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

The German Association of Medical Homeopaths (Deutscher Zentralverein homöopathischer Ärzte (DZVhÄ)) have recently published an article where, amongst other things, they lecture us about evidence-based medicine (EBM). If you feel that this might be a bit like an elephant teaching Fred Astaire how to step-dance, you could have a point. Here is their relevant paragraph:

… das Konzept der modernen Evidenzbasierte Medizin nach Sackett [stützt sich] auf drei Säulen: auf die klinischen Erfahrung der Ärzte, auf die Werte und Wünsche des Patienten und auf den aktuellen Stand der klinischen Forschung. Homöopathische Ärzte wehren sich gegen einen verengten Evidenzbegriff der Kritiker, der Evidenz allein auf die Säule der klinischen Forschung bzw. ausschließlich auf RCT verengen möchte und die anderen beiden Säulen ausblendet. Experten schätzen, dass bei einer solchen Auffassung von EbM rund 70 Prozent aller Leistungen der GKV nicht evidenzbasiert sei. Nötiger als eine Homöopathie-Debatte hat die deutsche Ärzteschaft aus unserer Sicht eine klare Verständigung darüber, welcher Evidenzbegriff nun gilt.

For those who cannot understand the full splendour of their argument because of the language problem, I translate as literally as I can:

… the concept of the modern EBM according to Sackett is based on three pillars: on the clinical experience of the doctors, on the values and wishes of the patient and on the current state of the clinical research. Homeopaths defend themselves against the narrowed understanding of ‘evidence’ of the critics which aims at narrowing evidence solely to the pillar of the clinical research or exclusively to RCT, while eliminating the other two pillars. Experts estimate that, with such an view of EBM, about 70% of all treatments reimbursed by our health insurances would not be evidence-based. We feel that we more urgently need a clear understanding which evidence definition applies than a debate about homeopathy.

END OF MY TRANSLATION

So, where is the hilarity in this?

I don’t know about you, but I find the following things worth a giggle:

  1. ‘narrowed understanding of evidence’ – this is a classical strawman; non-homeopaths tend to apply Sackett’s definition which states that ‘evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical experience with the best available external clinical evidence from systematic research‘;
  2. as we see, Sackett’s definition is quite different from the one cited by the homeopaths;
  3. the three pillars cited by the homeopaths are those subsequently developed for Evidence Based Practice (EBP) and include: A) patient values, B) clinical expertise and C) external best evidence;
  4. as we see, these three pillars are also not quite the same as those suggested by the homeopaths;
  5. non-homeopaths do certainly not aim at eliminating the ‘other two pillars’;
  6. current best evidence clearly includes much more than just RCTs – to mention RCTs in this context therefore suggests that the ones guilty of narrowing anything might, in fact, be the homeopaths;
  7. even if it were true that 70% of reimbursable treatments are not evidence-based, this would hardly be a good reason to employ homeopathic remedies of which 100% are not even remotely evidence-based;
  8. unbeknown to the German homeopaths, the discussion about a valid definition of EBM has been intense, is as old as EBM itself, and would by now probably fill a mid-size library;
  9. this discussion does, however, in no way abolish the need to bring the debate about homeopathy to the only evidence-based conclusion possible, namely the discontinuation of reimbursement of this and all other bogus therapies.

In conclusion, I do thank the German homeopaths for being such regular contributors to fun and hilarity. I shall miss them, once they have fully understood EBM and are thus compelled to stop prescribing placebos.

5 Responses to When homeopaths start lecturing us on EBM, hilarity is never far

  • Interesting that Sackett defined EBM as “integrating experience with best evidence from research.”

    So, EBM is “integrated medicine”.
    No room for integration with nonsense.

  • For all this, the word “chuzpe” is a smooth understatement, for it suggests a tongue-in-cheek, slightly ironic form of impertinence. The tongue in cheek, however, is missing, as is the irony.

    I have been observing for some time how homeopaths – in Germany – claim the EBM for themselves. (By the way, a front seems to be building up parallel to this, which homeopathy apparently wants to surround with the protective umbrella of a legitimate placebo therapy – this is how the new Review by Antonelli seems to me to be designed.)

    Be that as it may – in my blog (in German) I have already commented in detail on the EBM term of the chairwoman of the German Homeopathic Doctors’ Association. Excerpt:

    “Mrs. Bajic gets along additionally to the statement: ‘The medical homeopathy is effective and evidence-based. This is proven by numerous studies. In medical hands it is an important component of integrative medicine, which combines the best of conventional medicine and medical homeopathy for the benefit of the patient’.

    First we find here the “dual thinking” from the 1990s, which supposedly wants to unite “the best of both worlds”. And if homeopaths would at least combine “the best”, namely the pure devotion to the patient, with “conventional medicine” (what is that?). But that is precisely what they persistently refuse – which is expressed in every confrontation with positions critical of homeopathy. They insist on the right to exist of homeopathy as a specific drug therapy – and thus propagate esotericism. And that the assertion of the study is so fragile that its pronunciation should actually produce cracked lips, I don’t need to emphasize particularly.

    And as far as the evidence base is concerned, Mrs. Bajic’s interpretation is quite idiosyncratic. What evidence-based medicine is and is not, Cochrane explains sufficiently clearly. I would just like to briefly consider how the claim that homeopathy belongs to evidence-based medicine is compatible with these definitions:

    ‘External clinical evidence leads to the re-evaluation of previously accepted medical procedures.

    EbM is the conscientious, explicit and rational use of the best external scientific evidence currently available to make decisions in the medical care of individual patients.’

    The branches of the treating physician’s clinical experience, what constitutes the “medical art”, and the personal concerns of the patient do not outweigh the scientific evidence bases, but have them as a basis. That is why this is also called “evidence-based” and not “under equal consideration of the evident study situation”. One can imagine EbM as a triangle with the baseline of scientific evidence and the two aspiring lines of medical “art” and patient interests that converge at the summit to a result.

    And where does Mrs. Bajic now locate the “current scientific evidence” of homeopathy in this model? In her imagination, this triangle is more likely at the top – on a dimensionless point, a beautiful symbol of homeopathy. Then – fittingly – the line at the top would stand for an extended arbitrariness and would not, as in the opposite case, represent a result converging in a common point, an evidence-based therapy decision. A joke. A bad one.”

    Missing arguments, many words from the homeopaths. Blisters and bluff – but it still gets caught. Just recently, a German medical journal gave the chairman of the homeopathic medical association a forum to cite the “popularity” of homeopathy as an “argument”.

    Sometimes I begin to feel really angry.

  • This is once again a fine example of how practitioners of unproven (not to say utterly disproved) treatments try ‘integrating’ their nonsense into real medicine – in fact, it is exactly the way they practice their art: by producing humbug and twisting definitions, not by contributing anything solid and tangible (e.g. independently reproducible results). They seriously misrepresent EBM, fall for the old flying carpet fallacy (your bullet point #7), and accuse real science and medicine of ‘narrowing down’ the basis of the science and craft of medicine.

    I’m particularly amused about that last accusation, which is uttered by virtually all alternative practitioners and their following sooner rather than later, i.e. that those adhering to scientifically proven treatments are somehow ‘narrow-minded’ for not considering the arcane arts of homeopathy etc. as a serious option when practising medicine. Apparently, they have no idea that they’re the ones being seriously narrow-minded, by rejecting the vast bulk of scientific knowledge gathered in the past 200 years, by rejecting alternative (haha) explanations for the healing power of homeopathy that they claim to see all the time, and by sticking to the weird principles of their art no matter what – ‘principles’ that are often made up as they go along.

    Scientists, on the other hand, have taken homeopathy seriously from the onset, examined it very thoroughly for over two centuries now, and almost always reached the same conclusion: there’s literally nothing there. But only recently, 220 years after Hahnemann dreamed up homeopathy, science was finally confident enough to proclaim an outright rejection of homeopathy. And even now, they still leave the door ajar to any solid(!) evidence that they may be wrong after all – because that’s how science works. Homeopaths just have to show that e.g. patients with eczema respond better to ‘proper’ homeopathic treatment (personalized or not) than to a treatment with identical but unprocessed sugar crumbs.
    This is quite the contrary from the narrow-mindedness that homeopaths accuse the rest of the world of. Then again, homeopathic principles are topsy-turvy as they are: less is more, and whatever causes illness will also heal it. So it’s not really surprising that they get this thing about being narrow-minded completely backwards too…

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