A 2016 article set out to define the minimum core competencies expected from a certified paediatric doctor of chiropractic using a Delphi consensus process. The initial set of seed statements and sub-statements was modelled on competency documents used by organizations that oversee chiropractic and medical education. The statements were then distributed to the Delphi panel, reaching consensus when 80% of the panelists approved each segment. The panel consisted of 23 specialists in chiropractic paediatrics from across the spectrum of the chiropractic profession. Sixty-one percent of panellists had postgraduate paediatric certifications or degrees, 39% had additional graduate degrees, and 74% were faculty at a chiropractic institution and/or in a postgraduate paediatrics program. The panel was initially given 10 statements with related sub-statements formulated by the study’s steering committee. On all 3 rounds of the Delphi process the panelists reached consensus; however, multiple rounds occurred to incorporate the valuable qualitative feedback received.
The results of this process reveal that the Certified Paediatric Doctor of Chiropractic requires 8 sets of skills. (S)he will …
1) Possess a working knowledge and understanding of the anatomy, physiology, neurology, psychology, and developmental stages of a child. a) Recognize known effects of the prenatal environment, length of the pregnancy, and birth process on the child’s health. b) Identify and evaluate the stages of growth and evolution of systems from birth to adulthood. c) Appraise the clinical implications of developmental stages in health and disease, including gross and fine motor, language/communication, and cognitive, social, and emotional skills. d) Recognize normal from abnormal in these areas. e) Possess an understanding of the nutritional needs of various stages of childhood.
2) Recognize common and unusual health conditions of childhood. a) Identify and differentiate clinical features of common physical and mental paediatric conditions. b) Identify and differentiate evidence-based health care options for these conditions. c) Identify and differentiate clinical features and evidence-based health care options for the paediatric special needs population.
3) Be able to perform an age-appropriate evaluation of the paediatric patient. a) Take a comprehensive history, using appropriate communication skills to address both child and parent/ guardian. b) Perform age-appropriate and case-specific physical, orthopaedic, neurological, and developmental examination protocols. c) When indicated, utilize age-appropriate laboratory, imaging, and other diagnostic studies and consultations, according to best practice guidelines. d) Appropriately apply and adapt these skills to the paediatric special needs population. e) Be able to obtain and comprehend all relevant external health records.
4) Formulate differential diagnoses based on the history, examination, and diagnostic studies.
5) Establish a plan of management for each child, including treatment, referral to, and/or co-management with other health care professionals. a) Use the scientific literature to inform the management plan. b) Adequately document the patient encounter and management plan. c) Communicate management plan clearly (written, oral, and nonverbal cues) with both the child and the child’s parent/guardian. d) Communicate appropriately and clearly with other professionals in the referral and co-management of patients.
6) Deliver skilful, competent, and safe chiropractic care, modified for the paediatric population, including but not limited to: a) Manual therapy and instrument-assisted techniques including manipulation/adjustment, mobilization, and soft tissue therapies to address articulations and/or soft tissues. b) Physical therapy modalities. c) Postural and rehabilitative exercises. d) Nutrition advice and supplementation. e) Lifestyle and public health advice. f) Adapt the delivery of chiropractic care for the paediatric special needs population.
7) Integrate and collaborate with other health care providers in the care of the paediatric patient. a) Recognize the role of various health care providers in paediatric care. b) Utilize professional inter-referral protocols. c) Interact clearly and professionally as needed with health care professionals and others involved in the care of each patient. d) Clearly explain the role of chiropractic care to professionals, parents, and children.
8) Function as a primary contact, portal of entry practitioner who will. a) Be proficient in paediatric first aid and basic emergency procedures. b) Identify and report suspected child abuse.
9) Demonstrate and utilize high professional and ethical standards in all aspects of the care of paediatric patients and professional practice. a) Monitor and properly reports of effects/adverse events. b) Recognize cultural individuality and respect the child’s and family’s wishes regarding health care decisions. c) Engage in lifelong learning to maintain and improve professional knowledge and skills. d) Contribute when possible to the knowledge base of the profession by participating in research. e) Represent and support the specialty of paediatrics within the profession and to the broader healthcare and lay communities.
I find this remarkable in many ways. Let us just consider a few items from the above list of competencies:
Identify and differentiate evidence-based health care options… such options would clearly not include chiropractic manipulations.
Identify and differentiate clinical features and evidence-based health care options for the paediatric special needs population… as above. Why is there no mention of immunisations anywhere?
Perform age-appropriate and case-specific physical, orthopaedic, neurological, and developmental examination protocols. If that is a competency requirement, patients should really see the appropriate medical specialists rather than a chiropractor.
Establish a plan of management for each child, including treatment, referral to, and/or co-management with other health care professionals. The treatment plan is either evidence-based or it includes chiropractic manipulations.
Deliver skilful, competent, and safe chiropractic care… Aren’t there contradictions in terms here?
Manual therapy and instrument-assisted techniques including manipulation/adjustment, mobilization, and soft tissue therapies to address articulations and/or soft tissues. Where is the evidence that these treatments are effective for paediatric conditions, and which conditions would these be?
Clearly explain the role of chiropractic care to professionals, parents, and children. As chiropractic is not evidence-based in paediatrics, the role is extremely limited or nil.
Function as a primary contact, portal of entry practitioner… This seems to me as a recipe for disaster.
Demonstrate and utilize high professional and ethical standards in all aspects of the care of paediatric patients… This would include obtaining informed consent which, in turn, needs to include telling the parents that chiropractic is neither safe nor effective and that better therapeutic options are available. Moreover, would it not be ethical to make clear that a paediatric ‘doctor’ of chiropractic is a very far cry from a real paediatrician?
So, what should the competencies of a chiropractor really be when it comes to treating paediatric conditions? In my view, they are much simpler than outlined by the authors of this new article: I SEE NO REASON WHATSOEVER WHY CHIROPRACTORS SHOULD TREAT CHILDREN!
Who – apart from quacks – would not want to get rid of all quackery, once and for all? It would be a huge improvement to medicine, save thousands of lives, and reduce our expenditure for health care considerably.
But how? How can we possibly get rid of something that is as ancient as medicine itself?
All we need to do is to employ the existing ethical imperatives. I am thinking in particular about INFORMED CONSENT.
Informed consent is a process for obtaining permission from a patient before treating him/her. It requires the patient’s clear and full understanding of the relevant facts, implications, and consequences of the treatment. It is a ‘condition sine qua non’; no health care professional must commence a treatment without it.
And how would informed consent get rid of all quackery?
This is perhaps best explained by giving an example. Imagine a patient is about to receive a quack treatment – let’s take crystal healing (we could have chosen any other implausible non-evidence based therapy, e. g. homeopathy, chiropractic, Bach Flower Remedies, faith-healing, etc.) – for his/her condition – let’s say diabetes (we could have chosen any other condition, e. g. cancer, asthma, insomnia, etc.). Informed consent would require that, before starting the intervention, the therapist informs the patient about the relevant facts, implications and consequences of having crystal healing for diabetes. This would include the following:
- the therapy is not plausible, it is not in line with the laws of nature as we understand them today,
- there is no evidence that the treatment will cure your condition or ease your symptoms beyond a placebo-effect,
- the treatment may harm you in several ways: 1) it might cause direct harm (unlikely with crystal healing but not with chiropractic, for instance), 2) it will harm your finances because the therapist wants to be paid, 3) most importantly, if you believe that it could help you and therefore forego effective therapy for your diabetes, it could easily kill you within a few days.
It is impossible to dispute that these facts are true and relevant, I think. And if they are relevant, the practitioner must convey them in such a way that they are fully appreciated by the patient. If the patient comprehends the implications fully, he/she is unlikely to agree to the treatment. If most patients refuse to be treated, the market for crystal healing quickly collapses, and crystal healers move into other, more productive jobs. This might even help the general economy!
But quacks are not in the habit of obtaining fully informed consent, I hear you say. I agree, and this is why they must be taught to do so in their quack colleges. If informed consent was taught to all budding quacks, they would soon realise that quackery is not a viable business and go to a proper school where they lean something useful (this too might help the economy). If that happens, the quack colleges would soon run out of money and close.
Meanwhile, one could remind the existing quacks that they break the law, if they neglect informed consent. In the interest of the patient, one could closely monitor the consent giving process, and even think of increasingly heavy finds for those who break the law.
As we see, almost all the means for rendering health care quack-free already exist. All we need to do is implement them. That shouldn’t be difficult, should it?
AND NOW I STOP DAY-DREAMING AND DO SOMETHING USEFUL.
Medical ethics comprise a set of rules and principles which are essential for all aspects of medicine, including of course research. The main issues are:
- Respect for autonomy – patients must have the right to refuse or choose their treatments.
- Beneficence – researchers and clinicians must act in the best interest of the patient.
- Non-maleficence – the expected benefits of interventions must outweigh their risks.
- Justice – the distribution of health resources must be fair.
- Respect for persons – patients must be treated with dignity.
- Truthfulness and honesty – informed consent is an essential element in research and clinical practice.
While all of this has long been fairly standard in conventional health care, it is often neglected in alternative medicine. It is therefore timely to ask, how much of research in the realm of alternative medicine abides by the rules of medical ethics?
After more than two decades of involvement in this sector, I have serious and growing concerns. The subject is, of course complex, but the way I see it, in alternative medicine there are two main areas where medical ethics are violated with some regularity.
- Nonsensical research projects
- Lack of informed consent
NONSENSICAL RESEARCH PROJECTS
At best, nonsensical research is a waste of precious resources, at worst it violates the beneficence principle. In alternative medicine, nonsensical research seems to happen ad nauseam. Regular readers of this blog will have seen plenty of examples of such abuse – for instance, if researchers conduct a clinical trial of chiropractic spinal manipulation for improving the singing voices of choir singers, or homeopaths test whether their remedies enhance female fertility. Often, nonsensical research happens when naïve enthusiasts decide to dabble a bit in science in order to promote their trade – but without realising that research would require a minimum of education.
But there are other occasions when it seems that the investigators know only too well what they are doing. Take for instance the plethora of ‘pragmatic’ trials which are currently so much ‘en vogue’ in alternative medicine. They can be designed in such a way that their results must produce what the researchers intended to show; the ‘A+B versus B’ study design is a prominent and obvious example of this type of abuse which I have repeatedly written about on this blog.
I use the term ‘abuse’ intentionally, because that is precisely what it is, in my view. Nonsensical research abuses the willingness of patients to participate by misleading them that it is a worthwhile sacrifice. In reality it is an unethical attempt to generate findings that can mislead us all. Moreover, it gives science a bad name and can lead to patients’ unwillingness to take part in research that does need doing. The damage done by nonsensical research projects is therefore immeasurable.
Informed consent is essential in research for protecting the interests of the volunteering patients. When a clinical trial is first conceived, the researchers need to work out all the details, write a protocol and submit it to their ethics committee. Their submission has to give evidence that all the participating patients have given informed consent in writing before they are enrolled into the study. That means, they have to be told the essential details about what might happen to them during the trial.
In a placebo-controlled trial of homeopathy, for instance, they might be told that they will receive either a homeopathic remedy or a placebo during the study period. They might also be informed that there is some encouraging evidence that the former works, and that the trial is designed to define to what extend this is so. Generating this knowledge, they might further be told, will help future patients and will be an important contribution to improving health care. Based on such phraseology, the ethics committee is likely to allow the study to go ahead, and patients are likely to agree to take part.
But, of course, this information is less than truthful. An honest and full information for patients would need to include the following points:
- you will receive either a homeopathic remedy or a placebo,
- the former contains no active molecules and the totality of the most reliable evidence does not show that it works for your condition,
- this means that you will receive either a homeopathic or a conventional placebo,
- neither of these can possibly help your condition,
- the study can therefore not advance our knowledge in any way,
- during the trial your condition will remain untreated which is likely to increase your suffering unnecessarily.
If any research team would truthfully disclose this information, no ethics committee would pass their protocol. If by some weird mistake they did, no patients would volunteer to participate in the study.
I have chosen here the example of homeopathy (because most readers will understand it quite easily), but I could have used almost any other alternative treatment. The issues are identical or very similar: informed consent is usually misinformed consent. If it were fully and truthfully informed, it would neither pass the hurdle of the essential ethics approval nor would it lend itself to recruiting sufficiently large numbers of patients.
There are, I think, very serious concerns about the ethical standards in alternative medicine research. I have been banging on about these issues since many years (for instance here and here and here and here). Predictably, this did not find much resonance in the realm of alternative medicine. Regrettably, very few ethicists have so far taken this subject seriously; they seem to feel that these problems are trivial compared to the important issues medical ethics face in conventional health care. I remain unconvinced that this is true and believe it is high time to systematically address the ethics of alternative medicine.
Chiropractors like to promote themselves as primary healthcare professionals. But are they? A recent survey might go some way towards addressing this question. It was based on a cross sectional online questionnaire distributed to 4 UK chiropractic associations. The responses were collected over a period of two months from March 26th 2012 to May 25th 2012.
Of the 2,448 members in the 4 participating associations, 509 chiropractors (~21%) completed the survey. The results of the survey show that the great majority of UK chiropractors surveyed reported evaluating and monitoring patients in regards to posture (97.1%), inactivity/overactivity (90.8%) and movement patterns (88.6%). Slightly fewer provided this type of care for psychosocial stress (82.3%), nutrition (74.1%) and disturbed sleep (72.9%). Still fewer did so for smoking (60.7%) and over-consumption of alcohol (56.4%). Verbal advice given by the chiropractor was reported as the most successful resource to encourage positive lifestyle changes as reported by 68.8% of respondents. Goal-setting was utilised by 70.7% to 80.4% of respondents concerning physical fitness issues. For all other lifestyle issues, goal-setting was used by approximately two-fifths (41.7%) or less. For smoking and over-consumption of alcohol, a mere one-fifth (20.0% and 20.6% respectively) of the responding chiropractors set goals.
The authors of this survey concluded that UK chiropractors are participating in promoting positive lifestyle changes in areas common to preventative healthcare and health promotion areas; however, more can be done, particularly in the areas of smoking and over-consumption of alcohol. In addition, goal-setting to support patient-provider relationships should be more widespread, potentially increasing the utility of such valuable advice and resources.
When I saw that a new UK-wide survey of chiropractic has become available, I had great expectations. Sadly, they were harshly disappointed. I had hoped that, after going to the considerable trouble of setting up a nationwide survey of this nature, we would have some answers to the most urgent questions that currently plague chiropractic and are amenable to study by survey. In my view, some of these questions include:
- How many chiropractors actually see themselves as primary care professionals?
- What conditions do chiropractors treat?
- Specifically how many of them believe they can treat non-spinal conditions effectively?
- How many chiropractors regularly treat children?
- For which conditions?
- How many patients get X-rayed by chiropractors?
- How many are in favour of vaccinations?
- How many are aware of adverse effects of spinal manipulation?
- How chiropractors obtain informed consent before starting treatment?
- What percentage of chiropractors use spinal manipulation?
- What other treatments are used how often?
- How often do chiropractors advise their patients about medications prescribed by real doctors?
- How often do they refer patients to other health care providers?
All of these questions are highly relevant and none of them has recently been studied. But, sadly, the new paper does not answer them. Why? As I see it, there are several possibilities:
- Chiropractors do not find these questions as relevant as I do.
- They do not want to know the answers.
- They do not like to research issues that might shine a bad light on them.
- They view research mostly as a promotional exercise.
- They did research (some of) these questions but do not dare to publish the results.
- They will publish the results in a separate paper.
It would be interesting to hear from the authors which possibility applies.
In many countries, consumers seem to be fond of consulting chiropractors – mostly for back pain, but also for other conditions. I therefore think it is might be a good and productive idea to give anyone who is tempted to see a chiropractor some simple, easy to follow advice. Here we go:
- Ask your chiropractor what he/she thinks about the chiropractic concept of subluxation. This is the chiropractors’ term (real doctors use the word too but understand something entirely different by it) for an imagined problem with your spine. Once they have diagnosed you to suffer from subluxation, they will persuade you that it needs correcting which is done by spinal manipulation which they tend to call ‘adjustments’. There are several important issues here: firstly subluxations do not exist outside the fantasy world of chiropractic; secondly chiropractors who believe in subluxation would diagnose subluxation in about 100% of the population – also in individuals who are completely healthy. My advice is to return straight back home as soon as the chiropractor admits he believes in the mystical concept of subluxation.
- Ask your chiropractor what he/she thinks of ‘maintenance care’. This is the term many chiropractors use for indefinite treatments which do little more than transfer lots of cash from your account to that of your chiropractor. There is no good evidence to show that maintenance care does, as chiropractors claim, prevent healthy individuals from falling ill. So, unless you have the irresistible urge to burn money, don’t fall for this nonsense. You should ask your chiropractor how long and frequent your treatment will be, what it will cost, and then ask yourself whether it is worth it.
- Run a mile, if the chiropractor wants to manipulate your neck (which most will do regardless of whether you have neck-pain, some even without informed consent). Neck manipulation is associated with very serious complications; they are usually caused by an injury to an artery that supplies parts of your brain. This can cause a stroke and even death. Several hundred such cases have been documented in the medical literature – but the true figure is almost certainly much larger (there is still no system in place to monitor such events).
- Run even faster, if the chiropractor wants to treat your children for common paediatric conditions. Many chiropractors believe that their manipulations are effective for a wide range of health problems that kids frequently suffer from. However, there is not a jot of evidence that these claims are true.
- Be aware that about 50% of all patients having chiropractic treatments will suffer from side effects like pain and stiffness. These symptoms usually last for 2-3 days and can be severe enough to impede your quality of life. Ask yourself whether the risk is outweighed by the benefit of chiropractic.
- Remember that there is no good evidence that chiropractors can treat any condition effectively other than lower back pain (and even for that condition the evidence is far from strong). Many chiropractors claim to be able to treat a plethora of non-spinal conditions like asthma, ear infection, gastrointestinal complaints, autism etc. etc. There is no good evidence that these claims are correct.
- Distrust the advice given by many chiropractors regarding prescribed medications, vaccinations or surgery. Chiropractic has a long history of warning their patients against all sorts of conventional treatments. Depending on the clinical situation, following such advice can cause very serious harm.
I am minded to write similar posts for all major alternative therapies (this will not make me more popular with alternative therapists, but I don’t mind all that much) – provided, of course, that my readers find this sort of article useful. So, please do give me some feedback.
‘Healing, hype or harm? A critical analysis of complementary or alternative medicine’ is the title of a book that I edited and that was published in 2008. Its publication date coincided with that of ‘Trick or Treatment?’ and therefore the former was almost completely over-shadowed by the latter. Consequently few people know about it. This is a shame, I think, and this post is dedicated to encouraging my readers to have a look at ‘Healing, hype or harm?’
One reviewer commented on Amazon about this book as follows: Vital and informative text that should be read by everyone alongside Ben Goldacre’s ‘Bad Science’ and Singh and Ernt’s ‘Trick or Treatment’. Everyone should be able to made informed choices about the treatments that are peddled to the desperate and gullible. As Tim Minchin famously said ‘What do you call Alternative Medicine that has been proved to work? . . . Medicine!’
This is high praise indeed! But I should not omit the fact that others have commented that they were appalled by our book and found it “disappointing and unsettling”. This does not surprise me in the least; after all, alternative medicine has always been a divisive subject.
The book was written by a total of 17 authors and covers many important aspects of alternative medicine. Some of its most famous contributors are Michael Baum, Gustav Born, David Colquhoun, James Randi and Nick Ross. Some of the most important subjects include:
As already mentioned, our book is already 6 years old; however, this does not mean that it is now out-dated. The subject areas were chosen such that it will be timely for a long time to come. Nor does this book reflect one single point of view; as it was written by over a dozen different experts with vastly different backgrounds, it offers an entire spectrum of views and attitudes. It is, in a word, a book that stimulates critical thinking and thoughtful analysis.
I sincerely think you should have a look at it… and, in case you think I am hoping to maximise my income by telling you all this: all the revenues from this book go to charity.
The purpose of this paper by Canadian chiropractors was to expand practitioners’ knowledge on areas of liability when treating low back pain patients. Six cases where chiropractors in Canada were sued for allegedly causing or aggravating lumbar disc herniation after spinal manipulative therapy were retrieved using the CANLII database.
The patients were 4 men and 2 women with an average age of 37 years. Trial courts’ decisions were rendered between 2000 and 2011. The following conclusions from Canadian courts were noted:
- informed consent is an on-going process that cannot be entirely delegated to office personnel;
- when the patient’s history reveals risk factors for lumbar disc herniation the chiropractor has the duty to rule out disc pathology as an aetiology for the symptoms presented by the patients before beginning anything but conservative palliative treatment;
- lumbar disc herniation may be triggered by spinal manipulative therapy on vertebral segments distant from the involved herniated disc such as the thoracic spine.
The fact that this article was published by chiropractors seems like a step into the right direction. Disc herniations after chiropractic have been reported regularly and since many years. It is not often that I hear chiropractors admit that their spinal manipulations carry serious risks.
And it is not often that chiropractors consider the issue of informed consent. One the one hand, one hardly can blame them for it: if they ever did take informed consent seriously and informed their patients fully about the evidence and risks of their treatments as well as those of other therapeutic options, they would probably be out of business for ever. One the other hand, chiropractors should not be allowed to continue excluding themselves from the generally accepted ethical standards of modern health care.
It almost goes without saying that alternative practitioners contribute importantly to the ‘sea of misinformation’ about alternative medicine. Again, I could write books about this subject but have to refrain myself and therefore will merely put quick spotlights on several types of practitioners, mostly drawing from my own research on these subjects.
A survey of more than 9000 patients of U.K. non-medically trained acupuncturists showed that a considerable number had received advice from their therapists about prescribed medicines. Since these acupuncturists hold no medical qualifications, they are not qualified to issue such advice. It is therefore clear to me that the advice given is likely to be misleading. In 2000, we directly asked the U.K. acupuncturists’ advice about electro-acupuncture treatment for smoking cessation, a treatment which we previously had identified to be ineffective. The advice we received was frequently not based on current best evidence and some of it also raised serious safety concerns (Schmidt, K., & Ernst, E. Internet advice by acupuncturists—a risk factor for cardiovascular patients? Perfusion,2002, 15: 44-50. Article not Medline-listed).
Many chiropractors from the UK and other countries make unsustainable therapeutic claims on their websites. In 2002, at the height of the ‘‘MMR scare’’ in Britain, we conducted a study revealing that a sizable proportion of U.K. chiropractors advised mothers against having the measles-mumps-rubella (MMR) jab for their children. A survey of the U.K. chiropractors demonstrated that an alarming percentage of the U.K. chiropractors fail to provide advice about the risks of spinal manipulation before commencing treatment. As these risks are, in fact, considerable, this behaviour amounts to misinformation and is an obvious violation of medical ethics.
With osteopaths, it is a very similar story; the main difference is that there are far less investigations than for chiropractors. This may be due to the fact that, in the US, osteopaths are not alternative but conventional clinicians with much the same training and skills as proper doctors. But in Europe, they are strictly alternative and make as many bogus claims as chiropractors. Systematic investigations are rare, but I only need to remind us of my recent blog-post where I pointed out that:
Most osteopaths treat children for a wide range of conditions and claim that their interventions are helpful. They believe that children are prone to structural problems which can be corrected by their interventions. Here is an example from just one of the numerous promotional websites on this topic:
STRUCTURAL PROBLEMS, such as those affecting the proper mobility and function of the body’s framework, can lead to a range of problems. These may include:
- Postural – such as scoliosis
- Respiratory – such as asthma
- Manifestations of brain injury – such as cerebral palsy and spasticity
- Developmental – with delayed physical or intellectual progress, perhaps triggering learning behaviour difficulties
- Infections – such as ear and throat infections or urinary disturbances, which may be recurrent.
OSTEOPATHY can assist in the prevention of health problems, helping children to make a smooth transition into normal, healthy adult life.
Encouraging evidence exists for some specific herbs in the treatment of some specific conditions. Yet, virtually no good evidence exists to suggest that the prescriptions of individualized herbal mixtures by traditional herbalists across the globe generate more good than harm. Despite this lack of evidence, herbalists do not seem to offer this information voluntarily to his or her patients. When we directly asked the UK herbalists for advice on a clinical case, we found that it was ‘‘misleading at best and dangerous at worst’’ . In other words, herbalists misinform their patients and the public about the value of their treatments.
Many non-medically trained homeopaths advise their clients against the immunization of children. Instead, these practitioners often recommend using ‘‘homeopathic vaccinations’’ for which no good evidence exists. For instance, the vice-chair of the board of directors of ‘‘The Society of Homeopaths’’ had a site with the following statements: ‘‘Homeopathic alternatives to children’s immunisation are now available.’’ ‘‘Our clinic offers alternative immunisation programmes for the whole family.’’ Such statements amounts to misinformation which puts children’s health at risk.
Other alternative practitioners
I have chosen the above-listed professions almost at random and could have selected any other type as well. Arguably, all alternative practitioners who employ unproven treatments – and that must be the vast majority – misinform their patients to some extend. The only way to avoid this is to say: ‘look, I am going to give you a therapy for which there is no good evidence – I hope you don’t mind’. If they did that, they would be out of business in a flash. It follows, I think, that being in business is tantamount to misleading patients.
And there is, of course, another way of misinforming patients which is often forgotten yet very important: withholding essential information. In all of health care, informed consent is a ‘sine qua non’. Alternative practitioners very rarely obtain informed consent from their patients. The reason seems obvious (see above). I would argue that not informing people when they should be informed is a form of misinformation.
In this context, it is worth mentioning an investigation we did in 2009: We obtained the ethical codes of the following bodies: Association of Naturopathic Practitioners, Association of Traditional Chinese Medicine (UK), Ayurvedic Practitioners Association, British Acupuncture Council, Complementary and Natural Healthcare Council, European Herbal Practitioners Association, General Chiropractic Council, General Osteopathic Council, General Regulatory Council for Complementary Therapies, National Institute of Medical Herbalists, Register of Chinese Herbal Medicine, Society of Homeopaths, UK Healers, Unified Register of Herbal Practitioners. We then extracted the statements from these codes referring to evidence-based practice (EBP). The results showed that only the General Chiropractic Council, the General Osteopathic Council and the General Regulatory Council for Complementary Therapies oblige their members to adopt EBP.
It seems that misinformation is an alternative practitioner’s daily bread. Without it, alternative therapists would need to confine their practice to the few treatments/conditions for which the evidence is positive. If they ever followed this strategy, they would hardly be able to earn a living.
Alternative medicine has the image of being gentle and risk-free; it is therefore frequently used for children. German experts have just published an important article on this rather controversial topic.
They performed a systematic synthesis of all Cochrane reviews in paediatrics assessing the efficacy, clinical implications and limitations of alternative medicine use in children. The main outcome variables were: percentage of reviews concluding that a certain intervention provides a benefit, percentage of reviews concluding that a certain intervention should not be performed, and percentage of studies concluding that the current level of evidence is inconclusive. A total of 135 reviews were included – most from the United Kingdom (29), Australia (24) and China (24). Only 5 (3.7%) reviews gave a recommendation in favour of a certain intervention; 26 (19.4%) issued a conditional positive recommendation. The 5 positive recommendations were:
1) Calcium supplements during pregnancy for prevention of hypertension and related conditions
2) Creatinine supplements for treating muscular disorders
3) Zinc supplements for prevention of pneumonia
4) Probiotics for prevention of upper respiratory infections
5) Acupuncture for prevention of post-operative nausea and vomiting
Nine (6.6%) reviews concluded that certain interventions should not be performed. Ninety-five reviews (70.3%) were inconclusive. The proportion of inconclusive reviews increased over time. The three most common criticisms of the quality of the primary studies included were: more research needed (82), low methodological quality (57) and small number of study participants (48).
The authors concluded: Given the disproportionate number of inconclusive reviews, there is an ongoing need for high quality research to assess the potential role of CAM in children. Unless the study of CAM is performed to the same science-based standards as conventional therapies, CAM therapies risk being perpetually marginalised by mainstream medicine.
As it happens, we published a very similar review two years ago. At the time (and using slightly different inclusion criteria), we identified a total of 17 systematic reviews. They related to acupuncture, chiropractic, herbal medicine, homeopathy, hypnotherapy, massage and yoga. Results were unconvincing for most conditions, but there was some evidence to suggest that acupuncture may be effective for postoperative nausea and vomiting, and that hypnotherapy may be effective in reducing procedure-related pain. Most of the reviews failed to mention the incidence of adverse effects of the alternative treatments in question. Our conclusions were as follows: “Although there is some encouraging evidence for hypnosis, herbal medicine and acupuncture, there is insufficient evidence to suggest that other CAMs are effective for the treatment of childhood conditions. Many of the systematic reviews included in this overview were of low quality, as were the randomised clinical trials within those reviews, further reducing the weight of that evidence. Future research in CAM for children should conform to the reporting standards outlined in the CONSORT and PRISMA guidelines.”
Treating children with unproven or dis-proven therapies is even more problematic than treating adults in this way. The main reason is that children cannot give informed consent. Thus alternative medicine for children can open difficult ethical questions, and sometimes I wonder where the line is between the application of bogus treatments and child-abuse. Examples are parents who opt for homeopathic vaccinations instead of conventional ones, or paediatric cancer patients who are being treated with bogus alternatives such as laetrile.
Why would parents not want the most effective therapy for their children? Why would anyone opt for dubious alternatives? The main reason, I think, must be misinformation. Parents who use alternative medicine are convinced they are effective and safe because they have been misinformed. We only need to google ALTERNATIVE MEDICINE to see for ourselves what utter nonsense and dangerous rubbish is being promoted under this umbrella.
Misinformation is the foremost reason why well-meaning parents (mis-) treat their children with alternative medicine. The results can be disastrous. Misinformation can kill!
Daniels and Vogel recently published an article entitled “Consent in osteopathy: A cross sectional survey of patients’ information and process preferences” (INTERNATIONAL JOURNAL OF OSTEOPATHIC MEDICINE 2012, 15:3, p.92-102). It addresses an important yet woefully under-researched area.
I find most laudable that two osteopaths conduct research into medical ethics; but the questions still are, does the article tell us anything worth knowing and is it sufficiently rigorous and critical? As the journal does not seem to be available on Medline, I cannot provide a link. I therefore take the liberty of quoting the most important bits from directly the abstract here.
Objective: To explore and describe patients’ preferences of consent procedures in a sample of UK osteopathic patients.
Methods: A cross sectional survey using a new questionnaire was performed incorporating paper and web-based versions of the instruments. 500 copies were made available, (n = 200) to patients attending the British School of Osteopathy (BSO) clinic, and (n = 300) for patients attending 30 randomly sampled osteopaths in practice. Quantitative data were analysed descriptively to assess patient preferences; non-parametric analyses were performed to test for preference difference between patients using demographic characteristics.
Results: 124 completed questionnaires were returned from the BSO sample representing a 41% response rate. None were received from patients attending practices outside of the BSO clinic. The majority (98%) of patient respondents thought that having information about rare yet potentially severe risks of treatment was important. Patients’ preferred to have this information presented during the initial consultation (72%); communication method favoured was verbal (90%). 99% would like the opportunity to ask questions about risks, and all respondents (100%) consider being informed about their current diagnosis as important.
Conclusion: Patients endorse the importance of information exchange as part of the consent process. Verbal communication is very important and is the favoured method for both receiving information and giving consent. Further research is required to test the validity of these results in practice samples
The 0% response-rate in patients from non-BSO practices is, of course, remarkable and not without irony. In my view, it highlights better than anything else the fact that informed consent rarely appears on the osteopathic radar screen. In a way, this increases the praise we should give the two authors for tackling the issue.
The central question of the survey is whether patients want to know about the risks of osteopathy. This is more than a little bizarre: informed consent is not an option, it is a legal, moral and ethical obligation. It seems therefore odd to ask the question “do you want to learn about the risks which you are about to be exposed to?”
Even odder is, I think, the second question “when do you want to receive this information?” It goes without saying that informed consent has to happen before the intervention! This is what, common sense tells us, the law dictates and ethical codes prescribe.
There is general agreement amongst health care professionals and ethicist that verbal consent does suffice in most therapeutic situations, that patients must have the opportunity to ask questions, and that informed consent also extends to diagnostic issues. So, the questions referring to these issues are also a bit strange or naive, in my view.
The article might be revealing mostly by what it does not address rather than by what it tells us. It would be really valuable to know the percentage of osteopaths who abide by the legal, moral and ethical imperative of informed consent in their daily practice. To the best of my knowledge, this information is not available [if anyone has such information, please let me know and provide the reference]. Assuming that it is similar to the percentage of UK chiropractors who obtain informed consent, it might be seriously wanting: only 45% of them routinely obtain informed consent from their patients.
Another issue that, in my view, would be relevant to clarify is the nature of the information provided by osteopaths to patients, other than that of serious risks associated with spinal manipulation/mobilisation. Do they tell their patients about the evidence suggesting that osteopathy does (not) work for the condition at hand? Do they elaborate on non-osteopathic treatments for that disease? I fear that the answers to these questions might well be negative.
Imagine a patient being told that there is no good evidence for effectiveness of osteopathy, that the possibility of some harm exists, and that other interventions might actually do more good than harm than what the osteopath has to offer. How likely is it that this patient would agree to receiving osteopathic treatment?
For most alternative practitioners, including osteopaths, informed consent and most other important ethical issues have so far remained highly uncomfortable areas. This may have a good and simple reason: they have the potential to become real and serious threats to their current practice and business. I suspect this is why there is so very little awareness of and research into the ethics of alternative medicine: “best not to wake sleeping lions”, seems to be the general attitude.
The survey by Daniels and Vogel, even though it touches upon an important topic, avoids the truly pertinent questions. It therefore looks to me a bit like a fig leaf shamefully hiding an area of potential embarrassment.
And where do we go from here? I predict that the current strategy of alternative practitioners to ignore and violate medical ethics as much as possible will not be tolerated for much longer. Double standards in health care cannot and should not survive. The sooner we begin addressing some of these uncomfortable questions with rigorous research, the better – perhaps not for the practitioner but certainly for the patient.