Yesterday, I heard my ‘good friend’ Dr Michael Dixon (see here, here and here, for example) talk on the BBC about the “new thing” in healthcare: social prescribing. He explained, for instance, that social prescribing could mean treating a diabetic not with medication but with auto-hypnosis and other alternative therapies. At that moment, I wasn’t even entirely sure what the term ‘social prescribing’ meant, I have to admit – so I did some reading.
What is social prescribing?
The UK ‘Social Prescribing Network‘ defines it thus:
Social Prescribing is a means of enabling GPs and other frontline healthcare professionals to refer patients to a link worker – to provide them with a face to face conversation during which they can learn about the possibilities and design their own personalised solutions, i.e. ‘co-produce’ their ‘social prescription’- so that people with social, emotional or practical needs are empowered to find solutions which will improve their health and wellbeing, often using services provided by the voluntary and community sector. It is an innovative and growing movement, with the potential to reduce the financial burden on the NHS and particularly on primary care.
Does social prescribing work?
The UK King’s Fund is mildly optimistic:
There is emerging evidence that social prescribing can lead to a range of positive health and well-being outcomes. Studies have pointed to improvements in areas such as quality of life and emotional wellbeing, mental and general wellbeing, and levels of depression and anxiety. For example, a study into a social prescribing project in Bristol found improvements in anxiety levels and in feelings about general health and quality of life. In general, social prescribing schemes appear to result in high levels of satisfaction from participants, primary care professionals and commissioners.
Social prescribing schemes may also lead to a reduction in the use of NHS services. A study of a scheme in Rotherham (a liaison service helping patients access support from more than 20 voluntary and community sector organisations), showed that for more than 8 in 10 patients referred to the scheme who were followed up three to four months later, there were reductions in NHS use in terms of accident and emergency (A&E) attendance, outpatient appointments and inpatient admissions. The Bristol study also showed reductions in general practice attendance rates for most people who had received the social prescription.
However, robust and systematic evidence on the effectiveness of social prescribing is very limited. Many studies are small scale, do not have a control group, focus on progress rather than outcomes, or relate to individual interventions rather than the social prescribing model. Much of the evidence available is qualitative, and relies on self-reported outcomes. Researchers have also highlighted the challenges of measuring the outcomes of complex interventions, or making meaningful comparisons between very different schemes.
Determining the cost, resource implications and cost effectiveness of social prescribing is particularly difficult. The Bristol study found that positive health and wellbeing outcomes came at a higher cost than routine GP care over the period of a year, but other research has highlighted the importance of looking at cost effectiveness over a longer period of time. Exploratory economic analysis of the Rotherham scheme, for example, suggested that the scheme could pay for itself over 18–24 months in terms of reduced NHS use….
END OF QUOTES
Is there no harder evidence at all?
The only Medline-listed controlled study seems to have been omitted by the King’s Fund – I wonder why. Perhaps because it fails to share the optimism? Here is its abstract:
Social prescribing is targeted at isolated and lonely patients. Practitioners and patients jointly develop bespoke well-being plans to promote social integration and or social reactivation. Our aim was to investigate: whether a social prescribing service could be implemented in a general practice (GP) setting and to evaluate its effect on well-being and primary care resource use. We used a mixed method evaluation approach using patient surveys with matched control groups and a qualitative interview study. The study was conducted in a mixed socio-economic, multi-ethnic, inner city London borough with socially isolated patients who frequently visited their GP. The intervention was implemented by ‘social prescribing coordinators’. Outcomes of interest were psychological and social well-being and health care resource use. At 8 months follow-up there were no differences between patients referred to social prescribing and the controls for general health, depression, anxiety and ‘positive and active engagement in life’. Social prescribing patients had high GP consultation rates, which fell in the year following referral. The qualitative study indicated that most patients had a positive experience with social prescribing but the service was not utilised to its full extent. Changes in general health and well-being following referral were very limited and comprehensive implementation was difficult to optimise. Although GP consultation rates fell, these may have reflected regression to the mean rather than changes related to the intervention. Whether social prescribing can contribute to the health of a nation for social and psychological wellbeing is still to be determined.
So, there is a lack of evidence for social prescribing. Yet, this is not why I feel uneasy about the promotion of this “new thing”. The more i think about it, the more I realise that social prescribing is just good care and decent medicine. It is what I was taught at med school 40 years ago. It therefore seems like a fancy name for something that should be obvious.
But why my unease?
The way I see it, it will be (and perhaps already is) used to smuggle bogus alternative therapies into the mainstream. In this way, it could turn out to serve the same purpose as did the boom in integrative/integrated medicine/healthcare: a smokescreen to incorporate treatments into medical routine which otherwise would not pass muster. If advocates of this approach, like Michael Dixon, subscribe to it, the danger of this happening is hard to deny.
The disservice to patients (and medical ethics) would then be obvious: diabetics unquestionably can benefit from a change of life-style (and to encourage them is part of good conventional medicine), but I very much doubt that they should replace their anti-diabetic medications with auto-hypnosis or other alternative therapies.
Orac recently lost his rag over JOHN WEEKS, editor of JCAM (see also here, here, here and here), and was less than appreciative of his recent comments on the Samueli-donation. Personally, I think that this was a bit harsh. To compensate the poor chap for such an injustice, I herewith offer John a place in my ‘Alt Med Hall of Fame’.
There he is in good company:
Deepak Chopra (US entrepreneur)
Cheryl Hawk (US chiropractor)
David Peters (osteopathy, homeopathy, UK)
Nicola Robinson (TCM, UK)
Peter Fisher (homeopathy, UK)
Simon Mills (herbal medicine, UK)
Gustav Dobos (various, Germany)
Claudia Witt (homeopathy, Germany and Switzerland)
George Lewith (acupuncture, UK)
John Licciardone (osteopathy, US)
have all been honoured in the same way.
But John is special!
I have mentioned him several times before (see here, here and here); what makes him special, in my view, is that he is such a shining example of an expert in ‘integrative medicine’. He calls himself a “a writer, speaker, chronicler and organizer whose work in the movement for integrative health” and proudly presents his lifetime achievement award (I urge you to read it – everyone who is anyone in the US quackery-cult pored a little praise over John – but be careful, you might feel acutely nauseous). Towards the end of this document, John adds some self-praise by summarising the many other ‘HONORS’ he has received:
- – For public education, American Association of Naturopathic Physicians (1988)
- – For role in historic regional accreditation of a college of natural health sciences, Bastyr College/now Bastyr University (1989)
- – Commencement speaker, Bastyr College (1989)
- – Honorary Doctor of Naturopathic Medicine, Bastyr University (1992)
- – For service, American Association of Naturopathic Physicians (1993)
- – For service, Washington Mental Health Counselors Association (1995)
- – Commencement speaker, Northwestern Health Sciences University (2010)
- – Honorary Doctor of Laws, National University of Health Sciences (2011)
- – Honorary Doctor of Naturopathic Medicine, Canadian College of Naturopathic Medicine (2012)
- – Commencement speaker, New York Chiropractic College (2013)
- – Champion of Naturopathic Medicine, American Association of Naturopathic Physicians (2013)
So what? I hear you say, what is so special about that?
I will tell you what is special:
- John is not a doctor,
- John is not a practitioner,
- John is not a scientist,
- John has not published anything that we might call research,
- John has not studied any healthcare-related subject,
- John has, as far as I can see, no real university degree at all.
I find this remarkable and wonderful! It shows us like few other things what to think of the alternative medicine-cult. Not only can truly anyone become president in the US (as the last election has demonstrated); in the US anyone can become a celebrated and honoured champion of alternative medicine as well!
Welcome in my ‘Hall of Fame’ John!
It has been announced that Susan and Henry Samueli have given US$ 200 million to medical research at the University of California, Irvine (UCI). Surely this is a generous and most laudable gift! How could anyone doubt it?
As with any gift, one ought to ask what precisely it is for. If someone made a donation to research aimed at showing that climate change is a hoax, that white supremacy is justified, or that Brexit is going to give Brits their country back, I doubt that it would be a commendable thing. My point is that research must always be aimed at finding the truth and discovering facts. Research that is guided by creed, belief or misinformation is bound to be counter-productive, and a donation to such activities is likely to be detrimental.
Back to the Samuelis! The story goes that Susan once had a cold, took a homeopathic remedy, and subsequently the cold went away. Ever since, the two Samuelis have been supporters not just of homeopathy but all sorts of other alternative therapies. I have previously called this strikingly common phenomenon an ‘epiphany‘. And the Samuelis’ latest gift is clearly aimed at promoting alternative medicine in the US. We only need to look at what their other major donation in this area has achieved, and we can guess what is now going to happen at UCI. David Gorski has eloquently written about the UCI donation, and I will therefore not repeat the whole, sad story.
Instead I want to briefly comment on what, in my view, should happen, if a wealthy benefactor donates a large sum of money to medical research. How can one maximise the effects of such a donation? Which areas of research should one consider? I think the concept of prior probability can be put to good use in such a situation. If I were the donor, I would convene a panel of recognised experts and let them advise me where there are the greatest chances of generating important breakthroughs. If one followed this path, alternative medicine would not appear anywhere near the top preferences, I dare to predict.
But often, like in the case of the Samuelis, the donors have concrete ideas about the area of research they want to invest in. So, what could be done with a large sum in the field of alternative medicine? I believe that plenty of good could come it. All one needs to do is to make absolutely sure that a few safeguards are in place:
- believers in alternative medicine must be kept out of any decisions processes;
- people with a solid background in science and a track-record in critical thinking must be put in charge;
- the influence of the donor on the direction of the research must be minimised as much as possible;
- a research agenda must be defined that is meaningful and productive (this could include research into the risks of alternative therapies, the ethical standards in alternative medicine, the fallacious thinking of promoters of alternative medicine, the educational deficits of alternative practitioners, the wide-spread misinformation of the public about alternative medicine, etc., etc.)
Under all circumstances, one needs to avoid that the many pseudo-scientists who populate the field of alternative or integrative medicine get appointed. This, I fear, will not be an easy task. They will say that one needs experts who know all about the subtleties of acupuncture, homeopathy, energy-healing etc. But such notions are merely smoke-screens aimed at getting the believers into key positions. My advice is to vet all candidates using my concept of the ‘trustworthiness index’.
How can I be so sure? Because I have been there, and I have seen it all. I have researched this area for 25 years and published more about it than any of the untrustworthy believers. During this time I trained about 90 co-workers, and I have witnessed one thing over and over again: someone who starts out as a believer, will hardly ever become a decent scientist and therefore never produce any worthwhile research; but a good scientist will always be able to acquire the necessary knowledge in this or that alternative therapy to conduct rigorous and meaningful research.
So, how should the UCI spend the $ 200 million? Apparently the bulk of the money will be to appoint 15 faculty chairs across medicine, nursing, pharmacy and population health disciplines. They envisage that these posts will go to people with expertise in integrative medicine. This sounds extremely ominous to me. If this project is to be successful, these posts should go to scientists who are sceptical about alternative medicine and their main remit should be to rigorously test hypotheses. Remember: testing a hypothesis means trying everything to show that it is wrong. Only when all attempts to do so have failed can one assume that perhaps the hypothesis was correct.
My experience tells me that experts in integrative medicine are quite simply intellectually and emotionally incapable of making serious attempts showing that their beliefs are wrong. If the UCI does, in fact, appoint people with expertise in integrative medicine, it is, I fear, unavoidable that we will see:
- research that fails to address relevant questions;
- research that is of low quality;
- promotion masquerading as research;
- more and more misleading findings of the type we regularly discuss on this blog;
- a further boost of the fallacious concept of integrative medicine;
- a watering down of evidence-based medicine;
- irreversible damage to the reputation of the UCI.
In a nutshell, instead of making progress, we will take decisive steps back towards the dark ages.
We have repeatedly discussed on this blog the fact that many alternative practitioners are advising their patients against vaccinations, e. g.:
- Governments take action to prevent vaccination-rates from falling
- Use of alternative medicine is associated with low vaccination rates
- Integrative medicine physicians tend to harbour anti-vaccination views
- Vaccination: chiropractors “espouse views which aren’t evidence based”
- Faith-healing as an alternative to vaccination?
- Recommending homeoprophylaxis is unethical, irresponsible and possibly even criminal
- Chiropractors are undermining public health
- CAM use is risk factor for the failure to immunise children
- Let’s be blunt: homeopathy is bogus – but homeoprophylaxis is worse, much worse!
- Are mothers being taught by homeopaths to become anti-vaxers?
- Some naturopaths are clearly a danger to public health
There is little doubt that this phenomenon contributes to low immunisation rates. This, in turn, is a contributing factor to outbreaks of measles and other infectious diseases. The website of the European Centre for Disease Prevention and Control has recently published data on measles outbreaks in Europe:
Bulgaria: There is an increase by three cases since 21 July 2017. Since the beginning of 2017 and as of 16 July, Bulgaria reported 166 cases. During the same time period in 2016 Bulgaria reported one case.
France: On 27 July 2017 media quoting the French Minister of Health reported the death of a 16-year-old unvaccinated girl. She had fallen sick in Nice and died on 27 June 2017 in Marseille.
Germany: There is an increase by four cases since the last report on 21 July 2017. Since the beginning of 2017 and as of 26 July, Germany reported 801 cases. During the same time period in 2016 Germany reported 187 cases.
Italy: There is an increase by 170 cases since 21 July 2017. Since the beginning of 2017 and as of 25 July, Italy reported 3 842 cases, including three deaths. Among the cases, 271 are healthcare workers. The median age is 27 years, 89% of the cases were not vaccinated and 6% received only one dose of vaccine.
Romania: There is an increase by 229 cases, including one additional death, since 21 July 2017. Since 1 January 2016 and as of 21 July 2017, Romania reported 8 246 cases, including 32 deaths. Cases are either laboratory-confirmed or have an epidemiological link to a laboratory-confirmed case. Infants and young children are the most affected groups. Timis, in the western part of the country closest to the border with Serbia, is the most affected district with 1 215 cases. Vaccination activities are ongoing in order to cover communities with suboptimal vaccination coverage.
Spain: There is an increase by seven cases since 14 July 2017. Since the beginning of 2017 and as of 25 July, Spain reported 145 measles cases.
United Kingdom: Public Health Wales reported two additional cases related to the outbreak in Newport and Torfaen, bringing the total to ten cases related to this outbreak. In England and Wales there is an increase by 76 cases since 21 July 2017. Since the beginning of 2017 and as of 23 July 2017, England and Wales reported 922 cases. In the same time period in 2016, they reported 946 cases.
In addition to the updates listed above ECDC produces a monthly measles and rubella monitoring report with surveillance data provided by the member states through TESSy. The last report was published on 11 July 2017 with data up to 31 May 2017.
Measles outbreaks continue to occur in EU/EEA countries. There is a risk of spread and sustained transmission in areas with susceptible populations. The national vaccination coverage remains less than 95% for the second dose of MMR in the majority of EU/EEA countries. The progress towards elimination of measles in the WHO European Region is assessed by the European Regional Verification Commission for Measles and Rubella Elimination (RVC). Member States of the WHO European Region are making steady progress towards the elimination of measles. At the fifth meeting of the RVC for Measles and Rubella in October 2016, of 53 countries in the WHO European Region, 24 (15 of which are in the EU/EEA) were declared to have reached the elimination goal for measles, and 13 countries (nine in the EU/EEA) were deemed to have interrupted endemic transmission for between 12 and 36 months, meaning they are on their way to achieving the elimination goal. However, six EU/EEA countries were judged to still have endemic transmission: Belgium, France, Germany, Italy, Poland and Romania. More information on strain sequences would allow further insight into the epidemiological investigation.
All EU/EEA countries report measles cases on a monthly basis to ECDC and these data are published every month. Since 10 March 2017, ECDC has been reporting measles outbreaks in Europe on a weekly basis and monitoring worldwide outbreaks on a monthly basis through epidemic intelligence activities. ECDC published a rapid risk assessment on 6 March.
END OF QUOTE
Personally, I believe that it is high time to stop the rhetoric and actions of the anti-vaccination movements. This includes educating alternative practitioners and their patients. If necessary, we need regulation that prohibits their dangerous and unethical activities.
According to Wikipedia, “the Bundesverband der Pharmazeutischen Industrie (BPI) with headquarters in Berlin is an Eingetragener Verein and the German industry association/trade group for the pharmaceutical industry. It represents 240 German pharmaceutical and Biotech companies in with altogether approximately 70,000 employees. BPI has an office in Brussels. The focus of the BPI is on political consulting and public relations on the EU-level.”
The BPI has recently published a remarkable press-release about homeopathy. As it is in German, I will translate it for you (and append the original text for those who can read German).
HERE WE GO:
Homeopathy is a recognised and proven therapy for patients in Germany . This is demonstrated by a new, BPI-sponsored survey . About half of all questioned had experience with homeopathic remedies . More than 70% of those people are satisfied or very satisfied with their effectiveness and safety .
“Homeopathic remedies are important for many patients in Germany”, says Dr. Norbert Gerbsch, deputy chair of the BPI. ” If therapists and patients use them correctly, they can support the therapeutic success . Therefore, they should be recognised by conventional medicine as an integrative medicine  – that is what patients in Germany clearly want .”
Two thirds of the people surveyed think it is important or very important, that therapies like anthroposophical medicine and homeopathy are supported politically next to conventional medicine . More than 70% find it personally important or very important that health insurances pay for selected anthroposophical and homeopathic services . More than 80% said they would favour this. Thus, the majority is for keeping homeopathy amongst the services that can be chosen by the insurances for reimbursement .
Dr. Norbert Gerbsch: “The survey proves that very many individuals integrate, use and treasure homeopathy as an additional and usually safe therapy . Those who aim at curtailing therapeutic freedom patronise numerous patients in Germany who can benefit from it . There are numerous diseases for which homeopathy can be used as an integrative therapeutic option . Thus, many conventional physicians employ homeopathic and anthroposophic remedies in parallel to guideline-orientated medicine [3, 11].”
(Homöopathie ist eine anerkannte und bewährte Therapieform für Patienten in Deutschland. Das belegt eine neue, vom BPI beauftragte Forsa-Umfrage. Rund die Hälfte der Befragten hat demnach bereits Erfahrung mit homöopathischen Arzneimitteln. Über 70 Prozent von ihnen sind zufrieden oder sehr zufrieden mit der Wirksamkeit und Verträglichkeit.
„Homöopathische Arzneimittel haben für viele Patienten in Deutschland einen hohen Stellenwert“, sagt Dr. Norbert Gerbsch, stellvertretender BPI-Hauptgeschäftsführer. „Wenn Behandler und Patienten sie richtig und verantwortungsvoll einsetzen, kann sie den Therapieerfolg unterstützen. Sie sollte insofern als wichtige Ergänzung der Schulmedizin im Sinne einer Integrativen Medizin anerkannt werden – das wünschen sich die Patienten in Deutschland eindeutig.“
Fast zwei Drittel der von Forsa Befragten finden es wichtig bis sehr wichtig, dass sich die Politik neben schulmedizinischen Behandlungsmethoden auch aktiv für Heilmethoden wie etwa Homöopathie oder Anthroposophische Medizin einsetzt. Über 70 Prozent finden es persönlich wichtig bis sehr wichtig, dass Krankenkassen ihren Versicherten auch die Kosten für ausgewählte Leistungen aus dem Bereich der homöopathischen Medizin erstatten. Mit über 80 Prozent überdurchschnittlich häufig plädieren Befragte mit Homöopathie-Erfahrung für die Kostenübernahme ausgewählter Leistungen durch die Krankenkassen. Damit stimmt die Mehrheit für den Erhalt der Homöopathie im Rahmen von sogenannten Satzungsleistungen, die von den Krankenkassen individuell festgelegt werden können.
Dr. Norbert Gerbsch: „Die Umfrage belegt, dass sehr viele Menschen Homöopathie als ergänzende und in der Regel nebenwirkungsarme Therapieoption in die Behandlung integrieren, sie nutzen und achten. Wer die Therapiefreiheit und -vielfalt beschneiden will, bevormundet zahlreiche Patienten in Deutschland, die davon profitieren können. Es gibt eine Vielzahl an Erkrankungen, bei denen homöopathische Arzneimittel als integraler Bestandteil von Therapien einsetzbar sind. So nutzen viele Schulmediziner neben dem gesamten Spektrum der leitlinienorientierten Medizin gleichzeitig die integrativen Angebote der Homöopathie und Anthroposophischen Medizin.“)
I DO APPOLOGISE FOR MY POOR TRANSLATION; I HAVE ALWAYS FOUND THAT IT IS VERY HARD TO TRANSLATE SOMETHING THAT SIMPLY DOES NOT MAKE SENSE!
I have rarely seen such an unscientific, irrational, nonsensical and promotional comment from an organisation and an individual that should know better. Mr. Gerbsch studied biotechnology and graduated in 1997 in bioprocess engineering. He headed a scientific team following his promotion to director of a trans-departmental research topic with 13 professorships at the Technical University of Berlin. He later took on responsibilities as commissioner, officer and director of various companies. Since 2006, Mr. Gerbsch works as department manager of biotechnology / research & development at BPI and is responsible for the biotechnology department and innovation & research committee.
Here are just a few short points of criticism referring to the numbers I have added in my translation:
- Homeopathy is recognised and proven to be a pure placebo-therapy.
- A survey of this nature can at best gauge the current opinion.
- Fallacy: appeal to popularity.
- Perceived effectiveness/safety is not the same as true effectiveness/safety.
- There is no good evidence for this statement.
- What patients want might be interesting, but it cannot determine what they need; medicine is not a supermarket!
- I suspect this is the result of a leading question.
- This is where the BPI discloses the aim of the survey and their comment about it: they want the German health insurances to continue paying for homeopathic and anthroposophical placebos because some of their member companies earn their money selling them. In other words, the BPI actively hinder progress.
- No, those who advocate not paying for placebos want to encourage progress in healthcare for the benefit of patients and society.
- “Can be used” is an interesting phraseology! It is true, one can use homeopathy – but one cannot use it effectively because it has no effect beyond placebo.
- Yes, many physicians are sadly more focussed on their own cash-flow than on the best interest of their patients. Not all that different from the BPI, it seems.
It is beyond me how an organisation like the BPI can produce such shamefully misleading, dangerous and unethical drivel. Not one word about the fact that all international bodies have condemned homeopathy as being a useless and dangerous placebo-therapy! Who ever thought that the BPI was an independent organisation (homeopathy manufacturers belong to its membership) has been proven wrong by the above press-release.
The BPI clearly needs reminding of their duty to inform the public responsibly. I recommend that the leading heads of this organisation urgently attend one course on critical thinking followed by another on medical ethics.
In their now famous 1998 NEJM editorial about alternative medicine, Angell and Kassirer concluded that “It is time for the scientific community to stop giving alternative medicine a free ride. There cannot be two kinds of medicine — conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted. But assertions, speculation, and testimonials do not substitute for evidence. Alternative treatments should be subjected to scientific testing no less rigorous than that required for conventional treatments.”
Then and today, I entirely agree(d) with these sentiments. Years later, the comedian Tim Minchin brought it to the point: “You know what they call alternative medicine that’s been proved to work? – Medicine.” So, comedians have solved the terminology problem, but we, the experts, have not managed to get rid of the notion that there is another type of medicine. Almost 20 years after the above editorial, we still struggle to find the ideal name.
Despite their desperate demand ‘THERE CANNOT BE TWO KINDS OF MEDICINE’, Angell and Kassirer still used the word ALTERNATIVE MEDICINE. On this blog, I usually do the same. But there are many terms, and it is only fair to ask: which one is the most suitable?
- ALTERNATIVE MEDICINE is strictly speaking an umbrella term for modalities (therapy or diagnostic technique) employed as a replacement of conventional medicine; more commonly the term is used for all heterodox modalities.
- CHARLATANERY treatment by someone who professes to have expertise that he does not have.
- COMPLEMENTATY MEDICINE is an umbrella term for modalities usually employed as an adjunct to conventional healthcare.
- COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM) an umbrella term for both 1 and 3 often used because the same alternative modality can be employed either as a replacement of or an add-on to conventional medicine.
- COMPLEMENTARY AND INTEGRATIVE MEDICINE (CIM) a nonsensical term recently created by authors of an equally nonsensical BMJ review.
- DISPROVEN MEDICINE is an umbrella term for treatments that have been shown not to work (as proving a negative is usually impossible, there are not many such therapies).
- FRINGE MEDICINE is the term formerly used for alternative medicine.
- HETERODOX MEDICINE is the linguistically correct term for unorthodox medicine (this could be the most correct term but has the disadvantage that consumers are not familiar with it).
- HOLISTIC MEDICINE is healthcare that emphasises whole patient care (as all good medicine is by definition holistic, the term seems problematic).
- INTEGRATED MEDICINE describes the use of treatments that allegedly incorporate ‘the best of both worlds’, i.e. the best of alternative and conventional healthcare (integrated medicine can be shown to be little more than a smokescreen for adopting bogus treatments in conventional medicine).
- INTEGRATIVE MEDICINE is the same as 10 (10 is more common in the UK, 11 is more common in the US).
- NATURAL MEDICINE is healthcare exclusively employing the means provided by nature for treating disease.
- QUACKERY is the deliberate misinterpretation of the ability of a treatment or diagnostic technique to treat or diagnose disease (quackery exists in all types of healthcare).
- TRADITIONAL MEDICINE is healthcare that has been in use before the scientific era (the assumption is that such treatments have stood the test of time).
- UNCONVENTIONAL MEDICINE is healthcare not normally used in conventional medicine (this would include off-label use of drugs, for instance, and therefore does not differentiate well).
- UNORTHODOX MEDICINE the linguistically incorrect but often used term for healthcare that is not normally used in orthodox medicine.
- UNPROVEN MEDICINE is healthcare that lacks scientific proof (many conventional therapies fall in this category too).
These terms and explanations (mostly my own) are meant to bring out clearly that:
- none of them is perfect,
- none has ever been clearly defined,
- none describes the area completely,
- none is without considerable overlap to other terms,
- none is really useful.
My conclusion, after pondering about these terms for many years (it can be an intensely boring issue!), is that the best solution would be to abandon all umbrella terms (see Angell and Kassirer above). Alas, that hardly seems practical when running a blog on the subject. I think therefore that I will continue to (mostly) use the term ALTERNATIVE MEDICINE (consumers understand it best, in my experience) … unless, of course, someone has a better idea.
A recent post discussed a ‘STATE OF THE ART REVIEW’ from the BMJ. When I wrote it, I did not know that there was more to come. It seems that the BMJ is planning an entire series on the state of the art of BS! The new paper certainly looks like it:
Headaches, including primary headaches such as migraine and tension-type headache, are a common clinical problem. Complementary and integrative medicine (CIM), formerly known as complementary and alternative medicine (CAM), uses evidence informed modalities to assist in the health and healing of patients. CIM commonly includes the use of nutrition, movement practices, manual therapy, traditional Chinese medicine, and mind-body strategies. This review summarizes the literature on the use of CIM for primary headache and is based on five meta-analyses, seven systematic reviews, and 34 randomized controlled trials (RCTs). The overall quality of the evidence for CIM in headache management is generally low and occasionally moderate. Available evidence suggests that traditional Chinese medicine including acupuncture, massage, yoga, biofeedback, and meditation have a positive effect on migraine and tension headaches. Spinal manipulation, chiropractic care, some supplements and botanicals, diet alteration, and hydrotherapy may also be beneficial in migraine headache. CIM has not been studied or it is not effective for cluster headache. Further research is needed to determine the most effective role for CIM in patients with headache.
My BS-detector struggled with the following statements:
- integrative medicine (CIM), formerly known as complementary and alternative medicine (CAM) – the fact that CIM is a nonsensical new term has been already mentioned in the previous post;
- evidence informed modalities – another new term! evidence-BASED would be too much? because it would require using standards that do not apply to CIM? double standards promoted by the BMJ, what next?
- CIM commonly includes the use of nutrition – yes, so does any healthcare or indeed life!
- the overall quality of the evidence for CIM in headache management is generally low and occasionally moderate – in this case, no conclusions should be drawn from it (see below);
- evidence suggests that traditional Chinese medicine including acupuncture, massage, yoga, biofeedback, and meditation have a positive effect on migraine and tension headaches – no, it doesn’t (see above)!
- further research is needed to determine the most effective role for CIM in patients with headache – this sentence does not even make the slightest sense to me; have the reviewers of this article been asleep?
And this is just the abstract!
The full text provides enough BS to fertilise many acres of farmland!
Moreover, the article is badly researched, cherry-picked, poorly constructed, devoid of critical input, and poorly written. Is there anything good about it? You tell me – I did not find much!
My BS-detector finally broke when we came to the conclusions:
The use of CIM therapies has the potential to empower patients and help them take an active role in their care. Many CIM modalities, including mind-body therapies, are both self selected and self administered after an education period. This, coupled with patients’ increased desire to incorporate integrative medicine, should prompt healthcare providers to consider and discuss its inclusion in the overall management strategy. Low to moderate quality evidence exists for the effectiveness of some CIM therapies in the management of primary headache. The evidence for and use of CIM is continuously changing so healthcare professionals should direct their patients to reliable and updated resources, such as NCCIH.
WHAT IS HAPPENING TO THE BMJ?
IT USED TO BE A GOOD JOURNAL!
The BMJ has always been my favourite Medical journal. (Need any proof for this statement? A quick Medline search tells me that I have over 60 publications in the BMJ.) But occasionally, the BMJ also disappoints me a great deal.
One of the most significant disappointments was recently published under the heading of STATE OF THE ART REVIEW. A review that is ‘state of the art’ must fulfil certain criteria; foremost it should be informative, unbiased and correct. The paper I am discussing here has, I think, neither of these qualities. It is entitled ‘Management of chronic pain using complementary and integrative medicine’, and here is its abstract:
Complementary and integrative medicine (CIM) encompasses both Western-style medicine and complementary health approaches as a new combined approach to treat a variety of clinical conditions. Chronic pain is the leading indication for use of CIM, and about 33% of adults and 12% of children in the US have used it in this context. Although advances have been made in treatments for chronic pain, it remains inadequately controlled for many people. Adverse effects and complications of analgesic drugs, such as addiction, kidney failure, and gastrointestinal bleeding, also limit their use. CIM offers a multimodality treatment approach that can tackle the multidimensional nature of pain with fewer or no serious adverse effects. This review focuses on the use of CIM in three conditions with a high incidence of chronic pain: back pain, neck pain, and rheumatoid arthritis. It summarizes research on the mechanisms of action and clinical studies on the efficacy of commonly used CIM modalities such as acupuncture, mind-body system, dietary interventions and fasting, and herbal medicine and nutrients.
The full text of this article is such that I could take issue with almost every second statement in it. Obviously, this would be too long and too boring for this blog. So, to keep it crisp and entertaining, let me copy the (tongue in cheek) ‘letter to the editor’ some of us published in the BMJ as a response to the review:
“Alternative facts are fashionable in politics these days, so why not also in healthcare? The article by Chen and Michalsen on thebmj.com provides a handy set of five instructions for smuggling alternative facts into medicine.
1. Create your own terminology: the term ‘complementary and integrated medicine’ (CIM) is nonsensical. Integrated medicine (a hotly disputed field) already covers complementary and conventional medicine.
2. Pretend to be objective: Chen and Michalsen elaborate on the systematic searches they conducted. But they omit hundreds of sources which do not support their message, which cherry-picks only evidence for the efficacy of the treatments they promote.
3. Avoid negativity: they bypass any material that might challenge what they include. For instance, when discussing therapeutic risks, they omit the disturbing lack of post-marketing surveillance: the reason we lack information on adverse events. They even omit to mention the many fatalities caused by their ‘CIM’.
4. Create an impression of thoroughness: Chen and Michalsen cite a total of 225 references. This apparent scholarly attention to detail masks their misuse of many of they list. Reference 82, for example, is employed to back up the claim that “satisfaction was lowest among complementary medicine users with rheumatoid arthritis, vasculitis, or connective tissue diseases”. In fact, it shows nothing of the sort.
5. Back up your message with broad generalisations: Chen and Michalsen conclude that “Taken together, CIM has an increasing role in the management of chronic pain, but high quality research is needed”. The implication is that all the CIMs mentioned in their figure 1 are candidates for pain control – even discredited treatments such as homeopathy.
In our view, these authors render us a service: they demonstrate to the novice how alternative facts may be used in medicine.”
James May, Edzard Ernst, Nick Ross, on behalf of HealthWatch UK
END OF QUOTE
I am sure you have your own comments and opinions, and I encourage you to post them here or (better) submit them to the BMJ or (best) both.
On 13 March, the UK Charity Commission published the following announcement:
This consultation is about the Commission’s approach to deciding whether an organisation which uses or promotes CAM therapies is a charity. For an organisation to be charitable, its purposes must be exclusively charitable. Some purposes relate to health and to relieve the needs of the elderly and disabled.
We are seeking views on:
- the level and nature of evidence to support CAM
- conflicting and inconsistent evidence
- alternative therapies and the risk of harm
- palliative alternative therapy
Last year, lawyers wrote to the Charity Commission on behalf of the Good Thinking Society suggesting that, if the commission refused to revoke the charitable status of organisations that promote homeopathy, it could be subject to a judicial review. The commission responded by announcing their review which will be completed by 1 July 2017.
Charities must meet a “public benefit test”. This means that they must be able to provide evidence that the work they do benefits the public as a whole. Therefore the consultation will have to determine what nature of evidence is required to demonstrate that a CAM-promoting charity provides this benefit.
In a press release, the Charity Commission stated that it will consider what to do in the face of “conflicting or inconsistent” evidence of a treatment’s effectiveness, and whether it should approach “complementary” treatments, intended to work alongside conventional medicine, differently from “alternative” treatments intended to replace it. In my view, however, this distinction is problematic and often impossible. Depending on the clinical situation, almost any given alternative therapy can be used both as a complementary and as an alternative treatment. Some advocates seem to cleverly promote their therapy as complementary (because this is seen as more acceptable), but clearly employ it as an alternative. The dividing line is often far too blurred for this distinction to be practical, and I have therefore long given up making it.
John Maton, the commission’s head of charitable status, said “Our consultation is not about whether complementary and alternative therapies and medicines are ‘good’ or ‘bad’, but about what level of evidence we should require when making assessments about an organisation’s charitable status.” Personally, I am not sure what this means. It sounds suspiciously soft and opens all sorts of escape routes for even the most outright quackery, I fear.
Michael Marshall of the Good Thinking Society said “We are pleased to see the Charity Commission making progress on their review. Too often we have seen little effective action to protect the public from charities whose very purpose is the promotion of potentially dangerous quackery. However, the real progress will come when the commission considers the clear evidence that complementary and alternative medicine organisations currently afforded charitable status often offer therapies that are completely ineffective or even potentially harm the public. We hope that this review leads to a policy to remove such misleading charities from the register.”
On this blog, I have occasionally reported about charities promoting quackery (for instance here, here and here) and pointed out that such activities cannot ever benefit the public. On the contrary, they are a danger to public health and bring many good charities into disrepute. I would therefore encourage everyone to use this unique occasion to write to the Charity Commission and make their views felt.
The anti-vaccination attitudes of alternative practitioners such as chiropractors, homeopaths and naturopaths are well documented and have been commented upon repeatedly here. But most of these clinicians are non-doctors; they have not been anywhere near a medical school, and one might therefore almost excuse them for their ignorance and uneducated stance towards immunisations. As many real physicians have recently taken to practicing alternative therapies under the banner of ‘integrated medicine’, one may well ask: what do these doctors think about vaccinations?
This study tried to answer the question by evaluating the attitudes and practices regarding vaccination of members of the American Board of Integrative and Holistic Medicine (ABIHM). Prospective participants were 1419 diplomats of the ABIHM. The survey assessed members’ (1) use of and confidence in the vaccination recommendations of the Centers for Disease Control and Prevention (CDC) and of medical-specialty associations, (2) confidence in the manufacturing safety of vaccines and in manufacturer’s surveillance of adverse events, and (3) attitudes toward vaccination mandates. The questionnaire included 33 items, with 5 open-ended questions that provided a space for comments.
The survey was completed by 290 of 1419 diplomats (20%). Its findings showed a diversity of opinions in many vaccination issues. Integrative medicine physicians were less likely to administer vaccinations than physicians in traditional allopathic medicine. Among the 44% who provide vaccinations, 35% used alternative schedules regularly. Integrative medicine physicians showed a greater support of vaccination choice, were less concerned about maintaining herd immunity, and were less supportive of school, day care, and employment mandates. Toxic chemical and viral contaminants were of greater concern to a higher percentage of integrative medicine physicians. Integrative medicine physicians were also more likely to accept a connection between vaccinations and both autism and other chronic diseases. Overall, there was dissatisfaction with the Vaccine Adverse Event Reporting System as well as the vaccination recommendations of the CDC and their primary specialty.
The authors concluded that significant variations in the vaccination attitudes and practices of integrative medicine physicians. This survey provides benchmark data for future surveys of this growing specialty and other practitioners. It is important for public health leaders and the vaccination industry to be aware that integrative medicine physicians have vaccination attitudes and practices that differ from the guidelines of the CDC and the Advisory Council on Immunization Practices.
Now we know!
Physicians practicing integrative medicine (the 80% who did not respond to the survey were most likely even worse) not only use and promote much quackery, they also tend to endanger public health by their bizarre, irrational and irresponsible attitudes towards vaccination.
From bad to worse!