How often have we heard this? YOU ARE WRONG! MY TREATMENT DOES WORK!!! ONLY THE OTHER DAY, I HAD A PATIENT WHO WAS CURED BY IT.
Take for instance this tweet I got yesterday:
You go too far @EdzardErnst. In fact I was consulted about a child who hadn’t grown after an accident. She responded well to homoeopathy and grew. How much are you being paid for your attempts to deny people’s health choices?
The tweet refers to my last post where I exposed homeopathic child abuse. Having thought about Thomas’ tweet, I must say that I find it too to be abusive – even abusive on 4 different levels.
- First, the tweet is obviously a personal attack suggesting that I am bribed into doing what I do. I have stated it many times, and I do so again: I receive no payment from anyone for my work. How then do I survive? I have a pension and savings (not that this is anyone’s business).
- Second, it is abusive because it claims that children who suffer from a pathological growth retardation can benefit from homeopathy. There is no evidence for that at all, and making false claims of this nature is unethical and, in this case, even abusive.
- Third, if Thomas really did make the observation she suggests in her tweet and is convinced that her homeopathic treatment was the cause of the child’s improvement, she has an ethical duty to do something more about it than just shooting off a flippant tweet. She could, for instance, run a clinical trial to find out whether her observation was correct. I admit this might be beyond her means. So alternatively, she could write up the case in full detail and publish it for all of us to scrutinise her findings. This is the very minimum a responsible clinician ought to do when she comes across a novel and potentially important result. Anything else is my view unethical and hinders progress.
I do, of course, sympathise with lay people who fail to fully understand the concept of causality. But surely, healthcare professionals who pride themselves of taking charge of patients ought to have some comprehension of it. They should know that clinical improvements after a treatment is not necessarily the same as clinical improvement because of the treatment. Is it really too much to ask of them to know the criteria for causality? There is plenty of easy-reading on the subject; even Wikipedia has a good article on it:
In 1965, the English statistician Sir Austin Bradford Hill proposed a set of nine criteria to provide epidemiologic evidence of a causal relationship between a presumed cause and an observed effect. (For example, he demonstrated the connection between cigarette smoking and lung cancer.) The list of the criteria is as follows:
- Strength (effect size): A small association does not mean that there is not a causal effect, though the larger the association, the more likely that it is causal.
- Consistency (reproducibility): Consistent findings observed by different persons in different places with different samples strengthens the likelihood of an effect.
- Specificity: Causation is likely if there is a very specific population at a specific site and disease with no other likely explanation. The more specific an association between a factor and an effect is, the bigger the probability of a causal relationship.
- Temporality: The effect has to occur after the cause (and if there is an expected delay between the cause and expected effect, then the effect must occur after that delay).
- Biological gradient: Greater exposure should generally lead to greater incidence of the effect. However, in some cases, the mere presence of the factor can trigger the effect. In other cases, an inverse proportion is observed: greater exposure leads to lower incidence.
- Plausibility: A plausible mechanism between cause and effect is helpful (but Hill noted that knowledge of the mechanism is limited by current knowledge).
- Coherence: Coherence between epidemiological and laboratory findings increases the likelihood of an effect. However, Hill noted that “… lack of such [laboratory] evidence cannot nullify the epidemiological effect on associations”.
- Experiment: “Occasionally it is possible to appeal to experimental evidence”.
- Analogy: The effect of similar factors may be considered.
And this brings me to my 4th and last level of abuse in relation to the above tweet and most other claims of this nature: being ill-informed and stupid while insisting to make a nonsensical point is, in my view, offensive – so much so that it can reach the level of abuse.
13 Responses to …but my therapy DOES work … only recently, it cured a patient!
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Yes, Edzard Quixote Ernst, you are right – and you are also wrong.
Of course you are right repeating once again the evident truth “Improvement after treatment is no proof of improvement BECAUSE of a treatment” (and we have to state that 90 percent of so-called “case studies” in Traditional Chinese Medicine TCM as well as 100 percent in homeopathy are nothing but reports of “improvement after treatment”).
However, knowing this does not solve one of our basic problems: In more than half of the cases visiting a general practitioner the adequate therapy is DOING NOTHING.
And you might say: Homeopathy is one of the most convincing – and economic – ways to do nothing. (Another one, though personally I am convinced that it induces very clear and helpful physiological processes, might be acupuncture).
But as our patients not only expect us to do SOMETHING but also realize if we ourselves do not really believe in what we do or prescribe, there certainly is a dilemma: Concerning the patient, obviously the results are better if the doctor himself believes in homeopathy or other comparable methods.
Of course it is irresponsible to use homeopathy in cases of emergency or curable forms of cancer. But nevertheless you, Edzard Quixote Ernst, again and again ignore one of most difficult tasks of our profession: How do we deal RATIONALLY WITH THE IRRATIONAL?
“How do we deal RATIONALLY WITH THE IRRATIONAL?”
we should deal with it as we deal with most other things: provide evidence-based explanations, advice and action.
Again, a misunderstanding.
My question “How do we deal RATIONALLY WITH THE IRRATIONAL” is a question of PRACTICAL medicine. It descibes a frequent situation: The patient is afraid (the “irrational”), and I have to react in a helpful way. Giving him confidence is an important part of what I can do for him. If I know that the patient is a religious person – why shouldn’t I, though not believing in god myself, advise him or her to find strength in prayer? Or even pray together with him – or do you think this is ridiculous?
Your answer, however (“provide evidence-based explanations, advice and action”) is a SCIENTIFIC one, describing how to deal with this question in general. As to this, I think that this work has been done already, for instance in a certain branch of psychosomatic medicine called “psychoneuroimmunology”. It has been proven that confidence (even in cases where there might be no reason for confidence) usually is helpful. The question – not a theoretical one, but a question to be answered here and now – is therefore: Which is the adequate way to give confidence?
The IRRATIONAL in the patient is a fact. The history of our profession evolving from priesthood and shamanism is another fact. It is rather difficult to influence the irrational in the patient by presenting him essays or statistics. So why not, with clear concience and clear mind (which is, rationally) use methods rooted in our history of priesthood and shamanism? Or such harmless methods like acupuncture or even homeopathy?
my answer was not scientific but general; I feel that is all I can provide to a general question like this.
I know a “psychoneuroimmunologist” who previously made her living as an astrologist, reiki practitioner and natural health product purveyor. Andrew Wakefield is her hero.
You are wrong. Acupuncture is no more effective than homeopathy, but riskier.
If patients want shamans, healers, whatever, they are out there, see above.
Let’s just be clear about what they selling. That’s all. Confidence or confidence tricks?
@Dr:
Stephen Gould addressed the basic issue in Rock of Ages where he termed it NOMA: non-overlapping magiseria. His premise is that science and religion are rationality and irrationality personified (though not necessarily aggrandizing to the former or demeaning to the latter…just different. However most of his ‘work’ on this was effectively dismantled by Dawkins in The God Delusion).
With Alt-Med we are dealing with alternative-logic or at least poor comprehension of logical forms most often fueled by greed (just as with religious beliefs….most all religions persons live with the premise “God will do me some favors if I join in properly”).
The religious world “accepts” religion as metaphysical AND rational…the non-religious world denies “metaphysics” thus only leaving irrationality. And yet how many ‘good Catholics’ have tried to rescue their children from joining a “crazy religious cult”…? Or other utter contradictions?
The real problem is you present a case the Alt-Med would decry i.e. their effect(s) are not real; not neurological, mechanical or physiological….but just psychosomatic (and the push-back is well demonstrated on the blog).
Alt-Med and religion are deemed worthy-of-inclusion in societal life based on the provably non-sensical shibboleth that “science can’t explain everything” (because of course ONLY science can explain ANYTHING). Evidence is always a requirement: “man has a tremendous capacity to suffer if he knows WHY”. It’s just that the lack of education or lack of guidance in logic leads many to misinterpret and not recognize what evidence IS and make up a WHY….and of course to put their trust in other-worldly mystery and magic based on formulaic and institutional illogic driven by priests and shaman and their ilk.
Your suggestion of “giving confidence” is mis-guided in that lying to someone (irrespective of the apocryphal stories in Alt-Med and religion about the ‘power of belief’) never works…especially when distinct parameters can be applied to a disease process.
And if it does it too requires scientific-investigation and resulting evidence if it’s to be taken serious.
Why pander to non-sense when one knows better? Are you really certain that given a well-reasoned, research/evidenced based discussion by an MD it will inevitably result in the ‘irrational patient’ still seeking non-scientific answers?
If you grant a little latitude I would suggest modern-medicine has adopted many of its own ‘Alt-med’ methods….but it errs on the side of reason: e.g. “try a few days of bed rest, take Aspirin, try a hot or cold compress, flush your sinuses, rub it with menthol, walk, stretch, join a social-group, breath deeper, stand up straighter, put a pillow under your knees when you sleep, eat more fiber, chew slower, take a nap, masterbate….etc etc. etc
Not all (or any?) ‘evidenced-based’ per se BUT simple rational “alternative-methods” that offer value without side-effects or subjecting the gullible to lunacy and financial harm.
Adding needles, sugar pills, bone-cracking, and the like is the epitome of the doctor acting irrationally.
I have struggled with this as well. In the past, I have half-heartedly argued that homœopathy could be used as a more or less innocent entertainment for hypochondriacs that would lead to less burden on the medical system while keeping those people happy.
Harriet Hall contradicted me at the time, and she was right. Lying to patients is just not a reasonable option, even if it saves the medical system oodles of time and money. It contributes to a destruction of trust in both doctors and the system and is ultimately self-defeating.
Even hypochondriacs with whom nothing else is wrong, have a problem. They deserve to be treated as adults, not hapless children. And yes, it will probably take time and will also fail on occasion. Isn’t that the case with all diseases, and with reality in general?
Lying to patients does not seem a good way to do that, does it?
Intentional, deceptive use of placebo is unethical. On the other hand, a consultation with a sympathetic provider carries its own placebo benefit – without deception. The best combination of effects is when a competent provider makes a competent medical assessment, effectively communicates that assessment to the patient, and they agree on whether active treatment is required, or not.
On the other hand, offering a “therapy” for every symptom, hoping for placebo benefit, only teaches the patient that a treatment IS required for every symptom – even for self-limiting conditions. Far from empowering patients, this just creates further dependence on a health service provider for every perceived discomfort. That is not good medicine.
@Sue
Very well said.
The same degree of deception and trading of fake goods is punishable by law in any other field of commerce.
If I tried to exchange monopoly money (compare homeoremedies) in the bank my sanity would be in question, if I offered similarly invalid documents for sale with false promises of future gain (analogy to health improvement) I would be prosecuted by law.
The prefix “health-” is somehow protective against responsibility and liability.
FS Thomas
But where is the evidence?
Equally, I am a millionaire.
You’ll just have to trust me on this.
Lovely posts by thoughtful and committed Doctors. Made me think about them which is a good thing now in my 80s where analytical thinking comes at a premium. As a GP I was daily faced by patients in whom anxiety was the unexpressed predominate presentation and the symptom the complaint. Thus a patient, say, with headaches. What this, and every other patient required was a thorough examination,neurological in this case, done kindly and responsive in body language to the patients anxiety. Then 1. an explanation that there was a physical explanation, frequently irritation of the greater occipital nerve due to poor head posture. Then 2. And this vitally important, an inquiry what lay beneath! Often what would emerge was anxiety in case of a brain tumour. Perhaps a near relative had recently died of it. This opened a can of worms in that strong reassurance that it was not a brain tumour concealed the possibility to me that it was. So a referral to a Practitioner of Mindfulness and relaxation would be a good option plus follow up. This is the skill of a GP: seeing what lies beneath and dealing with it. Can this be done in the modern 10 minutes fits all? I doubt it. I had no appointment system. I gave to each patient what they needed; some a few minutes for a sick note, some half an hour. It all worked out and on average I saw about 15 patients per surgery with each patient getting what they needed. Acupuncture, homeopathy, Reiki, faith healing etc? All irrelevant.
I, once, went to a acupuncturist who helped. She stuck several needle into my back and then “glued” some small magnets onto my back with instructions to bring them back for reuse at the next appointment.
These had no effect but her advice to move to a harder sleeping surface made a big difference. Sleeping on a rug on the floor did wonders. Who can say acupuncture does not work?
Well, I think you just did. The needling and magnets did not help. This is acupuncture. Sleeping on a different surface is not, even though an acupuncturist suggested it.