MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Monthly Archives: December 2013

There are numerous types and styles of acupuncture, and the discussion whether one is better than the other has been long, tedious and frustrating. Traditional acupuncturists, for instance, individualise their approach according to their findings of pulse and tongue diagnoses as well as other non-validated diagnostic criteria. Western acupuncturists, by contrast, tend to use formula or standardised treatments according to conventional diagnoses.

This study aimed to compare the effectiveness of standardized and individualized acupuncture treatment in patients with chronic low back pain. A single-center randomized controlled single-blind trial was performed in a general medical practice of a Chinese-born medical doctor trained in both western and Chinese medicine. One hundred and fifty outpatients with chronic low back pain were randomly allocated to two groups who received either standardized acupuncture or individualized acupuncture. 10 to 15 treatments based on individual symptoms were given with two treatments per week.

The main outcome measure was the area under the curve (AUC) summarizing eight weeks of daily rated pain severity measured with a visual analogue scale. No significant differences between groups were observed for the AUC (individualized acupuncture mean: 1768.7; standardized acupuncture 1482.9; group difference, 285.8).

The authors concluded that individualized acupuncture was not superior to standardized acupuncture for patients suffering from chronic pain.

But perhaps it matters whether the acupuncturist is thoroughly trained or has just picked up his/her skills during a weekend course? I am afraid not: this analysis of a total of 4,084 patients with chronic headache, lower back pain or arthritic pain treated by 1,838 acupuncturists suggested otherwise. There were no differences in success for patients treated by physicians passing through shorter (A diploma) or longer (B diploma) training courses in acupuncture.

But these are just one single trial and one post-hoc analysis of another study which, by definition, cannot be fully definitive. Fortunately, we have more evidence based on much larger numbers. This brand-new meta-analysis aimed to evaluate whether there are characteristics of acupuncture or acupuncturists that are associated with better or worse outcomes.

An existing dataset, developed by the Acupuncture Trialists’ Collaboration, included 29 trials of acupuncture for chronic pain with individual data involving 17,922 patients. The available data on characteristics of acupuncture included style of acupuncture, point prescription, location of needles, use of electrical stimulation and moxibustion, number, frequency and duration of sessions, number of needles used and acupuncturist experience. Random-effects meta-regression was used to test the effect of each characteristic on the main effect estimate of pain. Where sufficient patient-level data were available, patient-level analyses were conducted.

When comparing acupuncture to sham controls, there was little evidence that the effects of acupuncture on pain were modified by any of the acupuncture characteristics evaluated, including style of acupuncture, the number or placement of needles, the number, frequency or duration of sessions, patient-practitioner interactions and the experience of the acupuncturist. When comparing acupuncture to non-acupuncture controls, there was little evidence that these characteristics modified the effect of acupuncture, except better pain outcomes were observed when more needles were used and, from patient level analysis involving a sub-set of 5 trials, when a higher number of acupuncture treatment sessions were provided.

The authors of this meta-analysis concluded that there was little evidence that different characteristics of acupuncture or acupuncturists modified the effect of treatment on pain outcomes. Increased number of needles and more sessions appear to be associated with better outcomes when comparing acupuncture to non-acupuncture controls, suggesting that dose is important. Potential confounders include differences in control group and sample size between trials. Trials to evaluate potentially small differences in outcome associated with different acupuncture characteristics are likely to require large sample sizes.

My reading of these collective findings is that it does not matter which type of acupuncture you use nor who uses it; the clinical effects are similar regardless of the most obvious potential determinants. Hardly surprising! In fact, one would expect such results, if one considered that acupuncture is a placebo-treatment.

One of the perks of researching alternative medicine and writing a blog about it is that one rarely runs out of good laughs. In perfect accordance with ERNST’S LAW, I have recently been entertained, amused, even thrilled by a flurry of ad hominem attacks most of which are true knee-slappers. I would like to take this occasion to thank my assailants for their fantasy and tenacity. Most days, these ad hominem attacks really do make my day.

I can only hope they will continue to make my days a little more joyous. My fear, however, is that they might, one day, run out of material. Even today, their claims are somewhat repetitive:

  • I am not qualified
  • I only speak tosh
  • I do not understand science
  • I never did any ‘real’ research
  • Exeter Uni fired me
  • I have been caught red-handed (not quite sure at what)
  • I am on BIG PHARMA’s payroll
  • I faked my research papers

Come on, you feeble-minded fantasists must be able to do better! Isn’t it time to bring something new?

Yes, I know, innovation is not an easy task. The best ad hominem attacks are, of course, always based on a kernel of truth. In that respect, the ones that have been repeated ad nauseam are sadly wanting. Therefore I have decided to provide all would-be attackers with some true and relevant facts from my life. These should enable them to invent further myths and use them as ammunition against me.

Sounds like fun? Here we go:

Both my grandfather and my father were both doctors

This part of my family history could be spun in all sorts of intriguing ways. For instance, one could make up a nice story about how I, even as a child, was brain-washed to defend the medical profession at all cost from the onslaught of non-medical healers.

Our family physician was a prominent homeopath

Ahhhh, did he perhaps mistreat me and start me off on my crusade against homeopathy? Surely, there must be a nice ad hominem attack in here!

I studied psychology at Munich but did not finish it

Did I give up psychology because I discovered a manic obsession or other character flaw deeply hidden in my soul?

I then studied medicine (also in Munich) and made a MD thesis in the area of blood clotting

No doubt this is pure invention. Where are the proofs of my qualifications? Are the data in my thesis real or invented?

My 1st job as a junior doctor was in a homeopathic hospital in Munich

Yes, but why did I leave? Surely they found out about me and fired me.

I had hands on training in several forms of alternative medicine, including homeopathy

Easy to say, but where are the proofs?

I moved to London where I worked in St George’s Hospital conducting research in blood rheology

Another invention? Where are the published papers to document this?

I went back to Munich university where I continued this line of research and was awarded a PhD

Another thesis? Again with dodgy data? Where can one see this document?

I became Professor Rehabilitation Medicine first at Hannover Medical School and later in Vienna

How did that happen? Did I perhaps bribe the appointment panels?

In 1993, I was appointed to the Chair in Complementary Medicine at Exeter university

Yes, we all know that; but why did I not direct my efforts towards promoting alternative medicine?

In Exeter, together with a team of ~20 colleagues, we published > 1000 papers on alternative medicine, more than anyone else in that field

Impossible! This number clearly shows that many of these articles are fakes or plagiaries.

My H-Index is currently >80

Same as above.

In 2012, I became Emeritus Professor of the University of Exeter

Isn’t ’emeritus’ the Latin word for ‘dishonourable discharge’?

I HOPE I CAN RELY ON ALL OF MY AD HOMINEM ATTACKERS TO USE THIS INFORMATION AND RENDER THE ASSAULTS MORE DIVERSE, REAL AND INTERESTING.

A recent interview on alternative medicine for the German magazine DER SPIEGEL prompted well over 500 comments; even though, in the interview, I covered numerous alternative therapies, the discussion that followed focussed almost entirely on homeopathy. Yet again, many of the comments provided a reminder of the quasi-religious faith many people have in homeopathy.

There can, of course, be dozens of reasons for such strong convictions. Yet, in my experience, some seem to be more prevalent and important than others. During my last two decades in researching homeopathy, I think, I have identified several of the most important ones. In this post, I try to outline a typical sequence of events that eventually leads to a faith in homeopathy which is utterly immune to fact and reason.

The epiphany

The starting point of this journey towards homeopathy-worship is usually an impressive personal experience which is often akin to an epiphany (defined as a moment of sudden and great revelation or realization). I have met hundreds of advocates of homeopathy, and those who talk about this sort of thing invariably offer impressive stories about how they metamorphosed from being a ‘sceptic’ (yes, it is truly phenomenal how many believers insist that they started out as sceptics) into someone who was completely bowled over by homeopathy, and how that ‘moment of great revelation’ changed the rest of their lives. Very often, this ‘Saulus-Paulus conversion’ relates to that person’s own (or a close friend’s) illness which allegedly was cured by homeopathy.

Rachel Roberts, chief executive of the Homeopathy Research Institute, provides as good an example of this sort of epiphany as anyone; in an article in THE GUARDIAN, she described her conversion to homeopathy with the following words:

I was a dedicated scientist about to begin a PhD in neuroscience when, out of the blue, homeopathy bit me on the proverbial bottom.

Science had been my passion since I began studying biology with Mr Hopkinson at the age of 11, and by the age of 21, when I attended the dinner party that altered the course of my life, I had still barely heard of it. The idea that I would one day become a homeopath would have seemed ludicrous.

That turning point is etched in my mind. A woman I’d known my entire life told me that a homeopath had successfully treated her when many months of conventional treatment had failed. As a sceptic, I scoffed, but was nonetheless a little intrigued.

She confessed that despite thinking homeopathy was a load of rubbish, she’d finally agreed to an appointment, to stop her daughter nagging. But she was genuinely shocked to find that, after one little pill, within days she felt significantly better. A second tablet, she said, “saw it off completely”.

I admit I ruined that dinner party. I interrogated her about every detail of her diagnosis, previous treatment, time scales, the lot. I thought it through logically – she was intelligent, she wasn’t lying, she had no previous inclination towards alternative medicine, and her reluctance would have diminished any placebo effect.

Scientists are supposed to make unprejudiced observations, then draw conclusions. As I thought about this, I was left with the highly uncomfortable conclusion that homeopathy appeared to have worked. I had to find out more.

So, I started reading about homeopathy, and what I discovered shifted my world for ever. I became convinced enough to hand my coveted PhD studentship over to my best friend and sign on for a three-year, full-time homeopathy training course.

Now, as an experienced homeopath, it is “science” that is biting me on the bottom. I know homeopathy works…

As I said, I have heard many strikingly similar accounts. Some of these tales seem a little too tall to be true and might be a trifle exaggerated, but the consistency of the picture that emerges from all of these stories is nevertheless extraordinary: people get started on a single anecdote which they are prepared to experience as an epiphanic turn-around. Subsequently, they are on a mission of confirming their new-found belief over and over again, until they become undoubting disciples for life.

So what? you might ask. But I do think this epiphany-like event at the outset of a homeopathic career is significant. In no other area of health care does the initial anecdote regularly play such a prominent role. People do not become believers in aspirin, for instance, on the basis of a ‘moment of great revelation’, they may take it because of the evidence. And, if there is a discrepancy between the external evidence and their own experience, as with homeopathy, most people would start to reflect: What other explanations exist to rationalise the anecdote? Invariably, there are many (placebo, natural history of the condition, concomitant events etc.).

Confirmation bias

Epiphany-stuck believers spends much time and effort to actively look for similar stories that seem to confirm the initial anecdote. They might, for instance, recommend or administer or prescribe homeopathy to others, many of whom would report positive outcomes. At the same time, all anecdotes that do not happen to fit the belief are brushed aside, forgotten, supressed, belittled, decried etc. This process leads to confirmation after confirmation after confirmation – and gradually builds up to what proponents of homeopathy would call ‘years of experience’. And ‘years of experience’ can, of course, not be wrong!

Again, believers neglect to question, doubt and rationalise their own perceptions. They ignore the fact that years of experience might just be little more than a suborn insistence on repeating one’s own mistakes. Even the most obvious confounders such as selective memory or alternative causes for positive clinical outcomes are quickly dismissed or not even considered at all.

Avoiding cognitive dissonance at all cost

But believers still has to somehow deal with the scientific facts about homeopathy; and these are, of course, grossly out of line with their belief. Thus the external evidence and the internal belief would inevitably clash creating a shrill cognitive dissonance. This must be avoided at all cost, as it might threaten the believer’s peace of mind. And the solution is amazingly simple: scientific evidence that does not confirm the believer’s conviction is ignored or, when this proves to be impossible, turned upside down.

Rachel Roberts’ account is most enlightening also in this repect:

And yet I keep reading reports in the media saying that homeopathy doesn’t work and that this scientific evidence doesn’t exist.

The facts, it seems, are being ignored. By the end of 2009, 142 randomised control trials (the gold standard in medical research) comparing homeopathy with placebo or conventional treatment had been published in peer-reviewed journals – 74 were able to draw firm conclusions: 63 were positive for homeopathy and 11 were negative. Five major systematic reviews have also been carried out to analyse the balance of evidence from RCTs of homeopathy – four were positive (Kleijnen, J, et al; Linde, K, et al; Linde, K, et al; Cucherat, M, et al) and one was negative (Shang, A et al). It’s usual to get mixed results when you look at a wide range of research results on one subject, and if these results were from trials measuring the efficacy of “normal” conventional drugs, ratios of 63:11 and 4:1 in favour of a treatment working would be considered pretty persuasive.

This statement is, in my view, a classic example of a desperate misinterpretation of the truth as a means of preventing the believer’s house of cards from collapsing. It even makes the hilarious claim that not the believers but the doubters “ignore” the facts.

In order to be able to adhere to her belief, Roberts needs to rely on a woefully biased white-wash from the ‘British Homeopathic Association’. And, in order to be on the safe side, she even quotes it misleadingly. The conclusion of the Cucherat review, for instance, can only be seen as positive by most blinkered of minds: There is some evidence that homeopathic treatments are more effective than placebo; however, the strength of this evidence is low because of the low methodological quality of the trials. Studies of high methodological quality were more likely to be negative than the lower quality studies. Further high quality studies are needed to confirm these results. Contrary to what Roberts states, there are at least a dozen more than 5 systematic reviews of homeopathy; my own systematic review of systematic reviews, for example, concluded that the best clinical evidence for homeopathy available to date does not warrant positive recommendations for its use in clinical practice.

It seems that, at this stage of a believer’s development, the truth gets all too happily sacrificed on the altar of faith. All these ‘ex-sceptics’ turned believers are now able to display is a rather comical parody of scepticism.

The delusional end-stage

The last stage in the career of a believer has been reached when hardly anything that he or she is convinced of resembles reality any longer. I don’t know much about Rachel Roberts, and she might not have reached this point yet; but there are many others who clearly have.

My two favourite examples of end-stage homeopathic delusionists are John Benneth and Dana Ullman. The final stage on the journey from ‘sceptic scientist’ to delusional disciple is characterised by an incessant stream of incoherent statements of vile nonsense that beggars belief. It is therefore easy to recognise and, because nobody can possibly take the delusionists seriously, they are best viewed as relatively harmless contributors to medical comedy.

Why does all of this matter?

Many homeopathy-fans are quasi-religious believers who, in my experience, have degressed way beyond reason. It is therefore a complete waste of time trying to reason with them. Initiated by a highly emotional epiphany, their faith cannot be shaken by rational arguments. Similar but usually less pronounced attitudes, I am afraid, can be observed in true believers of other alternative treatments as well (here I have chosen the example of homeopathy mainly because it is the area where things are most explicit).

True believers claim to have started out as sceptics and they often insist to be driven by a scientific mind. Yet I have never seen any evidence for these assumptions. On the contrary, for a relatively trivial episode to become a life-changing epiphany, the believer’s mind needs to be lamentably unscientific, unquestioning and simple.

In my experience, true believers will not change their mind; I have never seen this happening. However, progress might nevertheless be made, if we managed to instil a more (self-) questioning rationality and scientific attitudes into the minds of the next generations. In other words, we need better education in science and more training of critical thinking during their formative years.

For those who know about the subject, this is an old hat, of course. But for many readers of this blog, it might be news: ‘Traditional’ Chinese Medicine (TCM) is not nearly as traditional as it pretends to be. In fact, it is an artefact of recent creation. The man who has been saying that for years is Professor Paul Unschuld, one of the leading sinologist worldwide and an expert who has written many books and journal articles on the subject.

During an interview given in 2004, he defined TCM as “an artificial system of health care ideas and practices generated between 1950 and 1973 by committees in the People’s Republic of China, with the aim of restructuring the vast and heterogenous heritage of Chinese traditional medicine in such a way that it fitted the principles–Marxist Maoist type democracy and modern science and technology on which the future of the PRC was to be built…[the Daoist underpinning for TCM] is incorrect for two reasons.  First . . . TCM is a product of Communist China.  Second, even if we were to apply the term TCM to pre-revolutionary Chinese medicine, the Daoist impact should be considered minimal.”

In a much more recent interview entitled INVENTION FROM THE FAR EAST which he gave to DER SPIEGEL (in German), he explained this in a little more detail (I have tried to translate his words as literally as possible):

What is being offered in our country to patients as TCM is a construct that was created in China on an office desk which has been altered further on its way to the West.

Already at the beginning of the 20th century, reformers and revolutionaries urged that the traditional medicine in China should be abolished and that the western form of medicine should be introduced instead. Traditional thinking was seen as backwards and it was held responsible for the oppressing superiority of the West. The introduction of Western natural sciences, medicine and technology was also thought later, after the foundation of the People’s Republic, to be essential for rendering the country competitive again. Since the traditional Chinese medicine could not be totally abolished then because it offered a living to many citizens, it was reduced to a kernel, which could be brought just about in line with the scientific orientation  of the future communist society. In the 1950s and 60s, an especially appointed commission had been working on this task. The filtrate which they created from the original medical tradition was hence forward to be called TCM vis a vis foreigners.

There is little more to add, I think – perhaps just two brief after-thoughts. TCM is a most lucrative export article for China. So don’t expect Chinese officials to rid TCM of the highly marketable ‘TRADITIONAL’ label. And remember: the appeal to tradition’ argument is a fallacy anyway.

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