conflict of interest
According to its authors, this RCT was aimed at investigating the 1) specific effect of individualized homeopathic Q-potencies compared to placebo and 2) the effect of an extensive homeopathic case taking (case history I) compared to a shorter, rather conventional one (case history II) in the treatment of acute major depression. In particular the second research question is intriguing, I think – so let’s have a closer look at this trial.
The study was designed as a randomized, partially double-blind, placebo-controlled, four-armed, 2×2 factorial trial with a 6-week study duration. A total of 44 patients were randomized (2∶1∶2∶1 randomization: 16 homeopathic Q-potencies/case history I, 7 placebo/case history I, 14 homeopathic Q-potencies/case history II, 7 placebo/case history II). Because of recruitment problems, the study was terminated prior to full recruitment, and was thus underpowered for the pre-planned confirmatory hypothesis testing. Exploratory data analyses showed heterogeneous and inconclusive results with large variance. The mean difference for the Hamilton-D after 6 weeks was 2.0 (95%CI -1.2;5.2) for Q-potencies vs. placebo, and -3.1 (-5.9;-0.2) for case history I vs. case history II. Overall, no consistent or clinically relevant results between homeopathic Q-potencies versus placebo and homeopathic versus conventional case taking were observed. The frequency of adverse events was comparable for all groups.
The conclusions were remarkable: although our results are inconclusive, given that recruitment into this trial was very difficult and we had to terminate early, we cannot recommend undertaking a further trial addressing this question in a similar setting.
Alright, the authors encountered problems in recruiting enough patients and they therefore decided to stop the trial early. This sort of thing happens. Most researchers would then not publish any data at all. This team, however, did publish a report, and the decision to do so might be perfectly fine: other investigators might learn from the problems which led to early termination of the study.
But why do they conclude that the results were INCONCLUSIVE? I think the results were not inconclusive but non-existent; these were no results to report other than those related to the recruitment problems. And even if one insists on presenting outcome data as an exploratory analysis, one cannot honestly say they were INCONCLUSIVE, all one might state in this case is that the results failed to show an effect of the remedy or the consultation. This is far less favourable for homeopathy than stating the results were INCONCLUSIVE.
And why on earth do the authors conclude “we cannot recommend undertaking a further trial addressing this question in a similar setting”? This does not make the slightest sense to me. If the trialists encountered recruitment problems, others might find ways of overcoming them. The research question asking whether the effects of an extensive homeopathic case taking differ from those of a shorter conventional one seems important. If answered accurately, it could disentangle much of the confusion that surrounds clinical trials of homeopathy.
I have repeatedly commented on the odd conclusions drawn by proponents of alternative medicine on the basis of data that did not quite fulfil their expectations, and I often ask myself at what point this ‘prettification’ of the results via false positive conclusions crosses the line to scientific misconduct. My theory is that these conclusions appear odd to those capable of critical analysis because the authors bend over backwards in order to conclude more positively than the data would seem to permit. If we see it this way, such conclusions might even prove useful as a fairly sensitive ‘bullshit-detector’.
A most excellent comment by Donald Marcus on what many now call ‘quackademia‘ (the disgraceful practice of teaching quackery (alternology) such as homoeopathy, acupuncture or chiropractic at universities as if they were legitimate medical professions) has recently been published in the BMJ.
Please allow me to quote extensively from it:
A detailed review of curriculums created by 15 institutions that received educational grants from the National Center for Complementary and Alternative Medicine (NCCAM) showed that they failed to conform to the principles of evidence based medicine. In brief, they cited many poor quality clinical trials that supported the efficacy of alternative therapies and omitted negative clinical trials; they had not been updated for 6-7 years; and they omitted reports of serious adverse events associated with CAM therapies, especially with chiropractic manipulation and with non-vitamin, non-mineral dietary supplements such as herbal remedies. Representation of the curriculums as “evidence based” was inaccurate and unjustified. Similar defects were present in the curriculums of other integrative medicine programs that did not receive educational grants….
A re-examination of the integrative medicine curriculums reviewed previously showed that they were essentially unchanged since their creation in 2002-03…Why do academic centers that are committed to evidence based medicine and to comparative effectiveness analysis of treatments endorse CAM? One factor may be a concern about jeopardizing income from grants from NCCAM, from CAM clinical practice, and from private foundations that donate large amounts of money to integrative medicine centers. Additional factors may be concern about antagonizing faculty colleagues who advocate and practice CAM, and inadequate oversight of curriculums.
By contrast to the inattention of US academics and professional societies to CAM education, biomedical scientists in Great Britain and Australia have taken action. At the beginning of 2007, 16 British universities offered 45 bachelor of science degrees in alternative practices. As the result of a campaign to expose the lack of evidence supporting those practices, most courses in alternative therapies offered by public universities in Britain have been discontinued. Scientists, physicians, and consumer advocates in Australia have formed an organization, Friends of Science in Medicine, to counter the growth of pseudoscience in medicine.
The CAM curriculums violate every tenet of evidence based medicine, and they are a disservice to learners and to the public. It could be argued that, in the name of academic freedom, faculty who believe in the benefits of CAM have a right to present their views. However, as educators and role models they should adhere to the principles of medical professionalism, including “a duty to uphold scientific standards.” Faculty at health profession schools should urge administrators to appoint independent committees to review integrative medicine curriculums, and to consider whether provision of CAM clinical services is consistent with a commitment to scholarship and to evidence based healthcare.
One of the first who openly opposed science degrees without science was David Colquhoun; in an influential article published in Nature, he wrote:
The least that one can expect of a bachelor of science (BSc) honours degree is that the subject of the degree is science. Yet in December 2006 the UK Universities and Colleges Admissions Service advertised 61 courses for complementary medicine, of which 45 are BSc honours degrees. Most complementary and alternative medicine (CAM) is not science because the vast majority of it is not based on empirical evidence. Homeopathy, for example, has barely changed since the beginning of the nineteenth century. It is much more like religion than science. Worse still, many of the doctrines of CAM, and quite a lot of its practitioners, are openly anti-science.
More recently, Louise Lubetkin wrote in her post ‘Quackademia‘ that alternative medicine and mainstream medicine are absolutely not equivalent, nor are they by any means interchangeable, and to speak about them the way one might when debating whether to take the bus or the subway to work – both will get you there reliably – constitutes an assault on truth.
I think ‘quackademia’ is most definitely an assault on truth – and I certainly know what I am talking about. When, in 1993, I was appointed as Professor of Complementary Medicine at Exeter, I became the director of a pre-existing team of apologists teaching a BSc-course in alternative medicine to evangelic believers. I was horrified and had to use skill, diplomacy and even money to divorce myself from this unit, an experience which I will not forget in a hurry. In fact, I am currently writing it up for a book I hope to publish soon which covers not only this story but many similarly bizarre encounters I had while researching alternative medicine during the last two decades.
According to a recent comment by Dr Larry Dossey, sceptics are afflicted by “randomania,” “statisticalitis,” “coincidentitis,” or “ODD” (Obsessive Debunking Disorder). I thought his opinion was hilariously funny; it shows that this prominent apologist of alternative medicine who claims that he is deeply rooted in the scientific world has, in fact, understood next to nothing about the scientific method. Like all quacks who have run out of rational arguments, he resorts to primitive ad hominem attacks in order to defend his bizarre notions. It also suggests that he could do with a little scepticism himself, perhaps.
In case anyone wonders how the long-obsolete notions of vitalism, which Dossey promotes, not just survive but are becoming again wide-spread, they only need to look into the best-selling books of Dossey and other vitalists. And it is not just lay people, the target audience of such books, who are taken by such nonsense. Health care professionals are by no means immune to these remnants from the prescientific era.
A recent survey is a good case in point. It was aimed at exploring US student pharmacists’ attitudes toward complementary and alternative medicine (CAM) and examine factors shaping students’ attitudes. In total, 887 student pharmacists in 10 U.S. colleges/schools of pharmacy took part. Student pharmacists’ attitudes regarding CAM were quantified using the attitudes toward CAM scale (15 items), attitudes toward specific CAM therapies (13 items), influence of factors (e.g., coursework, personal experience) on attitudes (18 items), and demographic characteristics (15 items).
The results show a mean (±SD) score on the attitudes toward CAM scale of 52.57 ± 7.65 (of a possible 75; higher score indicated more favorable attitudes). There were strong indications that students agreed with the concepts of vitalism. When asked about specific CAMs, many students revealed positive views even on the least plausible and least evidence-based modalities like homeopathy or Reiki.
Unsurprisingly, students agreed that a patient’s health beliefs should be integrated in the patient care process and that knowledge about CAM would be required in future pharmacy practice. Scores on the attitudes toward CAM scale varied by gender, race/ethnicity, type of institution, previous CAM coursework, and previous CAM use. Personal experience, pharmacy education, and family background were important factors shaping students’ attitudes.
The authors concluded: Student pharmacists hold generally favorable views of CAM, and both personal and educational factors shape their views. These results provide insight into factors shaping future pharmacists’ perceptions of CAM. Additional research is needed to examine how attitudes influence future pharmacists’ confidence and willingness to talk to patients about CAM.
I find the overwhelmingly positive views of pharmacists on even over quackery quite troubling. One of the few critical pharmacists shares my worries and commented that this survey on CAM attitudes paints a concerning portrait of American pharmacy students. However, limitations in the survey process may have created biases that could have exaggerated the overall perspective presented. More concerning than the results themselves are the researchers’ interpretation of this data: Critical and negative perspectives on CAM seem to be viewed as problematic, rather than positive examples of good critical thinking.
One lesson from surveys like these is they illustrate the educational goals of CAM proponents. Just like “integrative” medicine that is making its ways into academic hospital settings, CAM education on campus is another tactic that is being used by proponents to shape health professional attitudes and perspectives early in their careers. The objective is obvious: normalize pseudoscience with students, and watch it become embedded into pharmacy practice.
Is this going to change? Unless there is a deliberate and explicit attempt to call out and push back against the degradation of academic and scientific standards created by existing forms of CAM education and “integrative medicine” programs, we should expect to see a growing normalizing of pseudoscience in health professions like pharmacy.
I have criticised pharmacists’ attitude and behaviour towards alternative medicine more often than I care to remember. I even contributed an entire series of articles (around 10; I forgot the precise number) to THE PHARMACEUTICAL JOURNAL in an attempt to stimulate their abilities to think critically about alternative medicine. Pharmacists could certainly do with a high dose of “randomania,” “statisticalitis,” “coincidentitis,” or “ODD” (Obsessive Debunking Disorder). In particular, pharmacists who sell bogus remedies, i.e. virtually all retail pharmacists, need to remember that
- they are breaking their own ethical code
- they are putting profit before responsible health care
- by selling bogus products, they give credibility to quackery
- they are risking their reputation as professionals who provide evidence-based advice to the public
- they might seriously endanger the health of many of their customers
In discussions about these issues, pharmacists usually defend themselves and argue that
- those working in retail chains cannot do anything about this situation; head office decides what is sold on their premises and what not
- many medicinal products we sell are as bogus as the alternative medicines in question
- other health care professions are also not perfect, blameless or free of fault and error
- many pharmacists, particularly those not working in retail, are aware of this lamentable situation but cannot do anything about it
- retail pharmacists are both shopkeepers and health care professionals and are trying their very best to cope with this difficult dual role
- we usually appreciate your work and critical comments but, in this case, you are talking nonsense
I do not agree with any of these arguments. Of course, each single individual pharmacist is fairly powerless when it comes to changing the system (but nobody forces anyone to work in a chain that breaks the ethical code of their profession). Yet pharmacists have their professional organisations, and it is up to each individual pharmacist to exert influence, if necessary pressure, via their professional bodies and representatives, such that eventually the system changes. In all this distasteful mess, only one thing seems certain: without a groundswell of opinion from pharmacists, nothing will happen simply because too many pharmacists are doing very nicely with fooling their customers into buying expensive rubbish.
And when eventually something does happen, it will almost certainly be a slow and long process until quackery has been fully expelled from retail pharmacies. My big concern is not so much the slowness of the process but the fact that, currently, I see virtually no groundswell of opinion that might produce anything. For the foreseeable future pharmacists seem to have decided to be content with a role as shopkeepers who do not sufficiently care about healthcare-ethics to change the status quo.
A recent article by a South African homeopath promoted the concept of homeopaths taking over the role of primary care practitioners. His argument essentially was that, in South Africa, homeopaths are well trained and thus adequately equipped to do this job responsibly. Responsibly, really? You find that hard to believe? Here are the essentials of his arguments including all his references in full. I think they are worth reading.
Currently, the Durban University of Technology (DUT) and the University of Johannesburg (UJ) offer degree’s in homoeopathy. This involves a 5-year full-time theoretical and practical training course, followed by a Master’s level research project. After fulfilment of these criteria, a Master’s Degree in Technology (Homoeopathy) is awarded. The course comprises of a strong core of medical subjects, such as the basic sciences of Anatomy, Physiology, Medical Microbiology, Biochemistry and Epidemiology, and the clinical sciences of Pathology and Diagnostics. This is complemented with subjects in Classical, Clinical and Modern Homoeopathy and Homoeopharmaceutics4,5…
By law, any person practicing homoeopathy in South Africa must be registered with the Allied Health Professions Council of South Africa (AHPCSA). This is essential, as the Council ensures both medical and homoeopathic competency of practitioners, and that the activities of registered practitioners are closely monitored by the Professional Board. The purpose of the AHPCSA is to ensure that only those with legitimate qualifications of a high enough standard are registered and allowed to practice in South Africa, thus protecting the public against any fraudulent behaviour and illegal practitioners. Therefore, in order to ensure effective homoeopathic treatment, it is essential that any person wishing to prescribe homoeopathic medicine or practice homoeopathy in South Africa must be registered as a Homoeopathic Practitioner with the Allied Health Professions Council of South Africa. This includes conventional Medical Practitioners (dual registration is allowed for Medical Practitioners with both the Health Professions Council and AHPCSA)6, as homoeopathy requires several years of training in order to apply effectively in clinical practice…
Registration with the Council affords medico-legal rights similar to those of a medical professional, where treatment is limited to the scope of homoeopathic practice. Thus a homoeopath is firstly a trained diagnostician, and with successful registration with the Council, obtains the title Doctor. A homoeopath is trained and legally obliged to conduct a full medical history, a comprehensive clinical examination, and request further medical investigations, such as blood tests and X-rays, in order to fully assess patients. This is coupled with the ability to consult with specialist pathologists and other medical specialists when necessary, and refer a patient to the appropriate practitioner if the condition falls outside the scope of homoeopathic practice. A homoeopath may also legally issue a certificate of dispensation (‘Doctor’s note’) with appropriate evidence and within reason, and is deemed responsible for the diagnosis and treatment of patients under their care6. A homoeopath is not trained or licensed in any form of surgery, specialist diagnostics (e.g. colonoscopy or angiograms), cannot prescribe prescription medication and is not lawfully allowed to conduct intra-venous treatment of any kind. However, a registered homoeopath is licensed to use intra-muscular homoeopathic injectables in the treatment of various local or systemic complaints when necessary.
Conventional (allopathic) medicine generally targets specific biochemical processes with mostly chemically synthesised medication, in an attempt to suppress a symptom. However, in doing so, this usually negatively affects other biochemical reactions which results in an imbalance within the system. Homoeopathy, by contrast, seeks to re-establish a balance within the natural functioning of the body, restore proper function and results in the reduction or cessation of symptoms. Homoeopathy therefore enables the body to self-regulate and self-heal, a process known as homeostasis that is intrinsic to every living organism.
Conventional medical treatment is by no means risk free. Iatrogenic (medically induced) deaths in the United States are estimated at 786 000 per year, deaths which are considered avoidable by medical doctors7,8. These figures put annual iatrogenic death in the American medical system above that of cardiovascular disease and cancer as the leading cause of death in that country9, a fact that is not widely reported! South African figures are not easily available, but it is likely that we have similar rates. Although conventional medications have a vital role, are sometimes necessary and can of-course be life-saving, all too often too many patients are put on chronic medication when there are numerous effective, natural, safe and scientifically substantiated options available….
According to the World Health Organisation (WHO), homeopathy is the second largest system of medicine in the world, and world-wide use continues to grow in developed and developing nations10. Homoeopathy is widely considered to be safe and effective, with both clinical and laboratory research providing evidence for the efficacy of homoeopathy11. As the range of potential conditions that homoeopathy can treat is almost limitless, and that treatment is not associated with adverse reactions, homoeopathy should be considered a first-line therapy for all ages. As homoeopaths in South Africa are considered primary health care practitioners, if a conventional approach is deemed necessary, and further diagnostics are required, your practitioner will not hesitate to refer you to the appropriate health care practitioner. Homeopathy is also used alongside conventional medicine and any other form of therapy, and should be seen as ‘complementary’ medicine and not ‘alternative’ medicine.
Homoeopathy is an approach that is widely considered to be safe, and when utilised correctly, can be effective for a wide range of conditions. As a primary health care practitioner, a homoeopath is able to handle all aspects of general practice and family health care, including diagnostics, case management and referral to other practitioners or medical specialists. A registered homoeopath is legally responsible to ensure the adequate treatment of their patients, and is accountable for all clinical decisions and advice. A registered homoeopath understands the role of conventional medicine, and will refer to the appropriate specialist in cases that fall outside the legal scope of practice.
1. http://homeopathyresource.wordpress.com/what-is-homeopathy (accessed 31 March 2010)
2. Bloch R, Lewis B. Homoeopathy for the home. Cape Town, South Africa: Struik Publishers: 2003
3. http://www.dut.ac.za/site/awdep.asp?depnum=22609 (accessed 1 April 2010)
4. http://dutweb.dut.ac.za/handbooks/HEALTH%20Homoeopathy.pdf (accessed 1 April 2010)
5. http://www.uj.ac.za/EN/Faculties/health/departments/homeopathy/coursesandprogrammes/undergraduate/Pages/default.aspx (accessed 1 April 2010)
6. http://www.ahpcsa.co.za/pb_pbhnp_homoeopathy.htm (accessed 6 April 2010)
7. Starfield, B. Is US Health Really the Best in the World? JAMA 2000; 284(4).
8. Null G, Dean C, et al. Death by Medicine. Nutrition Institute of America 2003. 9. http://www4.dr-rath-foundation.org/features/death_by_medicine.html (accessed 7 April 2010)
10. http://ukiahcommunityblog.wordpress.com/2010/03/04/worldwide-popularity-grows-for-homeopathy-alternative-medicine/#comments (accessed 7 April 2010)
11. http://liga.iwmh.net/dokumente/upload/556c7_SCIEN_FRA_2009_final_approved.pdf (accessed 7 April 2010)
I found this article extremely revealing and scary. It gives us an important glimpse into the way some or perhaps even most homeopaths think. They clearly believe that:
1) Their training is sufficient for them to become competent primary care professionals, i.e. clinicians who are the first port of call for sick people to be diagnosed and treated effectively.
2) Homeopathy is scientifically proven to be efficacious for an ‘almost limitless’ range of conditions. Interestingly, not a single reference is provided to support this claim. Nevertheless, homeopath believe it, and that seems to be enough.
3) Homeopaths seem convinced that they perfectly understand real medicine; yet all they really do is to denounce it as one of the biggest killer of mankind.
4) The fact that homeopaths cannot prescribe real medicine is not seen as a hindrance to their role as primary care practitioner; if anything, homeopaths consider this to be an advantage.
5) Homeopaths view registration with some sort of governing body as the ultimate legitimation of their trade. Once such regulatory measures are in place, the need to support any of their claims with evidence is nil and void.
This article did remind me of the wry statement that ‘HOMEOPATHY IS TO MEDICINE WHAT THE CARPET INDUSTRY IS TO AVIATION’. Homeopaths truly live on a different planet, a planet where belief is everything and responsibility is an alien concept. I certainly hope that they will not take over planet earth in a hurry. If I imagine a world where homeopaths dominate primary care in the way it is suggested in this article, I start having nightmares. It seems to me that people who harbour ideas of this type are not just deluded to the point of madness but they are a danger to public health.
This post will probably work best, if you have read the previous one describing how the parallel universe of acupuncture research insists on going in circles in order to avoid admitting that their treatment might not be as effective as they pretend. The way they achieve this is fairly simple: they conduct trials that are designed in such a way that they cannot possibly produce a negative result.
A brand-new investigation which was recently vociferously touted via press releases etc. as a major advance in proving the effectiveness of acupuncture is an excellent case in point. According to its authors, the aim of this study was to evaluate acupuncture versus usual care and counselling versus usual care for patients who continue to experience depression in primary care. This sounds alright, but wait!
755 patients with depression were randomised to one of three arms to 1)acupuncture, 2)counselling, and 3)usual care alone. The primary outcome was the difference in mean Patient Health Questionnaire (PHQ-9) scores at 3 months with secondary analyses over 12 months follow-up. Analysis was by intention-to-treat. PHQ-9 data were available for 614 patients at 3 months and 572 patients at 12 months. Patients attended a mean of 10 sessions for acupuncture and 9 sessions for counselling. Compared to usual care, there was a statistically significant reduction in mean PHQ-9 depression scores at 3 and 12 months for acupuncture and counselling.
From this, the authors conclude that both interventions were associated with significantly reduced depression at 3 months when compared to usual care alone.
Acupuncture for depression? Really? Our own systematic review with co-authors who are the most ardent apologists of acupuncture I have come across showed that the evidence is inconsistent on whether manual acupuncture is superior to sham… Therefore, I thought it might be a good idea to have a closer look at this new study.
One needs to search this article very closely indeed to find out that the authors did not actually evaluate acupuncture versus usual care and counselling versus usual care at all, and that comparisons were not made between acupuncture, counselling, and usual care (hints like the use of the word “alone” are all we get to guess that the authors’ text is outrageously misleading). Not even the methods section informs us what really happened in this trial. You find this hard to believe? Here is the unabbreviated part of the article that describes the interventions applied:
Patients allocated to the acupuncture and counselling groups were offered up to 12 sessions usually on a weekly basis. Participating acupuncturists were registered with the British Acupuncture Council with at least 3 years post-qualification experience. An acupuncture treatment protocol was developed and subsequently refined in consultation with participating acupuncturists. It allowed for customised treatments within a standardised theory-driven framework. Counselling was provided by members of the British Association for Counselling and Psychotherapy who were accredited or were eligible for accreditation having completed 400 supervised hours post-qualification. A manualised protocol, using a humanistic approach, was based on competences independently developed for Skills for Health. Practitioners recorded in logbooks the number and length of sessions, treatment provided, and adverse events. Further details of the two interventions are presented in Tables S2 and S3. Usual care, both NHS and private, was available according to need and monitored for all patients in all three groups for the purposes of comparison.
It is only in the results tables that we can determine what treatments were actually given; and these were:
1) Acupuncture PLUS usual care (i.e. medication)
2) Counselling PLUS usual care
3) Usual care
Its almost a ‘no-brainer’ that, if you compare A+B to B (or in this three-armed study A+B vs C+B vs B), you find that the former is more than the latter – unless A is a negative, of course. As acupuncture has significant placebo-effects, it never can be a negative, and thus this trial is an entirely foregone conclusion. As, in alternative medicine, one seems to need experimental proof even for ‘no-brainers’, we have some time ago demonstrated that this common sense theory is correct by conducting a systematic review of all acupuncture trials with such a design. We concluded that the ‘A + B versus B’ design is prone to false positive results…What makes this whole thing even worse is the fact that I once presented our review in a lecture where the lead author of the new trial was in the audience; so there can be no excuse of not being aware of the ‘no-brainer’.
Some might argue that this is a pragmatic trial, that it would have been unethical to not give anti-depressants to depressed patients and that therefore it was not possible to design this study differently. However, none of these arguments are convincing, if you analyse them closely (I might leave that to the comment section, if there is interest in such aspects). At the very minimum, the authors should have explained in full detail what interventions were given; and that means disclosing these essentials even in the abstract (and press release) – the part of the publication that is most widely read and quoted.
It is arguably unethical to ask patients’ co-operation, use research funds etc. for a study, the results of which were known even before the first patient had been recruited. And it is surely dishonest to hide the true nature of the design so very sneakily in the final report.
In my view, this trial begs at least 5 questions:
1) How on earth did it pass the peer review process of one of the most highly reputed medical journals?
2) How did the protocol get ethics approval?
3) How did it get funding?
4) Does the scientific community really allow itself to be fooled by such pseudo-research?
5) What do I do to not get depressed by studies of acupuncture for depression?
Has it ever occurred to you that much of the discussion about cause and effect in alternative medicine goes in circles without ever making progress? I have come to the conclusion that it does. Here I try to illustrate this point using the example of acupuncture, more precisely the endless discussion about how to best test acupuncture for efficacy. For those readers who like to misunderstand me I should explain that the sceptics’ view is in capital letters.
At the beginning there was the experience. Unaware of anatomy, physiology, pathology etc., people started sticking needles in other people’s skin, some 2000 years ago, and observed that they experienced relief of all sorts of symptoms.When an American journalist reported about this phenomenon in the 1970s, acupuncture became all the rage in the West. Acupuncture-fans then claimed that a 2000-year history is ample proof that acupuncture does work.
BUT ANECDOTES ARE NOTORIOUSLY UNRELIABLE!
Even the most enthusiastic advocates conceded that this is probably true. So they documented detailed case-series of lots of patients, calculated the average difference between the pre- and post-treatment severity of symptoms, submitted it to statistical tests, and published the notion that the effects of acupuncture are not just anecdotal; in fact, they are statistically significant, they said.
BUT THIS EFFECT COULD BE DUE TO THE NATURAL HISTORY OF THE CONDITION!
“True enough”, grumbled the acupuncture-fans and conducted the very first controlled clinical trials. Essentially they treated one group of patients with acupuncture while another group received conventional treatments as usual. When they analysed the results, they found that the acupuncture group had improved significantly more. “Now do you believe us?”, they asked triumphantly, “acupuncture is clearly effective”.
NO! THIS OUTCOME MIGHT BE DUE TO SELECTION BIAS. SUCH A STUDY-DESIGN CANNOT ESTABLISH CAUSE AND EFFECT.
The acupuncturists felt slightly embarrassed because they had not thought of that. They had allocated their patients to the treatment according to patients’ choice. Thus the expectation of the patients (or the clinician) to get relief from acupuncture might have been the reason for the difference in outcome. So they consulted an expert in trial-design and were advised to allocate not by choice but by chance. In other words, they repeated the previous study but randomised patients to the two groups. Amazingly, their RCT still found a significant difference favouring acupuncture over treatment as usual.
BUT THIS DIFFERENCE COULD BE CAUSED BY A PLACEBO-EFFECT!
Now the acupuncturists were in a bit of a pickle; as far as they could see, there was no good placebo for acupuncture! Eventually some methodologist-chap came up with the idea that, in order to mimic a placebo, they could simply stick needles into non-acupuncture points. When the acupuncturists tried that method, they found that there were improvements in both groups but the difference between real acupuncture and placebo was tiny and usually neither statistically significant nor clinically relevant.
NOW DO YOU CONCEDE THAT ACUPUNCTURE IS NOT AN EFFECTIVE TREATMENT?
Absolutely not! The results merely show that needling non-acupuncture points is not an adequate placebo. Obviously this intervention also sends a powerful signal to the brain which clearly makes it an effective intervention. What do you expect when you compare two effective treatments?
IF YOU REALLY THINK SO, YOU NEED TO PROVE IT AND DESIGN A PLACEBO THAT IS INERT.
At that stage, the acupuncturists came up with a placebo-needle that did not actually penetrate the skin; it worked like a mini stage dagger that telescopes into itself while giving the impression that it penetrated the skin just like the real thing. Surely this was an adequate placebo! The acupuncturists repeated their studies but, to their utter dismay, they found again that both groups improved and the difference in outcome between their new placebo and true acupuncture was minimal.
WE TOLD YOU THAT ACUPUNCTURE WAS NOT EFFECTIVE! DO YOU FINALLY AGREE?
Certainly not, they replied. We have thought long and hard about these intriguing findings and believe that they can be explained just like the last set of results: the non-penetrating needles touch the skin; this touch provides a stimulus powerful enough to have an effect on the brain; the non-penetrating placebo-needles are not inert and therefore the results merely depict a comparison of two effective treatments.
YOU MUST BE JOKING! HOW ARE YOU GOING TO PROVE THAT BIZARRE HYPOTHESIS?
We had many discussions and consensus meeting amongst the most brilliant brains in acupuncture about this issue and have arrived at the conclusion that your obsession with placebo, cause and effect etc. is ridiculous and entirely misplaced. In real life, we don’t use placebos. So, let’s instead address the ‘real life’ question: is acupuncture better than usual treatment? We have conducted pragmatic studies where one group of patients gets treatment as usual and the other group receives acupuncture in addition. These studies show that acupuncture is effective. This is all the evidence we need. Why can you not believe us?
NOW WE HAVE ARRIVED EXACTLY AT THE POINT WHERE WE HAVE BEEN A LONG TIME AGO. SUCH A STUDY-DESIGN CANNOT ESTABLISH CAUSE AND EFFECT. YOU OBVIOUSLY CANNOT DEMONSTRATE THAT ACUPUNCTURE CAUSES CLINICAL IMPROVEMENT. THEREFORE YOU OPT TO PRETEND THAT CAUSE AND EFFECT ARE IRRELEVANT. YOU USE SOME IMITATION OF SCIENCE TO ‘PROVE’ THAT YOUR PRECONCEIVED IDEAS ARE CORRECT. YOU DO NOT SEEM TO BE INTERESTED IN THE TRUTH ABOUT ACUPUNCTURE AT ALL.
Nobody really likes criticism, I suppose. Yet everyone with a functional brain agrees that criticism is a precondition to making progress. So most of us do listen to it, introspect and try to learn a lesson.
Not so in alternative medicine! The last post by Preston Long was a summary of constructive criticism of his own profession; it brought that message home to me much clearer than previous discussions on this blog (probably because it did not directly concern me) and, after some reflection, I realised that apologists of alternative medicine have developed five distinct strategies to avoid progress that otherwise might develop from criticism (alright, these strategies do exist in other fields too, but I think that many of the comments on this blog demonstrate that they are particularly evident in alternative medicine).
We could also call this method ‘The Prince of Wales Technique of Avoiding Progress’ because HRH is famous for making statements ‘ex cathedra’ without ever defending them or facing his critics or allowing others to directly challenge him. When he advocated the Gerson diet for cancer, for instance, Prof Baum challenged him in an open letter asking him to use his influence more wisely. Like with all other criticism directed to him, he decided to ignore it. This strategy is a safe bet for stalling progress and it has the added advantage that it does not require anything other than ignorance.
As it requires some basic understanding of the issues at hand, this method is a little more demanding. You need to look closely at the criticism and subsequently shoot holes in it. If you cannot find any, invent some. For instance, you might state that your critic misquoted the evidence. Very few people will bother to read up the original data, and you are likely to get away even with fairly obvious lies. To beef your response up a bit, pretend that there is plenty of good evidence demonstrating exactly the opposite of what your critic has said. If asked to provide actual references or sources for your claims, don’t listen. An extreme example of the bluff-method is to sue your critic for libel – but be careful, this can backfire in a major way!
A very popular method is to claim that the critic is not actually competent to criticise. The discussion of Long’s post demonstrated that technique in a classic fashion. His detractors argued that he was a failed chiropractor who had an axe to grind and thus had no right to criticise chiropractic (“Preston H Long you are a disgrace to the chiropractic profession…take off your chiropractic hat, you dont deserve to wear it. YOU sir are a shame and a folly!!”). Of course, you need to be a bit simple in order to agree with this type of logic, but lots of people seem to be just that!
Even more popular is the blame-game. It involves arguing that, ok not all is rosy on your side of the fence, but the other side is so, so much worse. Before they dare to challenge you, they should look at their own mess; and while it is not sorted, they must simply shut up. For instance, if the criticism is that chiropractors have put hundreds of their patients into wheelchairs with their neck-manipulations, you must point out that doctors with their nasty drugs are much, much worse (“Long discounts the multitudes that chiropractic has… saved from dangerous drugs and surgery. As far as risks of injury from seeing a chiropractor vs. medicine, all one needs to do is compare malpractice insurance rates to see that insurance carriers rate medicine as an exponentially more dangerous undertaking”). Few people will realise that this is a fallacy and that the risks of any therapy must be seen in relation to its potential benefits.
When criticised, you are understandably annoyed; most people will therefore forgive you calling your critic names which are not normally used in polite circles (“who is this idiot, who wouldnt know the first thing about chiropractic”). Ad hominem attacks are the last resort of apologists of alternative medicine which emerges with depressing regularity when they have run out of rational arguments; they are signs of victories of reason over unreason. In the case of those chiropractors who were unable to stomach Long’s critique, the insults were coming thick and fast. The reason for only very few being visible is quite simple: I often delete the worst excesses of such primitive reactions.
The following is a guest post by Preston H. Long. It is an excerpt from his new book entitled ‘Chiropractic Abuse—A Chiropractor’s Lament’. Preston H. Long is a licensed chiropractor from Arizona. His professional career has spanned nearly 30 years. In addition to treating patients, he has testified at about 200 trials, performed more than 10,000 chiropractic case evaluations, and served as a consultant to several law enforcement agencies. He is also an associate professor at Bryan University, where he teaches in the master’s program in applied health informatics. His new book is one of the very few that provides an inside criticism of chiropractic. It is well worth reading, in my view.
Have you ever consulted a chiropractor? Are you thinking about seeing one? Do you care whether your tax and health-care dollars are spent on worthless treatment? If your answer to any of these questions is yes, there are certain things you should know.
1. Chiropractic theory and practice are not based on the body of knowledge related to health, disease, and health care that has been widely accepted by the scientific community.
Most chiropractors believe that spinal problems, which they call “subluxations,” cause ill health and that fixing them by “adjusting” the spine will promote and restore health. The extent of this belief varies from chiropractor to chiropractor. Some believe that subluxations are the primary cause of ill health; others consider them an underlying cause. Only a small percentage (including me) reject these notions and align their beliefs and practices with those of the science-based medical community. The ramifications and consequences of subluxation theory will be discussed in detail throughout this book.
2. Many chiropractors promise too much.
The most common forms of treatment administered by chiropractors are spinal manipulation and passive physiotherapy measures such as heat, ultrasound, massage, and electrical muscle stimulation. These modalities can be useful in managing certain problems of muscles and bones, but they have little, if any, use against the vast majority of diseases. But chiropractors who believe that “subluxations” cause ill health claim that spinal adjustments promote general health and enable patients to recover from a wide range of diseases. The illustrations below reflect these beliefs. The one to the left is part of a poster that promotes the notion that periodic spinal “adjustments” are a cornerstone of good health. The other is a patient handout that improperly relates “subluxations” to a wide range of ailments that spinal adjustments supposedly can help. Some charts of this type have listed more than 100 diseases and conditions, including allergies, appendicitis, anemia, crossed eyes, deafness, gallbladder problems, hernias, and pneumonia.
A 2008 survey found that exaggeration is common among chiropractic Web sites. The researchers looked at the Web sites of 200 chiropractors and 9 chiropractic associations in Australia, Canada, New Zealand, the United Kingdom, and the United States. Each site was examined for claims suggesting that chiropractic treatment was appropriate for asthma, colic, ear infection/earache/otitis media, neck pain, whiplash, headache/migraine, and lower back pain. The study found that 95% of the surveyed sites made unsubstantiated claims for at least one of these conditions and 38% made unsubstantiated claims for all of them.1 False promises can have dire consequences to the unsuspecting.
3. Our education is vastly inferior to that of medical doctors.
I rarely encountered sick patients in my school clinic. Most of my “patients” were friends, students, and an occasional person who presented to the student clinic for inexpensive chiropractic care. Most had nothing really wrong with them. In order to graduate, chiropractic college students are required to treat a minimum number of people. To reach their number, some resort to paying people (including prostitutes) to visit them at the college’s clinic.2
Students also encounter a very narrow range of conditions, most related to aches and pains. Real medical education involves contact with thousands of patients with a wide variety of problems, including many severe enough to require hospitalization. Most chiropractic students see patients during two clinical years in chiropractic college. Medical students also average two clinical years, but they see many more patients and nearly all medical doctors have an additional three to five years of specialty training before they enter practice.
Chiropractic’s minimum educational standards are quite low. In 2007, chiropractic students were required to evaluate and manage only 15 patients in order to graduate. Chiropractic’s accreditation agency ordered this number to increase to 35 by the fall of 2011. However, only 10 of the 35 must be live patients (eight of whom are not students or their family members)! For the remaining cases, students are permitted to “assist, observe, or participate in live, paper-based, computer-based, distance learning, or other reasonable alternative.”3 In contrast, medical students see thousands of patients.
Former National Council Against Health Fraud President William T. Jarvis, Ph.D., has noted that chiropractic school prepares its students to practice “conversational medicine”—where they glibly use medical words but lack the knowledge or experience to deal appropriately with the vast majority of health problems.4 Dr. Stephen Barrett reported a fascinating example of this which occurred when he visited a chiropractor for research purposes. When Barrett mentioned that he was recovering from an attack of vertigo (dizziness), the chiropractor quickly rattled off a textbook-like list of all the possible causes. But instead of obtaining a proper history and conducting tests to pinpoint a diagnosis, he x-rayed Dr. Barrett’s neck and recommended a one-year course of manipulations to make his neck more curved. The medical diagnosis, which had been appropriately made elsewhere, was a viral infection that cleared up spontaneously in about ten days.5
4. Our legitimate scope is actually very narrow.
Appropriate chiropractic treatment is relevant only to a narrow range of ailments, nearly all related to musculoskeletal problems. But some chiropractors assert that they can influence the course of nearly everything. Some even offer adjustments to farm animals and family pets.
5. Very little of what chiropractors do has been studied.
Although chiropractic has been around since 1895, little of what we do meets the scientific standard through solid research. Chiropractic apologists try to sound scientific to counter their detractors, but very little research actually supports what chiropractors do.
6. Unless your diagnosis is obvious, it’s best to get diagnosed elsewhere.
During my work as an independent examiner, I have encountered many patients whose chiropractor missed readily apparent diagnoses and rendered inappropriate treatment for long periods of time. Chiropractors lack the depth of training available to medical doctors. For that reason, except for minor injuries, it is usually better to seek medical diagnosis first.
7. We offer lots of unnecessary services.
Many chiropractors, particularly those who find “subluxations” in everyone, routinely advise patients to come for many months, years, and even for their lifetime. Practice-builders teach how to persuade people they need “maintenance care” long after their original problem has resolved. In line with this, many chiropractors offer “discounts” to patients who pay in advance and sign a contract committing them for 50 to 100 treatments. And “chiropractic pediatric specialists” advise periodic examinations and spinal adjustments from early infancy onward. (This has been aptly described as “womb to tomb” care.) Greed is not the only factor involved in overtreatment. Many who advise periodic adjustments are “true believers.” In chiropractic school, one of my classmates actually adjusted his newborn son while the umbilical cord was still attached. Another student had the school radiology department take seven x-rays of his son’s neck to look for “subluxations” presumably acquired during the birth process. The topic of unnecessary care is discussed further in Chapter 8.
8. “Cracking” of the spine doesn’t mean much.
Spinal manipulation usually produces a “popping” or “cracking” sound similar to what occurs when you crack your knuckles. Both are due to a phenomenon called cavitation, which occurs when there is a sudden decrease in joint pressure brought on by the manipulation. That allows dissolved gasses in the joint fluid to be released into the joint itself. Chiropractors sometimes state that the noise means that something therapeutic has taken place. However, the noise has no health-related significance and does not indicate that anything has been realigned. It simply means that gas was allowed to escape under less pressure than normal. Knuckles do not “go back into place” when you crack them, and neither do spinal bones.
9. If the first few visits don’t help you, more treatment probably won’t help.
I used to tell my patients “three and through.” If we did not see significant objective improvement in three visits, it was time to move on.
10. We take too many x-rays.
No test should be done unless it is likely to provide information that will influence clinical management of the patient. X-ray examinations are appropriate when a fracture, tumor, infection, or neurological defect is suspected. But they are not needed for evaluating simple mechanical-type strains, such as back or neck pain that develops after lifting a heavy object.
The average number of x-rays taken during the first visit by chiropractors whose records I have been asked to review has been about eleven. Those records were sent to me because an insurance company had flagged them for investigation into excessive billing, so this number of x-rays is much higher than average. But many chiropractors take at least a few x-rays of everyone who walks through their door.
There are two main reasons why chiropractors take more x-rays than are medically necessary. One is easy money. It costs about 35¢ to buy an 8- x 10-inch film, for which they typically charge $40. In chiropractic, the spine encompasses five areas: the neck, mid-back, low-back, pelvic, and sacral regions. That means five separate regions to bill for—typically three to seven views of the neck, two to six for the low back, and two for each of the rest. So eleven x-ray films would net the chiropractor over $400 for just few minutes of work. In many accident cases I have reviewed, the fact that patients had adequate x-ray examinations in a hospital emergency department to rule out fractures did not deter the chiropractor from unnecessarily repeating these exams.
Chiropractors also use x-ray examinations inappropriately for marketing purposes. Chiropractors who do this point to various things on the films that they interpret as (a) subluxations, (b) not enough spinal curvature, (c) too much spinal curvature, and/or (d) “spinal decay,” all of which supposedly call for long courses of adjustments with periodic x-ray re-checks to supposedly assess progress. In addition to wasting money, unnecessary x-rays entail unnecessary exposure to the risks of ionizing radiation.
11. Research on spinal manipulation does not reflect what takes place in most chiropractic offices.
Research studies that look at spinal manipulation are generally done under strict protocols that protect patients from harm. The results reflect what happens when manipulation is done on patients who are appropriately screened—usually by medical teams that exclude people with conditions that would make manipulation dangerous. The results do not reflect what typically happens when patients select chiropractors on their own. The chiropractic marketplace is a mess because most chiropractors ignore research findings and subject their patients to procedures that are unnecessary and/or senseless.
12. Neck manipulation is potentially dangerous.
Certain types of chiropractic neck manipulation can damage neck arteries and cause a stroke. Chiropractors claim that the risk is trivial, but they have made no systematic effort to actually measure it. Chapter 9 covers this topic in detail.
13. Most chiropractors don’t know much about nutrition.
Chiropractors learn little about clinical nutrition during their schooling. Many offer what they describe as “nutrition counseling.” But this typically consists of superficial advice about eating less fat and various schemes to sell you supplements that are high-priced and unnecessary.
14. Chiropractors who sell vitamins charge much more than it costs them.
Chiropractors who sell vitamins typically recommend them unnecessarily and charge two to three times what they pay for them. Some chiropractors center their practice around selling vitamins to patients. Their recommendations are based on hair analysis, live blood analysis, applied kinesiology muscle-testing or other quack tests that will be discussed later in this book. Patients who are victimized this way typically pay several dollars a day and are encouraged to stay on the products indefinitely. In one case I investigated, an Arizona chiropractor advised an 80+-year-old grandma to charge more than $10,000 for vitamins to her credit cards to avoid an impending stroke that he had diagnosed by testing a sample of her pubic hair. No hair test can determine that a stroke is imminent or show that dietary supplements are needed. Doctors who evaluated the woman at the Mayo Clinic found no evidence to support the chiropractor’s assessment.
15. Chiropractors have no business treating young children.
The pediatric training chiropractors receive during their schooling is skimpy and based mainly on reading. Students see few children and get little or no experience in diagnosing or following the course of the vast majority of childhood ailments. Moreover, spinal adjustment has no proven effectiveness against childhood diseases. Some adolescents with spinal stiffness might benefit from manipulation, but most will recover without treatment. Chiropractors who claim to practice “chiropractic pediatrics” typically aim to adjust spines from birth onward and are likely to oppose immunization. Some chiropractors claim they can reverse or lessen the spinal curvature of scoliosis, but there is no scientific evidence that spinal manipulation can do this.6
16. The fact that patients swear by us does not mean we are actually helping them.
Satisfaction is not the same thing as effectiveness. Many people who believe they have been helped had conditions that would have resolved without treatment. Some have had treatment for dangers that did not exist but were said by the chiropractor to be imminent. Many chiropractors actually take courses on how to trick patients to believe in them. (See Chapter 8)
17. Insurance companies don’t want to pay for chiropractic care.
Chiropractors love to brag that their services are covered by Medicare and most insurance companies. However, this coverage has been achieved though political action rather than scientific merit. I have never encountered an insurance company that would reimburse for chiropractic if not forced to do so by state laws. The political pressure to mandate chiropractic coverage comes from chiropractors, of course, but it also comes from the patients whom they have brainwashed.
18. Lots of chiropractors do really strange things.
The chiropractic profession seems to attract people who are prone to believe in strange things. One I know of does “aura adjustments” to treat people’s “bruised karma.” Another rents out a large crystal to other chiropractors so they can “recharge” their own (smaller) crystals. Another claims to get advice by “channeling” a 15th Century Scottish physician. Another claimed to “balance a woman’s harmonics” by inserting his thumb into her vagina and his index finger into her anus. Another treated cancer with an orange light that was mounted in a wooden box. Another did rectal exams on all his female patients. Even though such exams are outside the legitimate scope of chiropractic, he also videotaped them so that if his bills for this service were questioned, he could prove that he had actually performed what he billed for.
19. Don’t expect our licensing boards to protect you.
Many chiropractors who serve on chiropractic licensing boards harbor the same misbeliefs that are rampant among their colleagues. This means, for example, that most boards are unlikely to discipline chiropractors for diagnosing and treating imaginary “subluxations.”
20. The media rarely look at what we do wrong.
The media rarely if ever address chiropractic nonsense. Reporting on chiropractic is complicated because chiropractors vary so much in what they do. (In fact, a very astute observer once wrote that “for every chiropractor, there is an equal and opposite chiropractor.”) Consumer Reports published superb exposés in 1975 and 1994, but no other print outlet has done so in the past 35 years. This lack of information is the main reason I have written this book.
1. Ernst E, Gilbey A. Chiropractic claims in the English-speaking world. New Zealand Medical Journal 123:36–44, 2010.
2. Bernet J. Affidavit, April 12, 1996. Posted to Chirobase Web site.
3. Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status. Council on Chiropractic Education, Scottsdale, Arizona, Jan 2007.
4. Jarvis WT. Why becoming a chiropractor may be risky. Chirobase Web site, October 5, 1999.
5. Barrett S. My visit to a “straight” chiropractor. Quackwatch Web site, Oct 10, 2002.
6. Romano M, Negrini S. Manual therapy as a conservative treatment for idiopathic scoliosis: A review. Scoliosis 3:2, 2008.
I regularly used to ask alternative practitioners what diseases they are good at treating. In fact, we once ran an entire research project dedicated to this question and found that their own impressions were generally based on wishful thinking rather than on evidence. The libel case of the BCA versus Simon Singh then brought this issue into the focus of the public eye, and consequently several professional organisations of alternative practitioners seem to have advised their members to be cautious about making unsubstantiated therapeutic claims. This could have been an important step into the right direction – unless, of course, a clever trick had not been devised to bypass the need for evidence. Today, when I ask alternative practitioners ‘what do you treat effectively?’ I tend to get answers like:
- Alternative practitioners, unlike conventional clinicians, do not treat diseases.
- I treat the whole person, not just the disease.
- I treat people and their specific set of signs and symptoms, rather than disease labels (this actually is a quote from the comments section of one of my recent posts).
- I focus on the totality of the symptoms; disease labels are irrelevant in the realm of my therapy.
- Chiropractors adjust subluxations which are the root cause for most diseases.
- Acupuncturists re-balance life energies which is a precondition for healing to commence irrespective of the disease.
- Homeopaths treat the totality of symptoms so that the patient’s vital force can do the healing.
- etc. etc.
All of these statements are deeply rooted in the long obsolete notions of vitalism, i.e. the assumption that a vital energy flows in all living organisms and is responsible for our health irrespective of the disease we happen to suffer from. But what do the answers to my question ‘what do you treat?’ really mean? If we analyse the above responses critically, they seem to imply that:
- Conventional clinicians do not treat patients but merely disease labels.
- Alternative practitioners can successfully treat any disease or condition.
Ad 1 In my view, it is arrogant and grossly unfair to claim that alternative practitioners work holistically, while conventional health care professionals do not. I have pointed out repeatedly that any good medicine always has been and always will be holistic. High-jacking holism as a specific characteristic for alternative medicine is misleading and an insult to all conventional clinicians who do their best to practice good medicine.
Ad 2 By claiming that they treat the whole person irrespective of her disease, alternative practitioners effectively try to give themselves a ‘carte blanche’ for treating any disease or any condition or any symptom. If a child has asthma, a chiropractor will find a subluxation, adjust it with spinal manipulation, and claim that the child’s condition will improve as a consequence of his treatment – NEVER MIND THE EVIDENCE. If a person wants to give up smoking, an acupuncturist will use acupuncture to re-balance her yin and yang claiming that this intervention will make smoking cessation more successful – NEVER MIND THE EVIDENCE. If a patient suffers from cancer, a homeopath might find a remedy that promotes her vital energy claiming that the cancer will subsequently be cured – NEVER MIND THE EVIDENCE which in all of the three cases is negative.
The claim of alternative practitioners to not treat disease labels but the whole patient is doubtlessly attractive to consumers and it is also extremely good for business. On closer inspection, however, it turns out to be a distraction from the fact that alternative practitioners treat everything and anything, usually without the slightest evidence that their interventions generates more good than harm. It allows alternative practitioners to live in a fool’s paradise of quackery where they believe themselves to be protected from any challenges and demands for evidence.
Homeopaths can bear criticism only when it is highly diluted. Any critique from the ‘outside’ is therefore dismissed by insisting that the author fails to understand the subtleties of homeopathy. And criticism from the ‘inside’ does not exist: by definition, a homeopath does not criticise his/her own trade. Through these mechanisms, homeopaths have more or less successfully shielded themselves from all arguments against their activities and have, for the last 200 years, managed to survive in a world of make-belief.
As I will show below, I started my professional life on the side of the homeopaths – I am not proud of this fact, but there is no use denying it. When the evidence told me more and more clearly that I had been wrong, about 10 years ago, I began expressing serious doubts about the plausibility, efficacy and safety of using homeopathic remedies to treat patients in need. Homeopaths reacted not just with anger, they were also at a loss.
Their little trick of saying ‘He does not understand homeopathy and therefore his critique is invalid’ could not possibly work in my case – I had been one of them: I had attended their meetings, chaired some of their sessions, edited a book on homeopathy, accepted an invitation to join the editorial board of the journal ‘HOMEOPATHY‘ as well as a EU-panel investigating homeopathy, conducted trials, systematic reviews and meta-analyses, published over 100 articles on the subject, accepted money from Prince Charles as well as from the ‘ueber-homeopath’ George Vithoulkas for my research, and even contributed to THE INTERNATIONAL DICTIONARY OF HOMEOPATHY. It would have not looked reasonable to suddenly deny my previously accepted expertise. Homeopaths thus found themselves in a pickle: critique from the ‘inside’ is not what they were used to or could easily cope with.
The homeopathic idyll was under threat, and a solution to the problem had to be found with some urgency. And soon enough, it was found. Homeopaths from across the world started claiming that I had been telling porkies about my training/qualifications in homeopathy: “Edzard Ernst has admitted that he has over the years lied or supported a lie about having homeopathic training. In reality he has had none at all! The leading so-called ‘expert’ and critic of homeopathy, Professor Edzard Ernst, has admitted that he has no qualifications in homeopathy. etc. etc. Diluting the truth to the extreme, they almost unanimously insisted that, contrary to my previous assertions, I had no training/qualifications in homeopathy. Thus, they began to argue, that I was an imposter and had insufficient knowledge, expertise and experience after all: Professor Edzard Ernst the leading ‘authority’ on homeopathy, and perhaps its most referenced critic, has no qualifications in homeopathy. William Alderson of HMC21 also claims that Ernst’s book Trick or Treatment? shows Ernst to be unreliable as a researcher into homeopathy. Opposition to homeopathy is based on propaganda, they stated. Others wrote that Edzard Ernst’ failure as a homeopath only proves he lacked some basic qualities essential to become a successful homeopath. He failed as a homeopath, and then turned a skeptic. His failure is only his failure- it does not disprove homeopathy by any way. Once he failed in putting a mark as a successful homeopath or CAM practitioner, he just tried the other way to become famous and respectable- he converted himself into a skeptic, which provided him with ample opportunities to appear on ‘anti-homeopathy’ platforms’ as an ‘authority’, ‘expert’ and ‘ex-homeopath’! Some went even further claiming that I had also lied about my medical qualifications.
These notions has been going around the internet for several years now and conveniently served as a reason to re-categorise me into the camp of the homeopathically unqualified pseudo-experts: ‘We believe that it is time to recognise that opposition to homeopathy is largely based on the opinions of individuals who are unqualified or unwilling to judge the evidence fairly’. I, by contrast, believe it is time that I disclose the full truth about ‘my double-life as a homeopath’. What exactly is my background in this area? Have I really been found out to be a confidence-trickster?
THE HOMEOPATHIC CLINICIAN
I graduated from medical school in Munich in the late 1970s and, looking for a job, I realised that there weren’t any. At the time, Germany had a surplus of doctors and all the posts I wanted were taken. Eventually, I found one in the only hospital that was run almost entirely homoeopathically, the KRANKENHAUS FUER NATURHEILWEISEN in Munich. Within about half a year, I learned how to think like a homeopath, diagnose like a homeopath and treat patients like a homeopath. I never attended formal courses or aspired to get a certificate; as far as I remember, none of the junior doctors working in the homeopathic hospital did that either. We were expected to learn on the job, and so we did.
Our teachers at medical school had hardly ever mentioned homeopathy, but one thing they had nevertheless made abundantly clear to us: homeopathy cannot possibly work; there is nothing in these pills and potions! To my surprise, however, my patients improved, their symptoms subsided and, in general, they were very happy with the treatment we provided. My professors had told me that homeopathy was rubbish, but they had forgotten to teach me a much more important lesson: critical thinking. Therefore, I might be forgiven for proudly assuming that my patients’ improvement was due to my skilful homeopathic prescriptions.
But then came another surprise: the boss of the homeopathic hospital, Dr Zimmermann, took me under his wings, and we had occasional discussions about this and that and, of course, about homeopathy. When I shyly mentioned what I had been told at medical school ( about homeopathy being entirely implausible), he agreed! I was speechless. Crucially, he considered that there were other explanations: “Our patients might improve because we look after them well and we discontinue all the unnecessary medication they come in with; perhaps the homeopathic remedies play only a small part”, he said.
THE INVESTIGATOR OF HOMEOPATHY
This may well have been the first time I started looking critically at homeopathy and my own clinical practice – and this is roughly where I left things as far as homeopathy is concerned until, in 1993, it became my job to research alternative therapies systematically and rigorously. Meanwhile I had done a PhD and tried my best to learn the skills of critical analysis. As I began to investigate homeopathy scientifically, I found that my former boss had been right: patients do indeed improve because of a multitude of factors: placebo-effects, natural history of the disease, regression towards the mean, to mention just three of a multitude of phenomena. At the same time, he had not been entirely correct: homeopathic remedies are pure placebos; they do not play a ‘small part’ in patients’ improvement, they play no part in this process.
As I began to state this more and more clearly, all sorts of ad hominem attacks were hauled in my direction, and recently I was even fired from the editorial board of the journal ‘HOMEOPATHY’ because allegedly I “…smeared homeopathy and other forms of complementary medicine…” I don’t mind any of that – but I do think that the truth about ‘my double-life as a homeopath’ should not be diluted like a homeopathic remedy until it suits those who think they can defame me by claiming I am a liar and do not know what I am talking about.
This rather depressing story shows, I think, that some homeopaths, rather than admitting they are in the wrong, are prepared to dilute the truth until it might be hard for third parties to tell who is right and who is wrong. But however they may deny it, the truth is still the truth: I have been trained as a homeopath.