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

conflict of interest

1 2 3 46

Ever since the government in Bavaria has been misguided enough to agree to a research programme testing whether homeopathy has a role in curtailing the over-use of anti-biotics, the subject of homeopathics as a replacement of antibiotics has been revived.

In this paper, homeopaths describe four female cases with recurrent urinary tract infections. The patients were treated successfully with the homeopathic strategy after several conventional approaches revealed no improvement. The follow-up period was a minimum of 3 years and the frequency of episodes with urinary tract infection as well as of antibiotic treatment was documented. Additionally, the patients were asked to assess the treatment outcome retrospectively in a validated questionnaire.

The treatment resulted in a reduction of urinary tract infections and the need for antibiotics from monthly to less than 3 times a year. Three of the four women had no cystitis and related intake of antibiotics for more than 1.5 years. A relapse of symptoms could be treated efficiently with a repetition of the homeopathic remedy. All subjective outcome assessments resulted positive.

The authors concluded that this case series suggests a possible benefit of individualized homeopathic treatment for female patients with recurrent urinary tract infections. Larger observational studies and controlled investigations are warranted. 

Such articles make me quite angry! They have the potential to mislead many patients and, in extreme cases, might even cost lives.

The ‘possible benefit’ of any treatment cannot be demonstrated with such flimsy case series. It has to be shown in properly controlled clinical trials. The findings of case series are confounded by dozens of variables and tell us next to nothing about cause and effect.

Case series make sense when they explore possible new therapeutic avenues. Homeopathy does certainly not fall into this category. The notion that homeopathics might be an alternative to antibiotics has been tested many times before in different settings, in animals, in humans, it vivo and in vitro. This has never generated convincingly positive findings. To re-address it by reporting uncontrolled cases is not just a nonsense; in my view, it is an unethical attempt to mislead us.

About 85% of German children are treated with herbal remedies. Yet, little is known about the effects of such interventions. A new study might tell us more.

This analysis accessed 2063 datasets from the paediatric population in the PhytoVIS data base, screening for information on indication, gender, treatment, co-medication and tolerability. The results suggest that the majority of patients was treated with herbal medicine for the following conditions:

  • common cold,
  • fever,
  • digestive complaints,
  • skin diseases,
  • sleep disturbances
  • anxiety.

The perceived effect of the therapy was rated in 84% of the patients as very good or good without adverse events.

The authors concluded that the results confirm the good clinical effects and safety of herbal medicinal products in this patient population and show that they are widely used in Germany.

If you are a fan of herbal medicine, you will be jubilant. If, on the other hand, you are a critical thinker or a responsible healthcare professional, you might wonder what this database is, why it was set up and how exactly these findings were produced. Here are some details:

The data were collected by means of a retrospective, anonymous, one-off survey consisting of 20 questions on the user’s experience with herbal remedies. The questions included complaints/ disease, information on drug use, concomitant factors/diseases as well as basic patient data. Trained interviewers performed the interviews in pharmacies and doctor’s offices. Data were collected in the Western Part of Germany between April 2014 and December 2016. The only inclusion criterion was the intake of herbal drugs in the last 8 weeks before the individual interview. The primary endpoint was the effect and tolerability of the products according to the user.

And who participated in this survey? If I understand it correctly, the survey is based on a convenience sample of parents using herbal remedies. This means that those parents who had a positive experience tended to volunteer, while those with a negative experience were absent or tended to refuse. (Thus the survey is not far from the scenario I often use where people in a hamburger restaurant are questioned whether they like hamburgers.)

So, there are two very obvious factors other than the effectiveness of herbal remedies determining the results:

  1. selection bias,
  2. lack of objective outcome measure.

This means that conclusions about the clinical effects of herbal remedies in paediatric patients are quite simply not possible on the basis of this survey. So, why do the authors nevertheless draw such conclusions (without a critical discussion of the limitations of their survey)?

Could it have something to do with the sponsor of the research?

The PhytoVIS study was funded by the Kooperation Phytopharmaka GbR Bonn, Germany.

Or could it have something to do with the affiliations of the paper’s authors:

1 Institute of Pharmacy, University of Leipzig, Brüderstr. 34, 04103, Leipzig, Germny. nieberkaren@gmx.de.

2 Kooperation Phytopharmaka GbR, Plittersdorfer Str. 218, 573, Bonn, Germany. nieberkaren@gmx.de.

3 Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.

4 ClinNovis GmbH, Genter Str. 7, 50672, Cologne, Germany.

5 Bayer Consumer Health, Research & Development, Phytomedicines Supply and Development Center, Steigerwald Arzneimittelwerk GmbH, Havelstr. 5, 64295, Darmstadt, Germany.

6 Kooperation Phytopharmaka GbR, Plittersdorfer Str. 218, 53173, Bonn, Germany.

7 Institute of Pharmaceutical Biology, Goethe University Frankfurt, Max-von-Laue-Str. 9, 60438, Frankfurt, Germany.

8 Chair of Naturopathy, University Medicine Rostock, Ernst-Heydemann Str. 6, 18057, Rostock, Germany.

WHAT DO YOU THINK?

Chiropractors have a thing about treating children, babies and infants – not, I suspect, because it works but because it fills their bank accounts. To justify this abuse, they seem to go to any lengths – even to extrapolating from anecdote to evidence. This recently published case-report, for instance, described the chiropractic care of a neonate immediately post-partum who had experienced birth trauma.

The attending midwife noted the infant had an asynclitic head presentation at birth and as a result was born with an elongation of the occiput due to cranial molding, bilateral flexion at the elbows and shoulders with decreased range of motion in the cervical spine with tongue and lip tie. Oedema of the occiput with bruising was notable along with hypertonicity of cervical musculature at C1, hypertonicity (bilaterally) of the pectoral and biceps muscles, blanching and tension of lip tie, decreased suck reflex and tongue retraction with sucking, fascial restrictions at the ethmoid bones, at the occipital condyles (bilaterally), as well as at the shoulders and clavicles, bilaterally. An anterior subluxation of left sphenoid was noted.

The infant was cared for with chiropractic including a sphenobasilar adjustment. Following this adjustment, significant reduction in occipital edema was noted along with normal suck pattern and breastfeeding normalized.

The authors concluded that this case report provides supporting evidence that patients suffering from birth trauma may benefit from subluxation-based chiropractic care.

Oh no, this case report provides nothing of the sort! If anything, it shows that some chiropractors are so deluded that they even publish their cases of child abuse. The poor infant would almost certainly have developed at least as well without a chiropractor having come anywhere near him/her. And if the infant had truly been in need of treatment, then not by a chiropractor (who has no knowledge or training in diagnosing or treating a new-born), but by a proper paediatrician.

Neurolinguistic programming (NLP) was developed in the mid-seventies. It is a so-called alternative therapy (SCAM) that is not easy to define. Those who started it and those involved in it use such vague language that NLP means different things to different people. One metaphor keeps recurring: NLP claims to help people change by teaching them to program their brains. We were given brains, we are told, without an instruction manual, and NLP offers a user-manual for the brain. Consciously or unconsciously, NLP is based on the assumptions that:

  • the unconscious mind constantly influences our conscious thoughts and actions;
  • Freud’s theories are correct;
  • hypnotherapy is effective.

Wikipedia is more outspoken about it: Neuro-linguistic programming (NLP) is a pseudoscientific approach to communication, personal development, and psychotherapy…

Despite the fact that NLP is unproven (to say the least), the COLLEGE OF MEDICINE AND INTEGRATED HEALTH (COMAIH) is sufficiently impressed by NLP to offer a course for GPs and SCAM practitioners. Here is their announcement:

Neurolinguistic Healthcare in association with the College of Medicine brings you a 2-day Introduction to Hypnosis, Neurolinguistic Programming (NLP) and Neurolinguistic Healthcare (NLH). Dr Wong and Dr Akhtar who lead the course are Trainers in NLP and Hypnosis and GPs who apply their skills in daily practice within the 10-minute consultation. The course is suitable for both medical professionals and complementary therapists. This is a limited training event offered by them to share their years of knowledge and skills with you.

You will learn:

    1. A basic overview of NLP and the most useful aspects to use it to begin making effective changes in how you and the people you treat think and behave
    2. An understanding of the NLH model of the mind so that you understand the concepts of therapy using this mixed hypnosis/ NLP approach in relation to health.
    3. The ability to Hypnotise effectively in a very short period of time with practical experience – the ability to go through all the stages of hypnosis – the induction, deepening, therapy, and emergence, including rapid hypnosis techniques. (Hypnosis courses which are less practical often charge in excess of £2000 for this)
    4. Learn at least 3 therapeutic techniques, including the NLP therapeutic techniques which work much better in trance, so using and applying the skills you will learn in hypnosis
    5. Access to an online mentorship programme with Dr Akhtar or Dr Wong for 6 months and who will provide 3x30mins group webinar meetings after the course to ensure any remaining questions get answered and that you are actually going forth to apply these skills. (worth another £600 in value)
    6. Access to an online learning membership site with educational videos and other content like pain relief techniques, papers with therapeutic scripts, etc

This is an opportunity to learn a different way of helping people from doctors who target the 10-minute consultation with fast, effective formal hypnosis techniques and sleight-of-mouth. It is possible to make change happen in 10-minutes.

Note that attending this course will not make you a certified hypnotherapist, but confer you the skills you will learn to use personally and in the context of guided meditations and relaxations that are commonplace now.

And what evidence do I have for stating that NLP is unproven?

Is there an up-to-date and sound systematic review of NLP?

The answer is yes.

This systematic review of NLP included 10 experimental studies. Five studies were RCTs and five were uncontrolled pre-post studies. Targeted health conditions were anxiety disorders, weight maintenance, morning sickness, substance misuse, and claustrophobia during MRI scanning. NLP interventions were mainly delivered across 4-20 sessions although three were single session. Eighteen outcomes were reported and the RCT sample sizes ranged from 22 to 106. Four RCTs reported no significant between group differences with the fifth finding in favour of NLP. Three RCTs and five pre-post studies reported within group improvements. Risk of bias across all studies was high or uncertain.

The authors concluded that there is little evidence that NLP interventions improve health-related outcomes. This conclusion reflects the limited quantity and quality of NLP research, rather than robust evidence of no effect. There is currently insufficient evidence to support the allocation of NHS resources to NLP activities outside of research purposes.

Surprised?

I am not!

I did not expect the COMAIH to allow critical thinking to get in the way of quackery-promotion.

Hurray, homeopaths have a new study to be jubilant about!

But how far can we trust its findings?

Let’s have a look.

The aim of this study was to evaluate the effects of homeopathy (H) as an adjunct to non-surgical periodontal therapy (NSPT) in individuals with type 2 diabetes (DMII) and chronic periodontitis (CP). Eighty individuals with CP and DM II participated in this randomized, double-blind, placebo-controlled study. They were randomly divided into two groups: control group (CG) and the test group (TG), and both groups received the NSPT. TG also received homeopathic therapy, including Berberis, Mercurius solubilis/Belladonna/Hepar sulphur and Pyrogenium, while CG received placebo, while the TG received placebos. Clinical and laboratorial examinations were evaluated at baseline and after 1, 6 and 12 months of treatment.

Both groups showed significant improvement throughout the study for most of the parameters studied, but TG presented a significative gain of clinical attachment at 1 and 12 months compared to CG. Mean glucose and glycated haemoglobin significantly decreased in both groups after 6 and 12 months. However, there was a significant further reduction of these parameters in TG, as compared to CG.

The authors concluded that homeopathy as supplement of NSPT may further improve health condition, including glycemic control, in DMII patients with CP.

Over the years, I have learnt how to ‘sniff out’ studies that are odd. This is one of them, I fear; it smells strangely ‘fishy’.

Here are some of the reasons why I remain sceptical:

  1. There does not seem to be an approval by an ethics committee.
  2. I also could also not find any mention of informed consent.
  3. There is no mention of conflicts of interest
  4. Neither is the source of funding disclosed.
  5. There were zero drop-outs which I find hard to believe.
  6. The trial started in 2013, but was published only recently.
  7. The treatment with homeopathy lacks biological plausibility.
  8. The authors conducted > 50 tests for statistical significance without correcting for multiple testing.
  9. The clinical relevance of the findings is unclear.

Even if we accepted the results of this study, we would require at least one independent replication before we allow them to influence our clinical practice.

I have been sceptical about Craniosacral Therapy (CST) several times (see for instance here, here and here). Now, a new paper might change all this:

The systematic review assessed the evidence of Craniosacral Therapy (CST) for the treatment of chronic pain. Randomized clinical trials (RCTs) assessing the effects of CST in chronic pain patients were eligible. Pain intensity and functional disability were the primary outcomes. Risk of bias was assessed using the Cochrane tool.

Ten RCTs with a total of 681 patients suffering from neck and back pain, migraine, headache, fibromyalgia, epicondylitis, and pelvic girdle pain were included.

Compared to treatment as usual, CST showed greater post intervention effects on:

  • pain intensity (SMD=-0.32, 95%CI=[−0.61,-0.02])
  • disability (SMD=-0.58, 95%CI=[−0.92,-0.24]).

Compared to manual/non-manual sham, CST showed greater post intervention effects on:

  • pain intensity (SMD=-0.63, 95%CI=[−0.90,-0.37])
  • disability (SMD=-0.54, 95%CI=[−0.81,-0.28]) ;

Compared to active manual treatments, CST showed greater post intervention effects on:

  • pain intensity (SMD=-0.53, 95%CI=[−0.89,-0.16])
  • disability (SMD=-0.58, 95%CI=[−0.95,-0.21]) .

At six months, CST showed greater effects on pain intensity (SMD=-0.59, 95%CI=[−0.99,-0.19]) and disability (SMD=-0.53, 95%CI=[−0.87,-0.19]) versus sham. Secondary outcomes were all significantly more improved in CST patients than in other groups, except for six-month mental quality of life versus sham. Sensitivity analyses revealed robust effects of CST against most risk of bias domains. Five of the 10 RCTs reported safety data. No serious adverse events occurred. Minor adverse events were equally distributed between the groups.

The authors concluded that, in patients with chronic pain, this meta-analysis suggests significant and robust effects of CST on pain and function lasting up to six months. More RCTs strictly following CONSORT are needed to further corroborate the effects and safety of CST on chronic pain.

Robust effects! This looks almost convincing, particularly to an uncritical proponent of so-called alternative medicine (SCAM). However, a bit of critical thinking quickly discloses numerous problems, not with this (technically well-made) review, but with the interpretation of its results and the conclusions. Let me mention a few that spring into my mind:

  1. The literature searches were concluded in August 2018; why publish the paper only in 2020? Meanwhile, there might have been further studies which would render the review outdated even on the day it was published. (I know that there are many reasons for such a delay, but a responsible journal editor must insist on an update of the searches before publication.)
  2. Comparisons to ‘treatment as usual’ do not control for the potentially important placebo effects of CST and thus tell us nothing about the effectiveness of CST per se.
  3. The same applies to comparisons to ‘active’ manual treatments and ‘non-manual’ sham (the purpose of a sham is to blind patients; a non-manual sham defies this purpose).
  4. This leaves us with exactly two trials employing a sham that might have been sufficiently credible to be able to fool patients into believing that they were receiving the verum.
  5. One of these trials (ref 44) is far too flimsy to be taken seriously: it was tiny (n=23), did not adequately blind patients, and failed to mention adverse effects (thus violating research ethics [I cannot take such trials seriously]).
  6. The other trial (ref 41) is by the same research group as the review, and the authors award themselves a higher quality score than any other of the primary studies (perhaps even correctly, because the other trials are even worse). Yet, their study has considerable weaknesses which they fail to discuss: it was small (n=54), there was no check to see whether patient-blinding was successful, and – as with all the CST studies – the therapist was, of course, no blind. The latter point is crucial, I think, because patients can easily be influenced by the therapists via verbal or non-verbal communication to report the findings favoured by the therapist. This means that the small effects seen in such studies are likely to be due to this residual bias and thus have nothing to do with the intervention per se.
  7. Despite the fact that the review findings depend critically on their own primary study, the authors of the review declared that they have no conflict of interest.

Considering all this plus the rather important fact that CST completely lacks biological plausibility, I do not think that the conclusions of the review are warranted. I much prefer the ones from my own systematic review of 2012. It included 6 RCTs (all of which were burdened with a high risk of bias) and concluded that the notion that CST is associated with more than non‐specific effects is not based on evidence from rigorous RCTs.

So, why do the review authors first go to the trouble of conducting a technically sound systematic review and meta-analysis and then fail utterly to interpret its findings critically? I might have an answer to this question. Back in 2016, I included the head of this research group, Gustav Dobos, into my ‘hall of fame’ because he is one of the many SCAM researchers who never seem to publish a negative result. This is what I then wrote about him:

Dobos seems to be an ‘all-rounder’ whose research tackles a wide range of alternative treatments. That is perhaps unremarkable – but what I do find remarkable is the impression that, whatever he researches, the results turn out to be pretty positive. This might imply one of two things, in my view:

I let my readers chose which possibility they deem to be more likely.

As reported previously the NHS NATURAL HEALTH SCHOOL in Harrogate, is a service that offered a range of free complementary therapy treatments to patients and their relatives who are affected by a cancer diagnosis and are either receiving their cancer treatment at Harrogate or live in the Harrogate and Rural District.

This NHS school offered alternative treatments to cancer patients and claim that they know from experience, that when Complementary Therapies are integrated into patient care we are able to deliver safe, high quality care which fulfils the needs of even the most complex of patients.

In addition, they also ran courses for alternative practitioners. Their reflexology course, for instance, covered all of the following:

  • Explore the history and origins of Reflexology
  • Explore the use of various mediums used in treatment including waxes, balms, powders and oils
  • Explore the philosophy of holism and its role within western bio medicine
  • Reading the feet/hands and mapping the reflex points
  • Relevant anatomy, physiology and pathology
  • Managing a wide range of conditions
  • Legal implications
  • Cautions and contraindications
  • Assessment and client care
  • Practical reflexology skills and routines
  • Treatment planning

I imagine that the initiators of the school are full of the very best, altruistic intentions. I therefore had considerable difficulties in criticising them. Yet, I do strongly feel that the NHS should be based on good evidence; and that much of the school’s offerings seemed to be the exact opposite. In fact, the NHS-label was being abused for giving undeserved credibility to outright quackery.

Therefore, I did something I do rarely: I filed an official complaint in September 2019.

What happened next?

Nothing!

I sent several reminders; and what happened then?

Almost nothing!

I got several assurances that a response was imminent.

And then I forgot all about it.

So, I was surprised to receive this email yesterday from the chief executive of the HARROGATE AND DISTRICT NHS FOUNDATION TRUST (I did not change or correct anything):

Dear Professor Ernst

Thank you for contacting our Chair about the Natural Health School and my apologies for the extended delay in replying to you.   We have reflected on the points you raised and I have set out a summary of this below in respect of the key issues.

  1. As a result of colleagues who set up the service having moved on to other posts outside of the Trust we have not been able to understand how the service was named.  However, I agree that the terminology “NHS Natural Health School” could be interpreted in a certain way and as such we have agreed it should instead be referred to as the Natural Health School only to avoid any interpretation that it has national NHS endorsement.  We will amend the information on the website and other material to reflect that the service is endorsed by the Trust.
  1. The service is hosted by HDFT, in that staff are employed by the Trust, but it is funded through charitable contributions.  No NHS resources are used in providing the school, or the complementary therapies which are provided to patients receiving treatment at the Sir Robert Ogden Centre.
  1. There is no intention to assert that the services provided (ie the complementary therapies) are treatment for cancer.  The ‘treatments’ referred to are complementary therapy treatments and are described as such.  They are focused on wellbeing concurrently to the medical treatment of cancer, and we are satisfied that this is clear in the current description.
  1. Whilst recognising the differences of views on the complementary therapy treatments, the service regularly secures feedback from patients and this has been positive and as such we continue to offer it to those patients who would wish to take it up.
  1. The school provides training to allow participants to achieve a qualification which is awarded at level 3 by the International Therapies Examination Council.

I hope this provides clarity on the context to the service.

Best wishes

… … …

___________________________________________________________________

I find this response more than a little unsatisfactory; here are just a few points I find worth mentioning:

  • As far as I can see, apart of the actual name of the school (it is now called ‘NATURAL HEALTH SCHOOL’), very little has changed. In particular, a NHS link is still implied in multiple different ways.
  • To claim that ‘we have not been able to understand how the service was named’ seems like someone is taking the Mikey.
  • So is the remark that ‘the terminology “NHS Natural Health School” could be interpreted in a certain way’.
  • The statement ‘there is no intention to assert that the services provided (ie the complementary therapies) are treatment for cancer’ is simply untrue; symptomatic treatment of cancer is still a treatment for cancer!
  • If the treatments are focussed on wellbeing, they nevertheless should be backed by evidence to show that they improve wellbeing. The label ‘complementary’ does not absolve a therapy from the need to be evidence-based.
  • There may be ‘different views’ on complementary therapies; yet, there is only one set of evidence – and that fails to support several of the treatments on offer.
  • Positive feedback from patients is no substitute for evidence.

I am not sure whether I should reply to the above letter. I take little pleasure in embarrassing chief excecutives.

WHAT DO YOU THINK I SHOULD DO?

 

 

Yesterday, we discussed a paper concluding (amongst other things) that there are insufficient high‐quality RCTs to judge the efficacy of acupuncture for cancer‐related pain. Today, we are looking at one that overtly contradicts this verdict.

This systematic review (published in JAMA Oncology) evaluated the existing randomized clinical trials (RCTs) for evidence of the association of acupuncture and acupressure with reduction in cancer pain. Randomized clinical trials that compared acupuncture and acupressure with a sham control, analgesic therapy, or usual care for managing cancer pain were included. The primary outcome was pain intensity measured by the Brief Pain Inventory, Numerical Rating Scale, Visual Analog Scale, or Verbal Rating Scale.

A total of 17 RCTs (with 1111 patients) were included, and data from 14 RCTs (with 920 patients) were used in the meta-analysis. Seven sham-controlled RCTs (35%) were notable for their high quality, being judged to have a low risk of bias for all of their domains, and showed that real (compared with sham) acupuncture was associated with reduced pain intensity. A favourable association was also seen when acupuncture and acupressure were combined with analgesic therapy in 6 RCTs for reducing pain intensity and in 2 RCTs for reducing opioid dose. The evidence grade was moderate because of the substantial heterogeneity among studies.

The authors concluded that this systematic review and meta-analysis found that acupuncture and/or acupressure was significantly associated with reduced cancer pain and decreased use of analgesics, although the evidence level was moderate. This finding suggests that more rigorous trials are needed to identify the association of acupuncture and acupressure with specific types of cancer pain and to integrate such evidence into clinical care to reduce opioid use.

So, which of the two conclusions should we trust?

Personally, I find the JAMA paper unimpressive to the point of being suspect. Here are some of my reasons:

  • About half of the primary studies are Chinese; and we have seen repeatedly that they are unreliable and report only positive results.
  • Many of the trials are published in Chinese and can thus not be checked by non-Chinese readers (nor, presumably, by the experts who acted as peer-reviewers for JAMA Oncology).
  • I have my doubts about the rigor of the peer-review of some of the journals that published the primary studies included in the review.
  • One paper included in the review is even a mere doctoral thesis which usually is not peer-reviewed in the usual sense.
  • The authors state that they included only clinical trials that compared acupuncture and acupressure with a sham control, analgesic therapy, or usual care. However, this is evidently not true; many of the studies had the infamous A+B versus B design comparing acupuncture plus a conventional therapy against the conventional therapy. As we have discussed ad nauseam on this blog, such trials cannot produce a negative finding even if ‘A’ is a placebo.
  • Contrary to what the authors claim, the quality of most of the included studies was extremely poor, as far as I can see.
  • One included paper which I cannot access is entitled ‘Clinical observation on 30 cases of moderate and severe cancer pain of bone metastasis treated by auricular acupressure‘. Are the review authors seriously claiming that this is an RCT?

The more I study the details of the JAMA Oncology paper, the more I feel it might be worth a complaint to the editor with a view of initiating a thorough investigation and a possible retraction.

 

I published this article 20 years ago! Yet, it is, I think, still relevant today. For the purpose of this blog, I have altered it marginally (mainly by using the acromym SCAM):

Whatever SCAM is, it is not an alternative to conventional medicine. Nevertheless, one might still ask why so many people pay for ‘unproven’ SCAM when they can have scientifically backed medicine at no extra expense. Chandola et al suggest that 44% who use CM hope for a cure, 30% fear adverse effects of mainstream drugs, and 27% are dissatisfied with conventional care. In a much larger survey conducted in the USA, Astin found that dissatisfaction with orthodox medicine was prevalent but did not predict use of SCAM. SCAM users tended to be better educated and to subscribe to a more ‘holistic’ philosophy of healthcare. Interestingly, they reported poorer health status than non-users. Moreover, SCAM attracts patients because it offers more personal autonomy or control and is less impersonal or high-tech than mainstream medicine. Finally patients, particularly those with chronic conditions, may simply try SCAM so as to leave no stone unturned.

‘Scientifically backed’ medicine may not be quite as helpful as one tends to assume at least not in the eyes of the patient. A survey of 1420 (mostly musculoskeletal) pain sufferers suggested that SCAMs were perceived as more successful than mainstream drugs. In fact, orthodox therapies such as parenteral injections and oral medications ranked only 8th and 11th, respectively. Perhaps more disturbingly, patients seem to experience the therapeutic encounter with SCAM practitioners as more satisfying, empathetic and informative than that with their general practitioners. While many physicians (rightly or wrongly) continue to see SCAM as a nuisance, maybe we should think again: SCAM’s popularity amounts to a biting criticism of mainstream medicine that ought to be taken seriously.

How are clinicians to reconcile the public demand for SCAM with the new zeal for evidence-based medicine? The apparently easy answer is to pursue a strategy of evidence-based SCAM. This is precisely what my department is doing. There are now about 2000 clinical trials in this diverse area. But clinical trials are often full of contradictions and seldom clarify clinical questions adequately. A US study, for instance, has contributed to increasing doubts about whether chiropractic is helpful for acute uncomplicated low back pain in a clinically relevant way. What we really need for informing clinicians’ decisions are systematic reviews incorporating the totality of the available data. For the past 5 years this has been the focus of my department’s work, and we have published a considerable number of such papers. The notion that SCAM is totally devoid of evidence is a cliché which, like many clichés, is not entirely true.

Undoubtedly, vast areas of uncertainty do remain. The more difficult question is, therefore, how should clinicians deal with their patients’ desire for SCAM in the absence of evidence? Embarrassingly few convincing answers are on offer. Physicians have become experts in dealing with uncertainty in many aspects of their work. A dose of common sense will usually go quite far. At the very least, doctors should know what type of treatments their patients are trying. Taking a detailed history should nowadays include asking specifically about use of SCAM. In order not to alienate patients, one should resist the temptation to be dismissive. If there are good reasons to warn of a certain form of SCAM, these are best offered in an objective manner. To give evidence-based advice, clinicians obviously have to be informed about the facts, and impartial information is hard to find. One ray of light in this relative darkness is the Cochrane Collaboration, which now has a ‘field’ working on SCAM. The number of systematic reviews available from the Cochrane database is growing rapidly.

Once a patient is using SCAM (with or against the doctor’s advice), it makes sense to monitor the effects. This increases the safety of the patient and contributes to the physician’s knowledge of and experience with SCAM. There is also a good argument for establishing working relationships with a selection of local SCAM therapists who have a good track record and adequate training. At present, communication between doctors and therapists is often poor or even non-existent. Surely this cannot be to the benefit of the patient.

For SCAM, the best chance of survival in a harsh climate of evidence-based medicine and increasing rationing of resources is to come up with the goods and demonstrate what treatments are effective, safe and cost-effective for which condition. For physicians, the best way of reconciling the ‘two worlds’ is to inform themselves adequately and guide their patients through the ‘SCAM maze’ with a generous helping of good common sense. For patients, last but not least, the best approach is to be cautious and remember that, if it sounds too good to be true, it probably is.

END OF QUOTE

Twenty years, and little has changed:

  1. There still are vast areas of uncertainty.
  2. Imparcial information about SCAM is still scarce.
  3. Patient demand for SCAM is still considerable.
  4. The implied criticism of conventional medicine is still not taken seriously.
  5. The communication between doctors and SCAM practitioners is still lamentable.
  6. Most doctors still do not include questions about SCAM in their medical history taking.
  7. Arguably, SCAM has become even less evidence-based.
  8. Most doctors remain blissfully uninformed about SCAM.
  9. Most of the claims made for SCAM are too good to be true.
  10.  …
  11. etc.

I think you get the gist.

Guest post by Richard Rasker

Almost two years ago, in March 2018, a group of 124 doctors and other medical professionals published an article in the French newspaper ‘Le Figaro’, warning the general public for the false promises, unproven claims and dangers of alternative medicine.

Homeopathy in particular is denounced as an unscientific belief in magic, utterly lacking in plausibility as well as in evidence of efficacy for any condition. Subjecting people to these kinds of unproven treatments is unethical, and may result in serious harm by delaying proper medical treatment. Also, homeopaths and other alternative practitioners often express anti-vaccine sentiments, endangering children by dissuading their parents from vaccination.

For these and several other reasons, these 124 medical professionals made an appeal for alternative and esoteric treatments to be excluded from the field of science-based medicine, and to stop reimbursement of homeopathic and other alternative treatments under France’s national health care insurance system.

In a somewhat belated response, French homeopaths are now filing no less than 63 disciplinary complaints with the French Medical Council against the signatories of the appeal in Le Figaro, apparently for “uncollegial behaviour” and “defiling medical ethics”. The homeopaths are represented by homeopathic doctor Daniel Scimeca, president of the French Federation of Homeopathic Societies, who also has close relations with Boiron laboratories, the biggest manufacturer of homeopathic products in the world.

At the time of this writing, 11 complaints have been adjudicated, resulting in 7 warnings, and 4 releases or dismissals. It is unclear how serious such a ‘warning’ should be taken, but it is clear that homeopaths are trying to punish real doctors for supporting and expressing an overwhelming scientific consensus, i.e. that there is no evidence whatsoever that homeopathy is actually good for anything.

And even though these French homeopaths do not resort to the sort of vile, underhanded media smear campaign perpetrated by the late Claus Fritzsche against Dr. Ernst, there are certain parallels – the most important of which is that proponents of unproven ‘medicine’ attempt to silence science-based criticism by unscientific means, instead of open discourse about the merits (or more precisely: the lack thereof) of their chosen profession.

I personally find it rather worrying that almost two-thirds of the complaints resulted in a slap on the wrist for the medical professional involved. Especially in a field that is so strongly dependent on both science and trust, well-founded criticism should be encouraged and made public, not punished and silenced.

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