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

doctors

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Guest post by Toby Katz

Who am I?

I’m a final-year graduate medic (also hold an Economics degree) studying at St George’s University. I founded the Integrative Medicine Society at the university, with the aim of hosting talks on evidence-based CAM. My interest in evidence-based CAM arose as many of my family members have benefitted from different CAM interventions (mostly due to chronic MSk pain), where conventional interventions (physiotherapy and chronic pain teams) have failed to resolve their issues.

When it comes to the CAM debate, I see myself as a centrist. I am both a CAM apologist and sceptic and in recent years I have looked to educate myself around this subject. I have read Ernst’s Desktop Guide to CAM and Moral Maze books, spoken to Professor Colquhoun and most recently I undertook the Foundation Course in CAM run by the College of Medicine. My review of the course follows.

Overall, there’s a lot to learn from both sides of the debate and the debate continues due to systematic issues in the UK. Ad hominem attacks don’t help anyone, but conversation can. I hope I can converse with many of you in the future.

The Foundation Course

Two days of fast-paced talks on Integrative/Complementary and Alternative Medicine. The topics included: Resilience, nutritional therapy, medical acupuncture, MSk methods for non-osteopaths, homeopathy, herbs and spices, imagery and relaxation, cancer, hypnotherapy and social prescribing.

The speakers included: Professor David Peters, Dr Catherine Zollman (Medical Director for Penny Brohn), Heather Richards (Nutritional Therapist), Dr Elizabeth Thompson (GP and homeopath), Trevor Hoskisson (Hypnotherapist), Dr Mike Cummings (BMAS), Simon Mills (Medical Herbalist) – at least two of these are already in the infamous Alt Med Hall of Fame!

Initial feelings

My initial feelings upon hearing the talks were that most of these individuals are inherently good people, who want the best outcomes for their patients. Their aim is to operate in the areas of medicine where conventional medicine doesn’t hold the answers – chronic pain, idiopathic headache, IBS etc. But there were also people who were advocating the use of unproven alternative therapies.

These were some of my thoughts I jotted down during the two days:

Professor Peters – Constantly speaking in generalisations. Uses historic references, romantic and philosophical language to entice listeners but generally has little point to what he says. Suffers from tangential thinking. Loses track of his own point. Very Freudian-like thinking (everyone has gone through childhood trauma according to him).

Dr Catherine Zollman – Brilliant. Absolutely brilliant. The doctor I resonate most closely with out of everyone speaking. Promoting the holistic management of a cancer diagnosis; integrating (not undermining) conventional medicine with complementary ways of dealing with the stress surrounding the diagnosis and much more. Works for a non-for-profit organisation. She has many years of oncology experience and strives to create a patient-centred approach to management.

Dr Mike Cummings – promoting medical acupuncture mainly for myofascial pain syndrome. I volunteered to receive acupuncture in my shoulder (have had post-op muscular pain since April). He dry-needled one of my trigger points and it helped, for a few days – this is better than anything a physio has done for me so far. I don’t know why dry-needling isn’t taught at medical school to help with myofascial pain syndrome.

Dr Elizabeth Thompson – Very respectable but I do feel the homeopathy ship has well and truly sailed. Provided ‘evidence’ on how ‘succussion’ changes the make-up of water molecules. Though Dr Thompson is medically trained, there are many non-medical homeopaths who promote things such as homeoprophylaxis and anti-vaccine views and I’m more worried about these such homeopaths. I do respect Dr Thompson and believe her when she says she has helped many patients. Whether this is due to placebo or the get-better-anyway effect I don’t know.

What they were promoting

On reflection, it’s clear that there was a real mix in promoting evidence-based therapies and eyebrow-raising alternatives – this is often difficult for those with an untrained eye to spot the difference. There was a general air of distrust with modern science and EBM floating around the room at all times. Sure, there are things wrong with it, but I think it’s done us pretty well over the last few decades!

I irritated a few speakers when I asked about the evidence behind their claims!

What to take away

There were many GPs present, who stated they’re often in a difficult position in the current system of healthcare we have in the UK. Around half of all consultations are MSk based, many of which are associated with chronic, muscular pain. The WHO analgesic pathway does little for these patients (unless you want to knock them for six with oxycodone) and physiotherapists struggle to make a real difference in a 30-minute appointment. The truth is, we are not providing GPs with the right toolkit to cope with these “difficult” patients.

Going forward

– Get a copy of Ernst et al.’s Desktop Guide for CAM

– Release more formal guidelines using this book as a base for any positive evidence

– Engage in conversation with those from both sides. We have a lot to learn from one another

– SCRAP the forms of CAM that have no plausibility

Food for thought

– If a patient’s pain improves after a session of acupuncture and not from physiotherapy, does it fit with a utilitarian ethical model to deny this person access to acupuncture if EBM shows acupuncture has rates similar to placebo?

– Chronic myofascial pain syndrome. Can we manage it better in primary care? Why not teach dry needling to healthcare professionals? (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4107879/ – Desai et al suggest it works)

– What is the alternative for no CAM for many patients who suffer? If patient’s choice is reduced, does that not reduce their autonomy?

If anyone wishes to contact me, you can at tkatz@live.co.uk

An article in the ‘Chronicle of Chiropractic’ defends the currently much debated chiropractic care for children. It is authored by ‘ChiroFuture‘, a Risk Purchasing Group founded by chiropractors. Here is the unabridged article (the references were added by me and refer to my comments below):

The chiropractic care of children has been the subject of increased media attention and scrutiny following decisions by chiropractic regulatory boards in Europe, Australia and Canada. These decisions were not based on science, research or data but rather a purposeful misrepresentation of the concept of evidence informed practice (1) and its application coupled with compelled speech.

As with the chiropractic care of adults, an evidence informed perspective (2) respects the needs and wants of parents for the care of their child, the published research evidence and the clinical expertise of chiropractors in the care of children.

ChiroFutures Malpractice Program does not base its malpractice insurance rates on the age of the patients a chiropractor sees.  In fact, we are not aware of any actuarial data showing an increase in adverse events from the tens of millions of pediatric chiropractic visits per year (3). The vast majority of claims or incidents alleging chiropractic negligence involve adult patients (4).

What chiropractors do is minimally invasive and typically nothing else but their hands are used to gently ease any obstruction to the functioning of the patient’s nervous system (5). Since the nervous system controls and coordinates all functions of the body it is important to be sure it is functioning as best it can with no obstructions and no matter the disease afflicting the patient.

State and provincial laws, federal governments, international, national and state chiropractic organizations and chiropractic educational institutions all support the role and responsibility of chiropractors in the management of children’s health (6). The rationale for chiropractic care of children is supported by published protocols that are safe, efficacious, and valid (7). The scientific literature is sufficiently supportive of the usefulness of these protocols in regard to the chiropractic care of children (8).

Those contending that there is no evidence supporting the safety and efficacy of the chiropractic care of children demonstrate a complete disregard for the evidence and scientific facts related to the chiropractic care of children (9).

ChiroFutures encourages and supports a shared decision making process between doctors (10) and patients regarding health needs. As a part of that process, patients have a right to be informed about the state of their health as well as the risks, benefits and alternatives related to care. Any restriction on that dialogue or compelled statements inconsistent with the doctrine of informed consent present a threat to public health (11).

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Here are my comments:

  1. Why ‘evidence informed’ and not evidence-based’? The term ‘evidence informed’ is popular with SCAM practitioners. Barratt and Hodson noted, “The evidence-informed practitioner carefully considers what research evidence tells them in the context of a particular child, family or service, and then weighs this up alongside knowledge drawn from professional experience and the views of service users to inform decisions about the way forward.”  This seems to imply that the two terms are synonymous. However, in reality they are not.
  2. Does that mean that ‘evidence-informed’ is defined as the practice wanted by patients, regardless of the evidence?
  3. There is no post-marketing surveillance in chiropractic. Therefore we do not have reliable data on adverse events.
  4. That might be true but it is unclear what it tells us. It might simply mean that chiropractors treat more adults than children.
  5. There is no good evidence to show that the function of the nervous system can be enhanced by manual therapy.
  6. Provincial laws and federal governments might tolerate but I don’t think they ‘support’ the role and responsibility of chiropractors. That chiropractic organisations support it surprises nobody.
  7. This sentence does not make sense to me. The facts, however, are clear: there is no sound rational for chiropractic manipulations and they are neither efficacious nor totally safe for children.
  8. The scientific evidence does not show that chiropractic care is effective for any paediatric condition.
  9. I think the complete disregard is shown not by critics but by the authors of these lines.
  10. Calling chiropractors ‘doctors’ gives the impression they have  been to medical school and is therefore misleading the public.
  11. The threat to public health are those chiropractors who advise parents not to immunise their children.

Perhaps ChiroFuture need to brush up on their knowledge of the evidence. Chiropractic has no place in the healthcare of children. Parents should be warned!

One of the favourite arguments of proponents of so-called alternative medicine (SCAM) is that conventional medicine is amongst the world’s biggest killers. The argument is used cleverly to discredit conventional medicine and promote SCAM. It has been shown to be wrong many times, but it nevertheless is much-loved by SCAM enthusiasts and thus refuses to disappear. Perhaps this new and important review might help instilling some realism into this endless discussion? Here is its abstract:

Objective To systematically quantify the prevalence, severity, and nature of preventable patient harm across a range of medical settings globally.

Design Systematic review and meta-analysis.

Data sources Medline, PubMed, PsycINFO, Cinahl and Embase, WHOLIS, Google Scholar, and SIGLE from January 2000 to January 2019. The reference lists of eligible studies and other relevant systematic reviews were also searched.

Review methods Observational studies reporting preventable patient harm in medical care. The core outcomes were the prevalence, severity, and types of preventable patient harm reported as percentages and their 95% confidence intervals. Data extraction and critical appraisal were undertaken by two reviewers working independently. Random effects meta-analysis was employed followed by univariable and multivariable meta regression. Heterogeneity was quantified by using the I2 statistic, and publication bias was evaluated.

Results Of the 7313 records identified, 70 studies involving 337 025 patients were included in the meta-analysis. The pooled prevalence for preventable patient harm was 6% (95% confidence interval 5% to 7%). A pooled proportion of 12% (9% to 15%) of preventable patient harm was severe or led to death. Incidents related to drugs (25%, 95% confidence interval 16% to 34%) and other treatments (24%, 21% to 30%) accounted for the largest proportion of preventable patient harm. Compared with general hospitals (where most evidence originated), preventable patient harm was more prevalent in advanced specialties (intensive care or surgery; regression coefficient b=0.07, 95% confidence interval 0.04 to 0.10).

Conclusions Around one in 20 patients are exposed to preventable harm in medical care. Although a focus on preventable patient harm has been encouraged by the international patient safety policy agenda, there are limited quality improvement practices specifically targeting incidents of preventable patient harm rather than overall patient harm (preventable and non-preventable). Developing and implementing evidence-based mitigation strategies specifically targeting preventable patient harm could lead to major service quality improvements in medical care which could also be more cost effective.

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One in 20 patients is undoubtedly an unacceptably high proportion, but it is nowhere close to some of the extraordinarily alarming claims by SCAM enthusiasts. And, as I try regularly to remind people, the harm must be viewed in relation to the benefit. For the vast majority of conventional treatments, the benefits outweigh the risks. But, if there is no benefit at all – as with some form of SCAM – a risk/benefit balance can never be positive. Moreover, many experts work hard and do their very best to improve the risk/benefit balance of conventional healthcare by educating clinicians, maximising the benefits, minimising the risks, and filling the gaps in our current knowledge. Do equivalent activities exist in SCAM? The answer is VERY FEW?

The NHS England has stopped paying for homeopathy in 2017. France has just announced to do likewise. What about Germany, the homeland of homeopathy?  

In Germany there are about 150,000 doctors, and around 7,000 specialize in homeopathy. Multiple surveys confirm that Germans do like their SCAMs, particularly homeopathy. Two examples:

  • A 2016 cross-sectional analysis conducted among all patients being referred to the Department of Internal and Integrative Medicine at Essen, Germany, over a 3-year period showed that 35% of the 2,045 respondents reported having used homeopathy for their primary medical complaint.  359 (50.2%) patients reported benefits and 15 (2.1%) reported harm.
  • More recently, a questionnaire survey concerning current and lifetime use of SCAM was distributed to German adults with autism spectrum disorder (ASD). The results suggested that 45% of the respondents were currently using or had used at least one SCAM modality in their life. Homeopathy and acupuncture were most frequently used SCAMs, followed by mind-body interventions.

But since a few years, the German opposition to homeopathy has become much more active. In particular the INH, the GWUP, and the Muensteraner Kreis have been instrumental in informing the public about the uselessness and dangers of homeopathy. The press has now taken up this message and, as this article explains, now the debate about homeopathy has finally reached the political level.

The head of the main doctors’ association and the SPD’s health specialist have called for an end to refunds for homeopathy treatments in Germany. The head of the National Association of Statutory Health Insurance Physicians (KBV), which represents 150,000 doctors and psychotherapists in Germany, recently urged health insurance companies to stop funding homeopathic services. “There is insufficient scientific evidence for the efficacy of homeopathic procedures,” Andreas Gassen told the Rheinische Post. “If people want homeopathic remedies, they should have them — but not at the expense of the community.

Gassen’s comments follow those of the Social Democrat (SPD) health issues specialist and lawmaker Karl Lauterbach who has pressed for a law banning refunds for homeopathy. “We have to talk about it in GroKo,” Lauterbach said earlier this month, suggesting a discussion in the government grand coalition. He said the benefits paid for by insurers should be medically and economically sensible. He has the support of the Federal Joint Committee which decides on what is covered by payments from the statutory health funds.

So, what is going to happen?

As I have written previously, one can only be sure of this:

  • The German homeopathy lobby will not easily give up; after all, they have half a billion Euros per year to lose.
  • They will not argue on the basis of science or evidence, because they know that neither are in their favour.
  • They will fight dirty and try to defame everyone who stands in their way.
  • They will use their political influence and their considerable financial power.

AND YET THEY WILL LOSE!

Not because we are so well organised or have great resources – in fact, as far as I can see, we have none – but because, in medicine, the evidence is invincible and will eventually prevail. Progress might be delayed, but it cannot be halted by those who cling to an obsolete dogma.

 

 

It is not that long ago that I published a post entitled HOMEOPATHY IN FRANCE: A TRIUMPH OF PROFIT OVER REASON. Today, I am pleased to post one with the reverse title.

It has taken a few years (compared to the UK where it has taken a few decades, it was nevertheless fast), but now it is done. Very briefly, this is what happened:

  • In 2014, our book was published in French. I might be fooling myself, but I do hope that it helped starting a ball rolling in France where, up to then, homeopathy had enjoyed a free ride.
  • Subsequently, French sceptics began raising their voices against quackery in general and homeopathy in particular.
  • In 2018, they got organised and 124 doctors published an open letter criticising the use of alternative medicine as dangerous practised by charlatans of all kinds.
  • In the same year, the Collège National des Généralistes Engseignants, the national association for teaching doctors, pointed out that there was no rational justification for the reimbursement of homeopathics nor for the teaching of homeopathy in medical schools stating that It is necessary to abandon these esoteric methods, which belong in the history books.
  • Also in 2018, the University of Lille announced its decision to stop its course on homeopathy. The faculty of medicine’s dean, Didier Gosset, said: It has to be said that we teach medicine based on proof – we insist on absolute scientific rigour – and it has to be said that homeopathy has not evolved in the same direction, that it is a doctrine that has remained on the margins of the scientific movement, that studies on homeopathy are rare, that they are not very substantial. Continuing to teach it would be to endorse it.
  • In 2019, the French Academies of Medicine and Pharmacy have published a document entitled ‘L’homéopathie en France : position de l’Académie nationale de médecine et de l’Académie nationale de pharmacie’. It stated that L’homéopathie a été introduite à la fin du XVIIIe siècle, par Samuel Hahnemann, postulant deux hypothèses : celle des similitudes (soigner le mal par le mal) et celle des hautes dilutions. L’état des données scientifiques ne permet de vérifier à ce jour aucune de ces hypothèses. Les méta-analyses rigoureuses n’ont pas permis de démontrer une efficacité des préparations homéopathiques. The academies concluded that no French university should offer degrees in homeopathy, and that homeopathy should no longer be funded by the public purse: “no homeopathic preparation should be reimbursed by Assurance Maladie [France’s health insurance] until the demonstration of sufficient medical benefit has been provided. No university degree in homeopathy should be issued by medical or pharmaceutical faculties … The reimbursing of these products by the social security seems aberrant at a time when, for economic reasons, we are not reimbursing many classic medicines because they are more or less considered to not work well enough …”
  • Only weeks later, the French health regulator (HAS) has recommended with a very large majority (only one vote against) for the discontinuation of the reimbursement of homeopathic products.
  • The health minister, Agnès Buzyn, announced “Je me tiendrai à l’avis de la Haute Autorité de santé”.
  • Consequently, the powerful French homeopathy lobby created political pressure in multiple ways, including a petition with over 1000000 signatures and the last minute press-release below.

It is important, I think, to use this occasion for considering the main arguments of the homeopathy lobby in their defence of homeopathy.

  1. Homeopathy is effective. This argument is demonstrably false and can only be made, if one abuses the published evidence. One way to demonstrate this is to look at the official verdicts from around the globe.
  2. Homeopathy may only be a placebo, but it prevents patients taking dangerous drugs instead. This argument is tricky but wrong. If patients are ill, they need an effective therapy and not homeopathy. If they are not ill, they need reassurance and not a placebo. We need to educate the public and doctors to understand this simple message rather than pulling wool over their eyes.
  3. Discontinuing homeopathy is an undesirable curtailment of our freedom of choice. This is a pseudo-argument, because nobody forbids anyone using homeopathy. All we advocate is that the public purse should only pay for effective treatments. Any other strategy means that we jeopardise funds for effective therapies.
  4. Homeopathy employs over 1000 workers, and any cut in reimbursement would jeopardise these jobs. This argument is also tricky (and it is probably the one that created a headache for politicians). It is, however, spurious. Firstly, job preservation is only a good thing, if the jobs in question are worth preserving. If they serve no good service to the public, they are probably not worth preserving. (We don’t need to all start smoking, for instance, in order to preserve the jobs in the tobacco industry.) Secondly, the argument contradicts the other arguments of the homeopathy lobby. If homeopathy were effective and helpful, people would carry on buying homeopathics regardless of any cut in reimbursement. Thirdly, I suspect the figure of > 1000 will turn out to be hugely exaggerated. Fourthly, arguments of this kind are deeply regressive; they have historically stood in the way of progress whenever an innovation was inescapable (think of the industrial revolution, for instance), and they have never succeeded.

To contemplate these arguments carefully is important, I feel, because this will help other rational thinkers to fight for progress, optimal healthcare and good science. There is still plenty of quackery out there. So, let’s celebrate the French triumph (à votre santé, Agnès Buzyn!!!) – and then roll up our sleeves and get cracking!

In Switzerland, so-called alternative medicine (SCAM) is officially recognised within the healthcare system and mainly practised in conjunction with conventional medicine. So far no research has been published into the attitude towards, training in and offer of SCAM among paediatricians in Switzerland. This survey addresses this gap by investigating these topics with an online survey of paediatricians in Switzerland.

It employed a 19-item, self-reporting questionnaire among all ordinary and junior members of the Swiss Society of Paediatrics (SSP). A comparison of the study sample with the population of all paediatricians registered with the Swiss Medical Association (FMH) allowed an assessment of the survey’s representativeness. The data analysis was performed on the overall group level as well as for predefined subgroups (e.g. sex, age, language, workplace and professional experience).

A total of 1890 paediatricians were approached and 640, from all parts of Switzerland, responded to the survey (response rate 34%). Two thirds of respondents were female, were aged between 35 and 55 years, trained as paediatric generalist and worked in a practice. Apart from young paediatricians in training, the study sample was representative of all Swiss paediatricians.

According to the authors’ statistics, the results suggest that

  • 23% had attended training in SCAM, most frequently in phytotherapy, homeopathy, acupuncture/traditional Chinese medicine (TCM) and anthroposophic medicine
  • 8% had a federal certificate in one or more SCAM methods.
  • 44% did not routinely ask their patients about their use of SCAM.
  • 84% did not offer SCAM.
  • 65% were interested in SCAM courses and training.
  • 16% provided SCAM services to their patients.
  • 97% were asked by patients/parents about SCAM therapies.
  • More than half of the responding paediatricians use SCAM for themselves or their families.
  • 42% were willing to contribute to paediatric SCAM research.

The authors concluded that in a representative sample of paediatricians in Switzerland, the overall attitude towards SCAM was positive, emphasised by great interest in SCAM training, willingness to contribute to SCAM research and, in particular, by the high rate of paediatricians using SCAM for themselves and their families. However, given the strong demand for SCAM for children, the rate of paediatricians offering SCAM is rather low, despite the official recognition of SCAM in Switzerland. Among the various reasons for this, insufficient knowledge and institutional barriers deserve special attention. The paediatricians’ great interest in SCAM training and support for SCAM research offer key elements for the future development of complementary and integrative medicine for children in Switzerland.

SCAM suffers from acute survey mania. I am anxiously waiting for a survey of SCAM use in left-handed, diabetic policemen in retirement from Devon. But every other variation of the theme has been exploited. And why not? It provides the authors with a most welcome addition to their publication list. And, of course, it lends itself very nicely to SCAM-promotion. Sadly, there is not much else that such surveys offer.

Except perhaps for an opportunity to do an alternative evaluation of their results. Here is an assessment the devil’s advocate in me proposes. Based on the reasonable assumption that those 34% of paediatricians who responded did so because they had an interest in SCAM, and the 64% who did not reply couldn’t care less, it is tempting to do an analysis of the entire population of Swiss paediatricians. Here are my findings:

  • Hardly anyone had attended training in SCAM.
  • Hardly anyone had a federal certificate in one or more SCAM methods.
  • Very few did not routinely ask their patients about their use of SCAM.
  • Hardly anyone offered SCAM.
  • Very few were interested in SCAM courses and training.
  • Hardly anyone provided SCAM services to their patients.
  • Quite a few were asked by patients/parents about SCAM therapies.
  • Very few paediatricians use SCAM for themselves or their families.
  • Few were willing to contribute to paediatric SCAM research.

These results might be closer to the truth but they have one very important drawback: they do not lend themselves to drawing the SCAM-promotional conclusions formulated by the authors.

Oh Yes, reality can be a painful thing!

The fact that homeopathy is under siege in France, has been discussed before. Now even the international media have picked up the story. Here are some excerpts from an interesting article in Bloomberg:

… The looming brawl gets to the heart of conflicting visions of the state’s involvement in the country’s health system at a time of eroding quality and services. Jobs are also at stake: France is home to Boiron SA, the leader in a global homeopathy market estimated at more than $30 billion.

Boiron’s pills and tinctures have long coexisted with conventional care in France, prescribed by regular doctors and dispensed in almost every pharmacy. Ending public support for the remedies would discredit homeopathy and “send a shock wave” through the industry worldwide, says Boiron’s chief executive officer, Valerie Poinsot. “We’ve been caught in this storm for the past year,” Poinsot says. “Why the hostility, when we contribute to caring for patients?”

Facing a possible backlash, Boiron, based in Lyon, teamed with rivals Weleda AG of Switzerland and closely held family group Lehning to fund a campaign called MyHomeoMyChoice. The push has garnered just over 1 million signatures in an online petition and placed bright-colored posters framed with the recognizable little white pills at pharmacies across the country. “Homeopathy has treated generations of French patients,” says one slogan. “Why deprive future generations?”

For now, French people can walk into any pharmacy and buy a tube of Arnica granules — recommended for shocks and bruises — or roughly a thousand other similar remedies for 1.6 euros ($1.80) with a prescription, because the state health system shoulders about 30% of its cost. In some cases, private insurers cover the remainder and patients pay nothing. That may all soon change. A science agency is wrapping up a study of the relative benefits of alternative medicine that will inform the government’s position: Keep the funding, trim it or scrap it altogether.

If the government cuts funding, Boiron would instantly feel the pain. Poinsot estimates that sales of reimbursed treatments could plummet by 50% in France, where the company brings in almost half its revenue. The company’s stock price has lost about 13% since May 15, when a French newspaper wrote that the panel reviewing homeopathy funding would probably rule against it…

In France, the controversy first erupted last year when the influential Le Figaro newspaper published a letter from a doctor’s collective called FakeMed lambasting alternative medicines. The authors called for ending support of “irrational and dangerous” therapies with “no scientific foundation.” The ensuing debate prompted Health Minister Agnes Buzyn to place funding under review and ask the country’s High Authority for Health to rule on homeopathy’s scientific merits…

David Beausire, a doctor in palliative care at the hospital in Mont de Marsan, in southwest France, is among those who signed the FakeMed letter. Beausire, who sees many terminally ill patients, said he regularly gets people who consult too late because they first explored alternative medicine paths that include homeopathy. “I am not an extremist,” he says. But homeopathy’s reimbursement by the state health system gives it legitimacy when “there’s no proof that it works.”…

Stung by accusations of quackery, Antoine Demonceaux, a doctor and homeopath in Reims, founded a group called SafeMed last November to relay the message that homeopathy has a role to play alongside standard care. He points to the growing number of cancer centers offering consultations to relieve treatment-related symptoms, such as nausea, with homeopathic medicine. Demonceaux says neither he nor his colleagues would ever use homeopathy as a substitute for treatments intended to, say, shrink tumors. “A general practitioner or a specialist who’d claim to be a homeopath and to cure cancer with homeopathy? Just sack him,” he says. “Let’s get real. We are doctors.”

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On the whole, this is a good report which – as far as I can see – describes the situation quite well and provides interesting details. What, however, with this articles and many like it is this: journalists (and others) are too often too lethargic or naïve to check the veracity of the claims that are being made during these disputes. For instance, it would not have been all that difficult to discover that:

  1. Hahnemann called clinicians who used homeopathy alongside conventional treatments ‘traitors‘! He categorically forbade it and denied that such an approach merits the name ‘HOMEOPATHY’. In other words, let’s get real and let’s not pull wool over the eyes of the public (and let’s be honest, it is not possible to practice homeopathy within the boundaries of medical ethics).
  2. Many homeopaths do advocate homeopathy as a sole treatment for cancer and other serious conditions (see for instance here, here and here).

The obvious risk of such lack of critical thinking is that homeopathy might be kept refundable on the basis of big, fat lies. And clearly, that would not be in the interest of anyone (with the exception of family Boiron, of course).

Indian doctors have just published the case of a 38-year old man with cirrhosis of the liver due to compensated non-alcoholic fatty-liver-disease. He presented with acute worsening of his chronic liver disease. The acute event was not discernible even after extensive work up. Eventually, a transjugular liver biopsy revealed features suggestive of severe alcoholic hepatitis.

The patient and the family denied occult alcohol use when questioned over multiple times. According to the authors, the culprit ‘alcohol’ was found to be the homoeopathy medicines: the patient had been consuming a homeopathic remedy over a month for treatment of Gilbert’s syndrome. The researchers retrieved and tested the homoeopathy drug for alcohol content and found it contained 18% of ethanol. This, they felt, confirmed their diagnosis of alcoholic liver disease caused by the regular consumption of a homeopathic remedy.

Why did the patient help from a homeopath? Gilbert’s syndrome doesn’t usually require any treatment at all. Two weeks into his new treatment, the patient claimed he was feeling drowsy and slurring his speech, as if intoxicated. The liquid homeopathic formulation was therefore reduced at this stage. A further two weeks passed when his eyes yellowed, his urine darkened, and his legs began to swell. A liver tests confirmed a spike in his bilirubin 10 times above normal, with liver enzymes also elevated. All signs were thus pointing to an acute form of hepatitis commonly associated with alcohol binges. With the patient adamant he hadn’t touched alcohol, the doctors looked for other causes of hepatitis. None were found. When the patient admitted using homeopathy, his doctors thought to have found an explanation for the problem.

Despite starting the patient on a range of treatments and referring him to a liver transplant centre for further management, the damage to the patient’s liver proved to be irreversible. One month and 12 days later, the patient developed multiple organ failure and passed away. The authors of this case report point out “at risk patients and the general population need to be educated regarding the fact that complementary and alternative medications are not without side-effects.”

I do agree with their comment, but I very much doubt that their diagnosis of homeopathy-induced liver disease was correct. If the alcohol in the homeopathic remedy truly had been the cause, the patient would have needed to consume well in excess of one litre of it per day. The authors do not tell us about the volume of consumption, but I doubt that a patient would be able to afford such an orgy in homeopathy.

Highly diluted homeopathic remedies contain nothing, it is often said. This is not entirely true. In the case of solid preparations (globuli), they do contain sugar, and in the case of liquid remedies, they contain alcohol. Yet, as a source of either ingredient, they are neither practical nor economical. I fear therefore that the medical team of the diseased man are mistaken when accusing homeopathy of being the cause of their patient’s death.

One of the most difficult things in so-called alternative medicine (SCAM) can be having a productive discussion with patients about the subject, particularly if they are deeply pro-SCAM. The task can get more tricky, if a patient is suffering from a serious, potentially life-threatening condition. Arguably, the discussion would become even more difficult, if the SCAM in question is relatively harmless but supported only by scarce and flimsy evidence.

An example might be the case of a cancer patient who is fond of mindfulness cognitive therapy (MBCT), a class-based program designed to prevent relapse or recurrence of major depression. To contemplate such a situation, let’s consider the following hypothetical exchange between a patient (P) and her oncologist (O).

P: I often feel quite low, do you think I need some treatment for depression?

O: That depends on whether you are truly depressed or just a bit under the weather.

P: No, I am not clinically depressed; it’s just that I am worried and sometimes see everything in black.

O: I understand, that’s not an unusual thing in your situation.

P: Someone told me about MBCT, and I wonder what you think about it.

O: Yes, I happen to know about this approach, but I’m not sure it would help you.

P: Are you sure? A few years ago, I had some MBCT; it seemed to work and, at least, it cannot do any harm.

O: Yes, that’s true; MBCT is quite safe.

P: So, why are you against it?

O: I am not against it; I just doubt that it is the best treatment for you.

P: Why?

O: Because there is little evidence for it and even less for someone like you.

P: But I have seen some studies that seem to show it works.

O: I know, there have been trials but they are not very reliable.

P: But the therapy has not been shown to be ineffective, has it?

O: No, but the treatment is not really for your condition.

P: So, you admit that there is some positive evidence but you are still against it because of some technicalities with the science?

O: No, I am telling you that this treatment is not supported by good evidence.

P: And therefore you want me to continue to suffer from low mood? I don’t call that very compassionate!

O: I fully understand your situation, but we ought to find the best treatment for you, not just one that you happen to be fond of.

P: I don’t understand why you are against giving MBCT a try; it’s safe, as you say, and there is some evidence for it. And I have already had a good experience with it. Is that not enough?

O: My role as your doctor is to provide you with advice about which treatments are best in your particular situation. There are options that are much better than MBCT.

P: But if I want to try it?

O: If you want to try MBCT, I cannot prevent you from doing so. I am only trying to tell you about the evidence.

P: Fine, in this case, I will give it a go.

___________________________________________________

Clearly this discussion did not go all that well. It was meant to highlight the tension between the aspirations of a patient and the hope of a responsible clinician to inform his patient about the best available evidence. Often the evidence is not in favour of SCAM. Thus there is a gap that can be difficult to breach. (Instead of using MBCT, I could, of course, have used dozens of other SCAMs like homeopathy, chiropractic, Reiki, etc.)

The pro-SCAM patient thinks that, as she previously has had a good experience with SCAM, it must be fine; at the very minimum, it should be tried again, and she wants her doctor to agree. The responsible clinician thinks that he ought to recommend a therapy that is evidence-based. The patient feels that scientific evidence tells her nothing about her experience. The clinician insists that evidence matters. The patient finds the clinician lacks compassion. The clinician feels that the most compassionate and ethical strategy is to recommend the most effective therapy.

As the discussion goes on, the gap is not closing but seems to be widening.

What can be done about it?

I wish I knew the answer!

Do you?

Bleach can be a useful product – but not as a medicine taken by mouth or for injection.

A 39-year-old man with a fracture of the right acetabulum underwent open reduction and internal fixation with a plate under general anaesthesia. At closure, the surgeons injected 0.75% ropivacaine into the subcutaneous tissue of the incision wound for postoperative analgesia. Soon after injection, subcutaneous emphysema at the injection site and a sudden decrease in end-tidal CO2 tension with crude oscillatory ripples during the alveolar plateau phase were observed. Shortly thereafter, it was found that the surgeons had mistakenly injected hydrogen peroxide instead of ropivacaine. Fortunately, the patient recovered to normal status after 10 minutes. After the surgery, the patient was carefully observed for suspected pulmonary embolism and discharged without complications.

A team from Morocco reported the case of a massive embolism after hydrogen peroxide use in the cleaning of infected wound with osteosynthesis material left femoral done under spinal anaesthesia in a young girl of 17 years admitted after to the ICU intubated ventilated. She was placed under mechanical ventilation with vasoactive drugs for ten hours and then extubated without neurological sequelae.

Tunisian doctors reported 2 cases of embolic events with neurological signs. The first, during a pleural cleaning with hydrogen peroxide after cystectomy of a pulmonary hydatic cyst at the right upper lobe. The second case, after a pleural washing during the treatment of hepatitic hydatidosis complicated by a ruptured cyst in the thorax.

Canadian anaesthetists reported a case of suspected oxygen venous embolism during lumbar discectomy in the knee-prone position after use of H2O2. Immediately after irrigation of a discectomy wound with H2O2, a dramatic decrease of the PETCO2, blood pressure and oxygen saturation coincident with ST segment elevation occurred suggesting a coronary gas embolism. Symptomatic treatment was initiated immediately and the patient recovered without any sequelae.

Indian nephrologists reported a case of chlorine dioxide poisoning presenting with acute kidney injury.

A 1-year-old boy presented to the emergency department with vomiting and poor complexion after accidentally ingesting a ClO2-based household product. The patient had profound hypoxia that did not respond to oxygen therapy and required endotracheal intubation to maintain a normal oxygen level. Methemoglobinemia was suspected based on the gap between SpO2 and PaO2, and subsequently increased methemoglobin at 8.0% was detected. The patient was admitted to the paediatric intensive care unit for further management. After supportive treatment, he was discharged without any complications. He had no cognitive or motor dysfunction on follow up 3 months later.

The medical literature is littered with such case-reports. They give us a fairly good idea that the internal use of bleach is not a good idea. In fact, it has caused several deaths. Yet, this is precisely what some SCAM practitioners are advocating.

Now one of them is in court for manslaughter. “If I am such a clear and present danger and a murderer, I should be in jail by now,” said doctor Shortt, who despite a criminal investigation, is still treating patients in his office on the outskirts of Columbia, S.C. Shortt got his medical degree 13 years ago on the Caribbean island of Montserrat. Being a “longevity physician” didn’t seem to bother anyone until one of his patients wound up dead. Shortt gave her an infusion of hydrogen peroxide. Katherine Bibeau, a medical technologist and a mother of two, had been battling multiple sclerosis for two years, and was looking for any treatment that might keep her out of a wheelchair. According to her husband, doctor Shortt said hydrogen peroxide was just the thing. “He had said that there was other people who had been in wheelchairs, and had actually gone through treatment and were now walking again.” It didn’t worry the Bibeaus that Shortt wasn’t affiliated with any hospital or university – and that insurance didn’t cover most of his treatments. “He was a licensed medical doctor in Carolina,” says Bibeau. “So I put my faith in those credentials.” According to Shortt’s own records, the patient subsequently complained of “nausea,” “leg pain,” and later “bruises” with no clear cause. “She went Tuesday, she went Thursday. And by 11 o’clock on Sunday, she died,” says Mr Bibeau. Shortt never told him or his wife about any serious risks. “Even if it wasn’t effective, it should not have been harmful.”

Shortt has been putting hydrogen peroxide in several of his patients’ veins, because he believes it can effectively treat illnesses from AIDS to the common cold. “I think it’s an effective treatment for the flu,” says Shortt, who also believes that it’s effective for multiple sclerosis, Lyme disease, and “as adjunctive therapy” for heart disease. “Things that involve the immune system, viruses, bacteria, sometimes parasites.”

He’s not the only physician using this treatment. Intravenous hydrogen peroxide is a SCAM touted as a cure the medical establishment doesn’t want you to know about. There even is an association that claims to have trained hundreds of doctors how to administer it. The theory is that hydrogen peroxide releases extra oxygen inside the body, killing viruses and bacteria.

Natural News, for instance, tells us that cancer has a rival that destroys it like an M-60 leveling a field of enemy soldiers. It’s called “hydrogen peroxide,” and the “lame-stream,” mainstream media will tell you how “dangerous” it is at 35%, but they won’t tell you that you can drip a couple drops in a glass of water each day and end cancer. Yes, it’s true.

And hydrogen peroxide is not the only bleach that found its way into the realm of SCAM.

Perhaps even worse (if that is possible), the Genesis II Church of Health and Healing promote MMS as a miracle cure. It consists of chlorine dioxide, a powerful bleach that has been banned in several countries around the world for use as a medical treatment. The ‘Church’ claim that MMS cures 95% of all diseases in the world by making adults and children, including infants, drink industrial bleach. The group is inviting members to attend what they call their “effective alternative healing”.

The organizer of the event, Tom Merry, has publicized it by telling people that learning how to consume the bleach “could save your life, or the life of a loved one sent home to die”. The “church” is asking attendants of the meeting to “donate” $450 each, or $800 per couple, in exchange for receiving membership to the organization as well as packages of the bleach, which they call “sacraments”. The chemical is referred to as MMS, or “miracle mineral solution or supplement”, and participants are promised they will acquire “the knowledge to help heal many people of this world’s terrible diseases”.

Fiona O’Leary, a tireless and courageous campaigner for putting an end to a wide variety of mistreatments of children and adults, whose work helped to get MMS banned in Ireland, said she was horrified that the Genesis II Church, which she called a “bleach cult”, was hosting a public event in Washington.

In Fiona’s words: “ Its experimentation and abuse”. I do agree and might just add this: selling bleach for oral or intravenous application, while pretending it is an effective medicine, seems criminal as well.

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