna investigation found that at least 1,377 bodies of executed victims (guillotined or shot by the Gestapo at a rifle range); about 7,000 bodies of fetuses and children; and “8 victims of Jewish origin” had been received by the Anatomy Institute. A statement for users of Pernkop’s Atlas sent out by the U of V to all libraries states: “it is therefore within the individual user’s ethical responsibility to decide whether and in which way he wishes to use this book.” (Hildebrandt, 2006). Hildebrandt states: “the influx of bodies from executions increased so much during the NS [Nazi] regime that the rooms of the anatomy institute were sometimes overfilled and executions had to be postponed because of this.” However, she notes that the true numbers are not known because of incomplete documentation.

Howard M. Spiro, M.D., director of Yale’s Program for Humanities in Medicine and professor of internal medicine, was among the noted speakers at the convocation in Vienna marking (1998) the 60th anniversary of the dismissal of Jewish faculty members from the Vienna Medical School. In his address The Silence of Words, Dr. Spiro said, “the things that we avoid and don’t talk about are the matters that mean the most to us. The shame that has no vent in words makes other organs weep.” Dr. Spiro acknowledged that current officials of the University of Vienna are attempting to recover information that has either been hidden or destroyed and trying to locate former faculty who were interned and exiled. “There is a new generation that has taken over, and they are not afraid to look into these atrocities.”

It is now understood that many of the incredibly detailed illustrations in Pernkopf’s atlas depicted the bodies of victims of Nazi terror.

END OF QUOTE

Why do I bring this up again today?

For two reasons: firstly, I have been invited to give two lecture about these events in recent weeks. Secondly and much more importantly, we seem to live in times when the threat of fascism in several countries has again become worrisomely acute, and I think reminding people of my conclusion drawn in 1995 might not be a bad idea:

This story needs to be told to honor its victims and to fortify us so that history does not repeat itself.

It would be wrong to call the Czech Republic the promised land for homeopathy. For instance, the only research paper by Czech authors related to the subject that I could locate was published in the Journal ‘Homeopathy‘ and, on even superficial reading, it has little to do with homeopathy. Here is the abstract:

We discovered a previously unknown phenomenon in liquid water, which develops over time when water is left to stand undisturbed, and which made precise gravimetric measurement impossible. We term this property autothixotropy (weak gel-like behaviour developing spontaneously over time) and propose a possible explanation. The results of quantitative measurements, performed by two different methods, are presented. We also report the newly discovered phenomenon of autothixotropy-hysteresis and describe the dependence of autothixotropy on the degree of molecular translative freedom. A very important conclusion is that the presence of very low concentration of salt ions, these phenomena do not occur in deionized water. Salt ions may be the determinative condition for the occurrence of the phenomena.

In fact, historically, homeopathy had had a hard time in this country. Until World War II only very few doctors practiced homeopathy on Czech territory. Dr. Quin, founder of British homeopathy, practiced a short time in the small town of Tisnov. A Catholic homeopathic hospital existed at Kromeriz since 1860. During the communist era of 1948-89, homeopathy was prohibited, and, until 1991, no books about homeopathy were available in the Czech language. More recently, about 20 titles were published by the Alternativa Publishing house. The Czech Homeopathic Medical Chamber is an organisation that only permits MDs and currently has about 1000 members. The Czech Medical Homeopathic Society has only about 300 members.

After the fall of the ‘iron curtain’, homeopathy evidently became more popular. It has recently been reported that the number of homeopathic remedies sold in the Czech Republic rose by over 50% during the past 15 years. Last year, Czechs bought homeopathic preparations for over 170 million crowns, which is 10% more than a year ago.  “The patients most frequently use homeopathics against the problems associated with common viral diseases,” said Ales Krebs, deputy chairman of the Czech Pharmacy Chamber.  The homeopathic flu remedy Oscillococcinum seems to be one of the most popular homeopathic preparation in the Czech Republic. Yet Czech chemists say that it is ‘absolute nonsense’.

Most physicians seem to be equally cynical about homeopathy and its practitioners: “Homeopathics are perfect drugs. The manufacturing is dirt cheap and they sell for 60 crowns. They cannot be forged because the fakes have the same effect as the original product,” Czech doctors joke about the growing interest in homeopathy. Stepan Svacina, chairman of the Czech Medical Society, says: “The doctor can use a placebo in a psychological therapy. It does not matter whether this may be a homeopathic preparation or jumping on one leg.” Another doctor is quoted as stating that “Advocates of homeopathy often argue with doctors’ conspiracy with pharmaceutical makers, but they themselves certainly do not offer their methods for free as a sort of philanthropy.”

The cost for a first consultation with a Czech homeopath ranges between 100 to 3,000 crowns. The patient pays another 800-1,000 crowns for each next examination. ($1 = 24.846 crowns)

In 2014, the Czech Republic Ministry of Health issued a press-release stating that…although the Ministry for Health of the Czech Republic does not perceive the evidence base for homeopathy to be strong enough yet, this does not prevent doctors from utilising this if it is desired and appropriate…

Because the use of homeopathy cannot ever be considered to be ‘appropriate’, this declaration could arguably be interpreted by those who insist on evidence as a new prohibition of homeopathy in the Czech Republic.

You have to excuse me, if I keep coming back to this theme: so-called ‘alternative cancer cures’ are truly dangerous. I have tried to explain this already many times, for instance here, here and here. And it is by no means just alternative therapists who make a living of such quackery. Sadly qualified medical doctors are often involved as well. As to prove my point, here is a tragic story that broke yesterday:

Former Miss New Hampshire, Rachel Petz Dowd, lost her battle with cancer on Sunday 12 June 2016 — a battle she fought publicly through personal writings in a blog in hopes of helping others on a similar journey toward healing. The singer/songwriter and mother of three from Auburn died about a month after traveling to Mexico for an aggressive form of alternative cancer treatment. She turned 47 last week. Dowd was diagnosed with stage 2 triple negative breast cancer in May 2014. The diagnosis led her to create a blog called “Rachel’s Healing” to document what she hoped would be a journey back to health. “I hope my readers can gain something from my journey and that they find their own personal way to combat this disease impacting too many women today,” she wrote. Dowd used the blog to share her experiences with traditional and natural medicine during her cancer fight.

On 5/3/16 Mrs Dowd wrote on her blog: “Well after some careful consideration and looking at different clinics and hospitals we’ve made a decision. Will be going to the CMN Hospital on the Yuma, Arizona border*. For 28 days of treatments. It’s not a day clinic but a full hospital servicing over the past 30 years. There’s a special wing dedicated to alternative cancer care and the treatment list is impressive.  Many treatments that are not available in this country. We feel this would be the best course of care daily for 28 days and then at the end of the 4 weeks I intend my immune system to be back on-line. I will be doing a stem cell boost of my bone marrow the last week. I know of a women, Shannon Knight, from The Truth About Cancer documentary, who had stage 4 metastasized into locations of her bones and her lungs and she came out of there completely cured. Her oncologist said it was nothing short of a miracle, but she said no it was just clean hard work!  She said no it was just clean the hard, aggressive treatments that only attack cancer, boost and prime your immune system, become a whole, healthy being once again:) It is possible and I am planning on being one of the exceptions like Shannon!”

  • The hospital is across the US border in Mexico; it is run by medically qualified personnel.

The hospital [“CMN Hospital’s facility is only 14 blocks away once you cross the border to begin your alternative cancer treatment”] has a website where they tell a somewhat confusing story about their treatment plans; here is a short but telling excerpt:

CMN’s protocols are individualized and comprehensive. You will benefit from oxidative therapies, IV minerals selenium and bicarbonate IV vitamins such as vitamin B-17 and IV vitamin C. Far infrared and others including MAHT, Cold Laser Therapy, Hyperbaric Oxygen Therapy and Ozone Therapy are a daily part of your protocol. Ultraviolet Blood Irradiation is effective in destroying pathogens in your blood and slows the growth of cancer cell growth. CMN’s Stem cell therapy and Dendritic cell therapy are just two of the advanced cancer treatments applied to patients.”

And here is what they say about three therapies as examples of treatments that have discussed before on this blog: vitamin C, Laetrile and Essiac.

IV Vitamin C If large amounts of vitamin C are presented to cancer cells, large amounts will be absorbed. In these unusually large concentrations, the antioxidant vitamin C will start behaving as a pro-oxidant as it interacts with intracellular copper and iron. This chemical interaction produces small amounts of hydrogen peroxide. Because cancer cells are relatively low in an intracellular anti-oxidant enzyme called catalase, the high dose vitamin C induction of peroxide will continue to build up until it eventually lyses the cancer cell from the inside out!

IV Vitamin B17 / Laetrile Also known as amygdaline, Vitamin B-17 is a molecule made up of four parts: -2 parts Glucose -1 part Benzaldahyde-1 part Hydrogen Cyanide. Laetrile is found in at least 1200 different plants, including apricots, peaches, apple seeds, lentils, cashews, brown rice, millet, and alfalfa. Commercial preparations of laetrile are obtained from the kernels of apricots, peaches and bitter almonds. The body requires an enzyme called beta-glucosidase in order to process laetrile and release the cyanide. Studies have shown that cancer cells contain more of this enzyme than normal cells, which allows for a higher release of cyanide at tumor sites. Another enzyme known as rhodanese is important in this process. Normal healthy cells contain rhodanese which protects them from the activated cyanide. Most cancer cells are deficient in this enzyme, leaving them vulnerable to the poison. Tumor destruction begins once the cyanide is released within the malignancies, meaning laetrile therapy is selectively toxic to cancer cells while remaining non-toxic to normal cells.

Essiac Tea / Order Original Essiac Tea Essiac, given its name by Rene Caisse (“caisse” spelt backwards), consists of four main herbs that grow in the wilderness of Ontario, Canada. The original formula is believed to have its roots from the native Canadian Ojibway Indians. The four main herbs that make up Essiac are Burdock Root, Slippery Elm Inner Bark, Sheep Sorrel and Indian Rhubarb Root. Essiac tea helps release toxins that build up in fat and tissues into the blood stream where they can be filtered and excreted by the liver and kidneys.  Cleaning the body of toxins and impurities frees up the immune system to focus on killing cancer cells and protecting the body.

 

I think I will abstain from further comments, firstly because I want to avoid getting sued by these people and secondly because it seems all too depressingly obvious.

Lots of people are puzzled how healthcare professionals – some with sound medical training – can become convinced homeopaths. Having done part of this journey myself, I think I know one possible answer to this question. So, let me try to explain it to you in the form of a ‘story’ of a young doctor who goes through this development. As you may have guessed, some elements of this story are autobiographical but others are entirely fictional.

Here is the story:

After he had finished medical school, our young and enthusiastic doctor wanted nothing more than to help and assist needy patients. A chain of coincidences made him take a post in a homeopathic hospital where he worked as a junior clinician alongside 10 experienced homeopaths. What he saw impressed him: despite of what he had learnt at med school, homeopathy seemed to work quite well: patients with all sorts of symptoms improved. This was not his or anybody else’s imagination, it was an undeniable fact.

As his confidence and his ability to think clearly grew, the young physician began to wonder nevertheless: were his patients’ improvements really due to the homeopathic remedies, or were these outcomes caused by the kind and compassionate care he and the other staff provided?

To cut a long story short, when he left the hospital to establish his own practice, he certainly knew how to prescribe homeopathics but he was not what one might call a convinced homeopath. He decided to employ homeopathy in parallel with conventional medicine and it turned out that he made less and less use of homeopathy as the months went by.

One day, a young women consulted him; she had been unsuccessfully trying to have a baby for two years and was now getting very frustrated, even depressed, with her childlessness. All tests on her and her husband had not revealed any abnormalities. A friend had told her that homeopathy might help, and see had therefore made this appointment to consult a doctor who had trained as a homeopath.

Our young physician was not convinced that he could help his patient but, in the end, he was persuaded to give it a try. As he had been taught by his fellow homeopaths, he conducted a full homeopathic history to find the optimal remedy for his patient, gave her an individualised prescription and explained that any effect might take a while. The patient was delighted that someone had given her so much time, felt well-cared for by her homeopaths, and seemed full of optimism.

Months passed and she returned for several further consultations. But sadly she failed to become pregnant. About a year later, when everyone involved had all but given up hope, her periods stopped and the test confirmed: she was expecting!

Everyone was surprised, not least our doctor. This outcome, he reasoned, could not possibly be due to placebo, or the good therapeutic relationship he had been able to establish with his patient. Perhaps it was just a coincidence?

In the small town where they lived, news spread quickly that he was able to treat infertility with homeopathy. Several other women with the same problem liked the idea of having an effective yet risk-free therapy for their infertility problem. The doctor thus treated several infertile women, about 10, during the next months. Amazingly most of them got pregnant within a year or so. The doctor was baffled, such a series of pregnancies could not be a coincidence, he reasoned.

Naturally, the cases that were talked about were the women who had become pregnant. And naturally, these were the patients our doctor liked to remember. Slowly he became convinced that he was indeed able to treat infertility homeopathically – so much so that he published a case series in a homeopathic journal about his successes.

In a way, he had hoped that, perhaps, someone would challenge him and explain where he had gone wrong. But the article was greeted nationally with much applause by his fellow homeopaths, and he was even invited to speak at several conferences. In short, within a few years, he made himself a name for his ability to help infertile women.

Patients now travelled from across the country to see him, and some even came from abroad. Our physician had become a minor celebrity in the realm of homeopathy. He also, one has to admit, had started to make very good money; most of his patients were private patients. Life was good. It almost goes without saying that all his former doubts about the effectiveness of homeopathic remedies gradually vanished into thin air.

Whenever now someone challenged his findings with arguments like ‘homeopathics are just placebos’, he surprised himself by getting quite angry. How do they dare doubt my data, he thought. The babies are there, to deny their existence means calling me a liar!

OUR DOCTOR HAD BECOME AN EVANGELICALLY CONVINCED HOMEOPATH, AND NO RATIONAL ARGUMENT COULD DISSUADE HIM.

And what arguments might that be? Isn’t he entirely correct? Can dozens of pregnancies be the result of a placebo effect, the therapeutic relationship or coincidence?

The answer is NO! The babies are real, very real.

But there are other, even simpler and much more plausible explanations for our doctor’s apparent success rate: otherwise healthy women who don’t get pregnant within months of trying do very often succeed eventually, even without any treatment whatsoever. Our doctor struck lucky when this happened a few times after the first patient had consulted him. Had he prescribed non-homeopathic placebos, his success rate would have been exactly the same.

As a clinician, it is all too easy and extremely tempting not to adequately rationalise such ‘success’. If the ‘success’ then happens repeatedly, one can be in danger of becoming deluded, and then one almost automatically ‘forgets’ one’s failures. Over time, this confirmation bias will create an entirely false impression and often even a deeply felt conviction.

I am sure that this sort of thing happens often, very often. And it happens not just to homeopaths. It happens to all types of quacks. And, I am afraid, it also happens to many conventional doctors.

This is how ineffective treatments survive for often very long periods. This is how blood-letting survived for centuries. This is how millions of patients get harmed following the advice of their trusted physicians to employ a useless or even dangerous therapy.

HOW CAN THIS SORT OF THING BE STOPPED?

The answer to this most important question is very simple: health care professionals need to systematically learn critical thinking early on in their education. The answer may be simple but its realisation is unfortunately not.

Even today, courses in critical thinking are rarely part of the medical curriculum. In my view, they would be as important as anatomy, physiology or any of the other core subjects in medicine.

The BMJ is my favourite medical journal by far; I think it is full of good science as well as entertaining to read, and I look forward to finding it in my letter box every Friday. It is thus hard for me to criticise the BMJ, and this is not made easier by the fact that I am the author of one of the two pieces in question. However, the current ‘HEAD TO HEAD’ entitled ‘SHOULD DOCTORS RECOMMEND HOMEOPATHY’ does, in my view, not mark the finest hour of this journal. Let me explain why.

The first question that arises is whether homeopathy is a good subject for such a debate. As several commentators have pointed out, it is not – the debate has long been closed; to serious scientists and many doctors, homeopathy tends to be a subject that is nothing more than an odd, obsolete triviality that does not even deserve a mention in the BMJ or any other serious publication. In a way, this notion has almost been proven wrong by the high level of interest the subject quickly generated. So, I will not dwell on this point any longer.

The second issue that arises just from nothing more than merely reading the title of the debate is that the question posed is imprecise. ‘Homeopathy’ is too broad a term for a focussed discussion; it includes amongst other phenomena empathetic encounters, remedies with material doses of highly active ingredients (e.g. Arsenic D1) and remedies that contain absolutely nothing at all (any ‘potency’ beyond C12). In my piece, I tried to make it clear that I speak mostly about ultra-molecular dilutions. This is less obvious in Peter Fisher’s article, and there is doubtlessly a lot of confusion in the debate as well as the comments that follow.

The two articles had to be written without either author knowing the text of the other. Consequently the issues raised by one author were not necessarily addressed by the other. This is somewhat frustrating, as it fails to clarify issues that could easily have been dealt with. In a previous post, I have already explained that the peer-review process of the two articles was seriously flawed. It failed to correct the many misleading statements in Fisher’s piece, as Alan Henness has pointed out in his response both in the BMJ and on this blog. In fact, reading Fisher’s article, I fail to find a single passage that is not factually wrong or highly misleading (the accompanying podcast is even worse, in my view). To me it is obvious that the debate about homeopathy cannot advance, if one side continues to behave in this fashion.

Homeopaths are very adept at recruiting ‘grass roots’ for public relation activities. We know this from various previous experiences. It was therefore predictable that this would swiftly get organised also in this instance. I happen to know from more than one source that there was a highly active campaign by homeopaths trying to persuade their supporters to post responses on the BMJ site and to vote on the BMJ straw poll (scientists, by contrast, know that such polls are silly gadgets and tend to view homeopathy as a triviality that is not worth the effort). In this way, they try to generate the impression that the majority of the public stands firmly behind homeopathy and want doctors to recommend it. It does not need too much to realise that popularity is not a measure of efficacy. Homeopaths, however, tend to relish logical fallacies and therefore will rejoice at such nonsense and celebrate it as their very own victory.

So, was this ‘HEAD TO HEAD’ a mistake? Should I have refused to participate? With hindsight, perhaps. My main reason for accepting was that, had I declined the offer, someone else would have written the piece (there are plenty of excellent scientists who could do an excellent job at this). As sure as hell, that person would subsequently gotten attacked for not ever having researched and/or practiced homeopathy (in the podcast, Fisher even tried to undermine my authority by pointing out that 1) I have not worked as a clinician for decades and 2) I have no NHS contract). I think I may be one of the few critics of homeopathy who cannot possibly be accused of not knowing enough about homeopathy to discuss the subject.

My hope is that, because the BMJ is such an excellent journal, the two articles will survive the current hoo-hah and some people will read them carefully, look up and study the references, analyse all this critically and weigh the arguments responsibly. Then they must be able to discern the fiction from the facts. And in this case, perhaps it was worth it after all.

Many experts have argued that the growing popularity of alternative medicine (AM) mandates their implementation into formal undergraduate medical education. Most medical students seem to feel a need to learn about AM. Yet little is known about the student-specific need for AM education. The objective of this paper was address this issue, specifically the authors wanted to assess the self-reported need for AM education among Australian medical students.

Thirty second-year to final-year medical students participated in semi-structured interviews. A constructivist grounded theory methodological approach was used to generate, construct and analyse the data.

The results show that these medical students generally held favourable attitudes toward AM but had knowledge deficits and did not feel adept at counselling patients about AMs. All students were supportive of integrating AM into education, noting its importance in relation to the doctor-patient encounter, specifically with regard to interactions with medical management. Students recognised the need to be able to effectively communicate about AMs and advise patients regarding safe and effective AM use.

The authors of this survey concluded that Australian medical students expressed interest in, and the need for, AM education in medical education regardless of their opinion of it, and were supportive of evidence-based AMs being part of their armamentarium. However, current levels of AM education in medical schools do not adequately enable this. This level of receptivity suggests the need for AM education with firm recommendations and competencies to assist AM education development required. Identifying this need may help medical educators to respond more effectively.

One might object to such wide-reaching conclusions based on a sample size of just 30. However, there are several similar surveys from other parts of the world which seem to paint a similar picture: most medical students clearly do want to learn about AM. But this issue raises several important questions:

  • How can this be squeezed into the already over-full curriculum?
  • Should students learn about AM or should they learn how to practice AM?
  • Who should teach this subject?

In my view, students should learn the essentials about AM but not how to do this or that therapy. Most deans of medical schools seem to agree with me on that particular point.

The question as to who should teach students about AM is, however, much more contentious. Most conventional medical instructors have no interest in and/or no knowledge of the subject. Consequently, there is a tendency for medical schools to delegate AM by hiring a few alternative practitioners to cover AM. Thus we see homeopaths teaching medical students all (well, almost all) about homeopathy, acupuncturists teaching acupuncture, herbalists teaching herbal medicine etc. To many observers, this might sound right and reasonable – but I beg to differ resolutely.

Most alternative practitioners who I have met (and these were many over the last 20 years) are clearly not capable of teaching their own subject in a way that befits a medical school. They have little or no idea about the nature of scientific evidence and usually lack the slightest hint of critical analysis. Thus a homeopaths might teach homeopathy such that students get the impression that it is well grounded in evidence, for instance. Students who have been taught in this fashion are not likely to advise their future patients responsibly on the subject in question: THE TEACHING OF NONSENSE IS BOUND TO RESULT IN NONSENSICAL PRACTICE!

In my view, AM is an ideal subject to acquaint medical students with the concepts of critical thinking. In this respect, it offers an almost opportunity for medical schools to develop much-needed skills in their students. Sadly, however, this is not what is currently happening. All too often, medical school deans find themselves caught between the devil and the deep blue sea. In the end, they tend to delegate the subject of AM to people who are not competent and should not be let loose on impressionable students.

I fear that progress and care of future patients are bound to suffer.

 

As I grew up in Germany, it was considered entirely normal that I was given homeopathic remedies when ill. I often wondered whether, with the advent of EBM, this has changed. A recent paper provides an answer to this question.

In this nationwide German survey, data were collected from 3013 children on their utilization of medicinal products, including homeopathic and other alternative remedies.

In all, 26% of the reported 2489 drugs were from the realm of alternative medicine. The 4-week prevalence for homeopathy was 7.5%. Of the drugs identified as alternative, 53.7% were homeopathic remedies, and 30.8% were herbal drugs. Factors associated with higher medicinal use of alternative remedies were female gender, residing in Munich, and higher maternal education. A homeopathy user utilized on average homeopathic remedies worth EUR 15.28. The corresponding figure for herbal drug users was EUR 16.02, and EUR 18.72 for overall medicinal CAM users. Compared with data from 4 years before, the prevalence of homeopathy use had declined by 52%.

The authors concluded that CAM use among 15-year-old children in the GINIplus cohort is popular, but decreased noticeably compared with children from the same cohort at the age of 10 years. This is possibly mainly because German health legislation normally covers CAM for children younger than 12 years only.

The survey shows that homeopathy is still a major player in the health care of German children. From the point of view of a homeopath, this makes a lot of sense: children are supposed to respond particularly well to homeopathy. But is that really true? The short answer is NO.

Our systematic review of all relevant studies tells it straight: The evidence from rigorous clinical trials of any type of therapeutic or preventive intervention testing homeopathy for childhood and adolescence ailments is not convincing enough for recommendations in any condition.

In other words, the evidence is very much at odds with the practice. This begs the question, I think, HOW SHOULD WE INTERPRET THIS DISCREPANCY?

A few possibilities come into mind, and I would be grateful to hear from my readers which they think might be correct:

  • Homeopathy is used as a ‘benign placebo’ [clinicians know that most paediatric conditions are self-limiting and thus prefer to give placebos rather than drugs that can cause adverse effects].
  • Doctors prescribe homeopathy mainly because the kids’ parents insist on them.
  • Doctors believe that homeopathic remedies are more than just placebos [in which case they are clearly ill-informed].
  • German doctors do not believe in scientific evidence and prefer to rely on their intuition.
  • This high level of homeopathy usage misleads the next generation into believing in quackery.
  • It amounts to child abuse and should be stopped.

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