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

Monthly Archives: February 2015

Here is a third excerpt from my new book A SCIENTIST IN WONDERLAND. It describes the thinking behind the research strategy my team and I adopted and the main arguments for and against it.

After roughly one year of preparatory work, everything seemed to be in place for our research to start in earnest. Around this time, I was asked to write a “mission statement” for my new research unit, which had by then been given the official title of the Department of Complementary Medicine. “A very British thing”, a friend explained when I enquired what a mission statement might be. “Just put on paper what your unit stands for.” I gave it some thought and formulated our mission as clearly and concisely as I could:

  • To conduct rigorous, inter-disciplinary and international collaborative research into the efficacy, safety and cost of complementary medicine.
  • To further analytical thinking in this area.

People reading my mission statement tended to be slightly puzzled by the inclusion of “analytical thinking” as a specific, separate item, but even after two decades, I am still pleased that I added it. The fostering of critical analysis is vital to any scientific endeavour, and perhaps particularly so in a field that, until now, has been so accustomed to special pleading and so sheltered from objective evaluation.

While studying medicine, I had not been well instructed in critical thinking. It was only later that I had realized how vulnerable health care can be without it. In Vienna, we had managed to smuggle the subject onto the medical curriculum. In Exeter, I soon discovered how woefully uncritical the attitude towards alternative medicine frequently was. This phenomenon was noticeable not just when reading the popular press or when talking to lay people but also, and perhaps even more worryingly, it was equally obvious in discussions with health care professionals. This lack of critical thinking, I felt, had the potential to hinder progress or even to cause significant harm. Particularly during the later years of my time in Exeter, the theme of critical analysis would dominate my work.

My peers were happy with the mission statement, and most rational thinkers who saw it thought it was ambitious but sound. However, in many alternative medicine enthusiasts it aroused suspicion; they seemed dismayed and felt that it was misguided. Some offered the opinion that alternative medicine should not be scientifically scrutinized at all. Others believed that my work should be directed much more at promoting alternative medicine rather than questioning it. Some argued that a professor of complementary medicine should be unabashedly sympathetic towards those working in this area, and that this attitude should be specifically articulated in any mission statement. Yet others argued that the mission statement should focus primarily on sociological or psychological issues rather than medical questions.

I listened patiently and politely to everyone who wanted to comment. I discussed, re-evaluated, re-discussed and reconsidered my position. But whichever way I looked at it, I couldn’t escape the conclusion that the arguments of my critics were at best unconvincing or irrelevant, and at worst they were down-right misleading—and I became determined to show why.

I was not a politician, nor was I a propagandist or an ideologue: I was simply a scientist, and as such my role was not to further the ambitions of interested parties but to determine the true value of alternative medicine. Patients and consumers have an absolute right to know the truth about the value of the treatments they frequently use, and the obligation of a researcher is to determine truth. That required a rigorous medical research agenda which would steer us clear of the post-modernist approach advocated by so many who tried to influence me and my growing team of investigators.

Over the years, my resolve to stay on this straight and narrow path of objective medical research has provoked endless criticism. Indeed, the potential for conflict had been there from the outset, when, at that very first lecture for alternative practitioners, I had been publicly challenged: “How did they dare to appoint a doctor to this chair?” Now that I had realized that this tension existed, I had to decide how to deal with it in my professional capacity.

Initially I made a conscious effort to avoid discord, not because I lacked the necessary courage or convincing arguments, but for a variety of other reasons, both personal and pragmatic. Firstly, I do not enjoy disagreements nearly as much as some people seem to think. If conflict becomes unavoidable, I can certainly put up a good fight, but that does not mean I enjoy the process. Secondly, I was honestly tired of having disputes. The battles I had fought in Vienna had left me drained and somewhat bruised. Over the years, I did develop a thicker skin but it certainly was not something I was born with. Thirdly, conflicts take far too much time, energy and concentration away from one’s real work: the more time I was compelled to spend locked in combat, the less time I would have to focus on the science I was so eager to generate. Fourthly, if the worst came to the worst, and if I was going to have to defend my views at every turn, I needed to be entirely sure of my ground. Solid research was the only way to ensure that; and I felt the need to do the research first and have the arguments later.

Multivitamins are widely used, mainly for disease prevention, and particularly cardiovascular disease (CVD). But there are only few prospective studies investigating their association with both long- and short-term risk. In view of these facts, new evidence is more than welcome.

The objective of this study was to investigate how multivitamin use is associated with the long- and short-term risk of CVD. A prospective cohort study was conducted of 37,193 women from the Women’s Health Study aged ≥45 y and free of CVD and cancer at baseline who were followed for an average of 16.2 y. At baseline, women self-reported a wide range of lifestyle, clinical, and dietary factors. Women were categorized into 1) no current use and 2) current use of multivitamins. Duration and updated measures over the course of the follow-up to address short-term effects were also considered. Women were followed for major CVD events, including myocardial infarction (MI), stroke, and CVD death.

During the follow-up, 1493 incident cases of CVD [defined as myocardial infarction (MI), stroke, and CVD death] occurred. In multivariable analyses, multivitamin use compared with no use was not associated with major CVD event, stroke, or CVD death. A non-significant inverse association was observed between baseline multivitamin use and major CVD events among women aged ≥70 y (P-interaction = 0.04) and those consuming <3 servings/d of fruit and vegetables (P-interaction = 0.01). When updating information on multivitamin use during the course of follow-up, no associations were observed for major CVD events, MI, stroke, and CVD death.

The authors concluded that, in this study of middle-aged and elderly women, neither baseline nor time-varying multivitamin use was associated with the long-term risk of major CVD events, MI, stroke, cardiac revascularizations, or CVD death. Additional studies are needed to clarify the role of multivitamins on CVD.

Even the most enthusiastic vitamin fan will find it hard to argue with these findings; they seem rock solid. Vitamins have their name from the fact that they are vital for our survival – we all need them. But, in developed countries, we all get them through our daily food. Any excess of water-soluble vitamins is swiftly excreted via the urine. Any excess of fat-soluble vitamins is stored in the body and may, in some cases, even represent a health risk.

Exceptions are vulnerable groups such as children, the elderly, pregnant women and patients with certain diseases. These individuals can suffer from hypovitaminoses, the only reason for regularly using vitamin supplements. But for the vast majority of the population, the only effects of regular vitamin supplementation are that we enrich the manufacturers and render our urine expensive.

Highly diluted homeopathic remedies are pure placebos; at least this is what sceptics have been saying for about 200 years. This assumption is based on the fact that homeopathy’s plausibility is close to zero and that the totality of the reliable evidence fails to demonstrate that it works beyond placebo for any condition.

But, if this is true,  why do so many patients swear by homeopathy and experience benefit from it? This question has been answered many times: THE BENEFIT IS NOT DUE TO THE REMEDY BUT TO NON-SPECIFIC EFFECTS OF THE CONSULTATION.

More confirmation for this conclusion comes from an unexpected source.

Indian homeopaths recently published a trial of individualized homeopathy in osteoarthritis. To be more precise, it was a prospective, parallel-arm, double-blind, randomized, placebo-controlled pilot study which was conducted from January to October 2014 involving 60 patients (homeopathy, n = 30; placebo, n = 30). All patients were suffering from acute painful episodes of knee osteoarthritis and visiting the outpatient clinic of Mahesh Bhattacharyya Homeopathic Medical College and Hospital, West Bengal, India.

The results show statistically significant reduction in 3 visual analogue scales (measuring pain, stiffness, and loss of function) and Osteoarthritis Research Society International scores in both groups over 2 weeks (P < .05). However, group differences were not significant (P > .05).

The authors conclude that, overall, homeopathy did not appear to be superior to placebo; still, further rigorous evaluation in this design involving a larger sample size seems feasible in future.

Considering what I wrote above, I would alter these conclusion to something much more reasonable: further studies of homeopathy are certainly feasible. However, they are neither necessary nor desirable.

TO PUT IT DIFFERENTLY: HOMEOPATHY BELONGS IN THE BOOKS OF MEDICAL HISTORY.

Here is another short passage from my new book A SCIENTIST IN WONDERLAND. It describes the event where I was first publicly exposed to the weird and wonderful world of alternative medicine in the UK. It is also the scene which, in my original draft, was the very beginning of the book.

I hope that the excerpt inspires some readers to read the entire book – it currently is BOOK OF THE WEEK in the TIMES HIGHER EDUCATION!!!

… [an] aggressive and curious public challenge occurred a few weeks later during a conference hosted by the Research Council for Complementary Medicine in London. This organization had been established a few years earlier with the aim of conducting and facilitating research in all areas of alternative medicine. My impression of this institution, and indeed of the various other groups operating in this area, was that they were far too uncritical, and often proved to be hopelessly biased in favour of alternative medicine. This, I thought, was an extraordinary phenomenon: should research councils and similar bodies not have a duty to be critical and be primarily concerned about the quality of the research rather than the overall tenor of the results? Should research not be critical by nature? In this regard, alternative medicine appeared to be starkly different from any other type of health care I had encountered previously.

On short notice, I had accepted an invitation to address this meeting packed with about 100 proponents of alternative medicine. I felt that their enthusiasm and passion were charming but, no matter whom I talked to, there seemed to be little or no understanding of the role of science in all this. A strange naïvety pervaded this audience: alternative practitioners and their supporters seemed a bit like children playing “doctor and patient”. The language, the rituals and the façade were all more or less in place, but somehow they seemed strangely detached from reality. It felt a bit as though I had landed on a different planet. The delegates passionately wanted to promote alternative medicine, while I, with equal passion and conviction, wanted to conduct good science. The two aims were profoundly different. Nevertheless, I managed to convince myself that they were not irreconcilable, and that we would manage to combine our passions and create something worthwhile, perhaps even groundbreaking.

Everyone was excited about the new chair in Exeter; high hopes and expectations filled the room. The British alternative medicine scene had long felt discriminated against because they had no academic representation to speak of. I certainly did sympathize with this particular aspect and felt assured that, essentially, I was amongst friends who realized that my expertise and their enthusiasm could add up to bring about progress for the benefit of many patients.
During my short speech, I summarized my own history as a physician and a scientist and outlined what I intended to do in my new post—nothing concrete yet, merely the general gist. I stressed that my plan was to apply science to this field in order to find out what works and what doesn’t; what is safe and what isn’t. Science, I pointed out, generates progress through asking critical questions and through testing hypotheses. Alternative medicine would either be shown by good science to be of value, or it would turn out to be little more than a passing fad. The endowment of the Laing chair represented an important mile-stone on the way towards the impartial evaluation of alternative medicine, and surely this would be in the best interest of all parties concerned.

To me, all this seemed an entirely reasonable approach, particularly as it merely reiterated what I had just published in an editorial for The Lancet entitled “Scrutinizing the Alternatives”.

My audience, however, was not impressed. When I had finished, there was a stunned, embarrassed silence. Finally someone shouted angrily from the back row: “How did they dare to appoint a doctor to this chair?” I was startled by this question and did not quite understand. What had prompted this reaction? What did this audience expect? Did they think my qualifications were not good enough? Why were they upset by the appointment of a doctor? Who else, in their view, might be better equipped to conduct medical research?

It wasn’t until weeks later that it dawned on me: they had been waiting for someone with a strong commitment to the promotion of alternative medicine. Such a commitment could only come from an alternative practitioner. A doctor personified the establishment, and “alternative” foremost symbolized “anti-establishment”. My little speech had upset them because it confirmed their worst fears of being annexed by “the establishment”. These enthusiasts had hoped for a believer from their own ranks and certainly not for a doctor-scientist to be appointed to the world’s first chair of complementary medicine. They had expected that Exeter University would lend its support to their commercial and ideological interests; they had little understanding of the concept that universities should not be in the business of promoting anything other than high standards.

Even today, after having given well over 600 lectures on the topic of alternative medicine, and after coming on the receiving end of ever more hostile attacks, aggressive questions and personal insults, this particular episode is still etched deeply into my memory. In a very real way, it set the scene for the two decades to come: the endless conflicts between my agenda of testing alternative medicine scientifically and the fervent aspirations of enthusiasts to promote alternative medicine uncritically. That our positions would prove mutually incompatible had been predictable from the very start. The writing had been on the wall—but it took me a while to be able to fully understand the message.

Iyengar Yoga, named after and developed by B. K. S. Iyengar, is a form of Hatha Yoga that has an emphasis on detail, precision and alignment in the performance of posture (asana) and breath control (pranayama). The development of strength, mobility and stability is gained through the asanas.

B.K.S. Iyengar has systematised over 200 classical yoga poses and 14 different types of Pranayama (with variations of many of them) ranging from the basic to advanced. This helps ensure that students progress gradually by moving from simple poses to more complex ones and develop their mind, body and spirit step by step.

Iyengar Yoga often makes use of props, such as belts, blocks, and blankets, as aids in performing asanas (postures). The props enable students to perform the asanas correctly, minimising the risk of injury or strain, and making the postures accessible to both young and old.

Sounds interesting? But does it work?

The objective of this recent systematic review was to conduct a systematic review of the existing research on Iyengar yoga for relieving back and neck pain. The authors conducted extensive literature searches and found 6 RCTs that met the inclusion criteria.

The difference between the groups on the post-intervention pain or functional disability intensity assessment was, in all 6 studies, favouring the yoga group, which projected a decrease in back and neck pain.

The authors concluded that Iyengar yoga is an effective means for both back and neck pain in comparison to control groups. This systematic review found strong evidence for short-term effectiveness, but little evidence for long-term effectiveness of yoga for chronic spine pain in the patient-centered outcomes.

So, if we can trust this evidence (I would not call the evidence ‘strong), we have yet another treatment that might be effective for acute back and neck pain. The trouble, I fear, is not that we have too few such treatments, the trouble seems to be that we have too many of them. They all seem similarly effective, and I cannot help but wonder whether, in fact, they are all similarly ineffective.

Regardless of the answer to this troubling question, I feel the need to re-state what I have written many times before: FOR A CONDITION WITH A MULTITUDE OF ALLEGEDLY EFFECTIVE THERAPIES, IT MIGHT BE BEST TO CHOSE THE ONE THAT IS SAFEST AND CHEAPEST.

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