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

EBM

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?

Chiropractic spinal manipulative therapy (CSMT) for migraine?

Why?

There is no good evidence that it works!

On the contrary, there is good evidence that it does NOT work!

A recent and rigorous study (conducted by chiropractors!) tested the efficacy of chiropractic CSMT for migraine. It was designed as a three-armed, single-blinded, placebo -controlled RCT of 17 months duration including 104 migraineurs with at least one migraine attack per month. Active treatment consisted of CSMT (group 1) and the placebo was a sham push manoeuvre of the lateral edge of the scapula and/or the gluteal region (group 2). The control group continued their usual pharmacological management (group 3). The results show that migraine days were significantly reduced within all three groups from baseline to post-treatment. The effect continued in the CSMT and placebo groups at all follow-up time points (groups 1 and 2), whereas the control group (group 3) returned to baseline. The reduction in migraine days was not significantly different between the groups. Migraine duration and headache index were reduced significantly more in the CSMT than in group 3 towards the end of follow-up. Adverse events were few, mild and transient. Blinding was sustained throughout the RCT. The authors concluded that the effect of CSMT observed in our study is probably due to a placebo response.

One can understand that, for chiropractors, this finding is upsetting. After all, they earn a good part of their living by treating migraineurs. They don’t want to lose patients and, at the same time, they need to claim to practise evidence-based medicine.

What is the way out of this dilemma?

Simple!

They only need to publish a review in which they dilute the irritatingly negative result of the above trial by including all previous low-quality trials with false-positive results and thus generate a new overall finding that alleges CSMT to be evidence-based.

This new systematic review of randomized clinical trials (RCTs) evaluated the evidence regarding spinal manipulation as an alternative or integrative therapy in reducing migraine pain and disability.

The searches identified 6 RCTs eligible for meta-analysis. Intervention duration ranged from 2 to 6 months; outcomes included measures of migraine days (primary outcome), migraine pain/intensity, and migraine disability. Methodological quality varied across the studies. The results showed that spinal manipulation reduced migraine days with an overall small effect size as well as migraine pain/intensity.

The authors concluded that spinal manipulation may be an effective therapeutic technique to reduce migraine days and pain/intensity. However, given the limitations to studies included in this meta-analysis, we consider these results to be preliminary. Methodologically rigorous, large-scale RCTs are warranted to better inform the evidence base for spinal manipulation as a treatment for migraine.

Bob’s your uncle!

Perhaps not perfect, but at least the chiropractic profession can now continue to claim they practice something akin to evidence-based medicine, while happily cashing in on selling their unproven treatments to migraineurs!

But that’s not very fair; research is not for promotion, research is for finding the truth; this white-wash is not in the best interest of patients! I hear you say.

Who cares about fairness, truth or conflicts of interest?

Christine Goertz, one of the review-authors, has received funding from the NCMIC Foundation and served as the Director of the Inter‐Institutional Network for Chiropractic Research (IINCR). Peter M. Wayne, another author, has received funding from the NCMIC Foundation and served as the co‐Director of the Inter‐Institutional Network for Chiropractic Research (IINCR)

And who the Dickens are the  NCMIC and the IINCR?

At NCMIC, they believe that supporting the chiropractic profession, including chiropractic research programs and projects, is an important part of our heritage. They also offer business training and malpractice risk management seminars and resources to D.C.s as a complement to the education provided by the chiropractic colleges.

The IINCR is a collaborative effort between PCCR, Yale Center for Medical Informatics and the Osher Center for Integrative Medicine at Brigham and Women’s Hospital and Harvard Medical School. They aim at creating a chiropractic research portfolio that’s truly translational. Vice Chancellor for Research and Health Policy at Palmer College of Chiropractic Christine Goertz, DC, PhD (PCCR) is the network director. Peter Wayne, PhD (Osher Center for Integrative Medicine at Brigham and Women’s Hospital and Harvard Medical School) will join Anthony J. Lisi, DC (Yale Center for Medical Informatics and VA Connecticut Healthcare System) as a co-director. These investigators will form a robust foundation to advance chiropractic science, practice and policy. “Our collective efforts provide an unprecedented opportunity to conduct clinical and basic research that advances chiropractic research and evidence-based clinical practice, ultimately benefiting the patients we serve,” said Christine Goertz.

Really: benefiting the patients? 

You could have fooled me!

In a previous post, I have tried to explain that someone could be an expert in certain aspects of homeopathy; for instance, one could be an expert:

  • in the history of homeopathy,
  • in the manufacture of homeopathics,
  • in the research of homeopathy.

But can anyone really be an expert in homeopathy in a more general sense?

Are homeopaths experts in homeopathy?

OF COURSE THEY ARE!!!

What is he talking about?, I hear homeopathy-fans exclaim.

Yet, I am not so sure.

Can one be an expert in something that is fundamentally flawed or wrong?

Can one be an expert in flying carpets?

Can one be an expert in quantum healing?

Can one be an expert in clod fusion?

Can one be an expert in astrology?

Can one be an expert in telekinetics?

Can one be an expert in tea-leaf reading?

I am not sure that classical homeopaths can rightfully called experts in classical homeopathy (there are so many forms of homeopathy that, for the purpose of this discussion, I need to focus on the classical Hahnemannian version).

An expert is a person who is very knowledgeable about or skilful in a particular area. An expert in any medical field (say neurology, gynaecology, nephrology or oncology) would need to have sound knowledge and practical skills in areas including:

  • organ-specific anatomy,
  • organ-specific physiology,
  • organ-specific pathophysiology,
  • nosology of the medical field,
  • disease-specific diagnostics,
  • disease-specific etiology,
  • disease-specific therapy,
  • etc.

None of the listed items apply to classical homeopathy. There are no homeopathic diseases, homeopathy is largely detached from knowledge in anatomy, physiology and pathophysiology, homeopathy disregards the current knowledge of etiology, homeopathy does not apply current criteria of diagnostics, homeopathy offers no rational mode of action for its interventions.

An expert in any medical field would need to:

  • deal with facts,
  • be able to show the effectiveness of his methods,
  • be part of an area that makes progress,
  • benefit from advances made elsewhere in medicine,
  • would associate with other disciplines,
  • understand the principles of evidence-based medicine,
  • etc.

None of these features apply to a classical homeopath. Homeopaths substitute facts for fantasy and wishful thinking, homeopaths cannot rely on sound evidence regarding the effectiveness of their therapy, classical homeopaths are not interested in progressing their field but religiously adhere to Hahnemann’s dogma, homeopaths do not benefit from the advances made in other areas of medicine, homeopaths pursue their sectarian activities in near-complete isolation, homeopaths make a mockery of evidence-based medicine.

Collectively, these considerations would seem to indicate that an expert in homeopathy is a contradiction in terms. Either you are an expert, or you are a homeopath. To be both seems an impossibility – or, to put it bluntly, an ‘expert’ in homeopathy is an adept in nonsense and a virtuoso in ignorance.

The PGIH (currently chaired by the Tory MP David Tredinnick) was founded in 1992 (in the mid 1990, they once invited me to give a lecture which I did with pleasure). Its overriding aim is to bring about improvements in patient care. The PGIH have conducted a consultation that involved 113 SCAM-organisations and other stakeholders. The new PGIH-report is based on their feedback and makes 14 recommendations. They are all worth studying but, to keep this post concise, I have selected the three that fascinated me most:

Evidence Base and Research

NICE guidelines are too narrow and do not fit well with models of care such as complementary, traditional and natural therapies, and should incorporate qualitative evidence and patient outcomes measures as well as RCT evidence. Complementary, traditional and natural healthcare associations should take steps to educate and advise their members on the use of Measure Yourself Medical Outcome Profiles (MYMOP), and patient outcome measures should be collated by an independent central resource to identify for what conditions patients are seeking treatment, and with what outcomes.

Cancer Care

Every cancer patient and their families should be offered complementary therapies as part of their treatment package to support them in their cancer journey. Cancer centres and hospices providing access to complementary therapies should be encouraged to make wider use of Measure Yourself Concerns and Wellbeing (MYCaW) to evaluate the benefits gained by patients using complementary therapies in cancer support care. Co-ordinated research needs to be carried out, both clinical trials and qualitative studies, on a range of complementary, traditional and natural therapies used in cancer care support.

Cost Savings

The government should run NHS pilot projects which look at non-conventional ways of treating patients with long-term and chronic conditions affected by Effectiveness Gaps, such as stress, arthritis, asthma and musculoskeletal problems, and audit these results against conventional treatment options for these conditions to determine whether cost savings and better patient outcomes could be achieved.

END OF QUOTE

Here are a few brief comments on those three recommendations.

Evidence base and research

NICE guidelines are based on rigorous assessments of efficacy, safety and costs. Such evaluations are possible for all interventions, including SCAM. Qualitative data are useless for this purpose. Outcome measures like the MYMOP are measures that can and are used in clinical trials. To use them outside clinical trials would not provide any relevant information about the specific effects of SCAM because this cannot account for confounding factors like the natural history of the disease, regression towards the mean, etc. The entire paragraph disclosed a remarkable level of naivety and ignorance about research on behalf of the PGIH.

Cancer care

There is already a significant amount of research on SCAM for cancer (see for instance here). It shows that no SCAM is effective in curing any form of cancer, and that only very few SCAMs can effectively improve the quality of life of cancer patients. Considering these facts, the wholesale recommendation of offering SCAM to cancer patients can only be characterised as dangerous quackery.

Cost savings

Such a pilot project has already been conducted at the behest of Price Charles (see here). Its results show that flimsy research will generate flimsy findings. If anything, a rigorous trial would be needed to test whether more SCAM on the NHS saves or costs money. The data currently available suggests that the latter is the case (see also here, here, here, here, etc.).

Altogether, one gets the impression that the PGIH need to brush up on their science and knowledge (if they invite me, I’d be delighted to give them another lecture). As it stands, it seems unlikely that their approach will, in fact, bring about improvements in patient care.

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

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

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

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

END OF MY TRANSLATION

So, where is the hilarity in this?

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

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

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

The inventor of homeopathy, Samuel Hahnemann, was a German physician. It is therefore not surprising that homeopathy quickly took hold in Germany. After its initial success, homeopathy’s history turned out to be a bit of a roller coaster. But only recently, a vocal and effective opposition has come to the fore (see my previous post).

Despite the increasing opposition, the advent of EBM, and the much-publicised fact that the best evidence fails to show homeopathy’s effectiveness, there are many doctors who still practice it. According to one website, there are 4330 doctor homeopaths in Germany (plus, of course, almost the same number of Heilpraktiker who also use homeopathy). This figure is, however, out-dated. The German Medical Association told a friend that, at the end of 2017, there were 5612 doctors practising in Germany who hold the additional qualification (‘Zusatz-Weiterbildung’) homeopathy.

That’s a lot, I find.

Why so many?

Whenever I give lectures on the subject, this is the question that comes up with unfailing regularity. Many people who ask would also imply that, if so many doctors use it, homeopathy must be fine, because doctors have studied and know what they are doing.

My answer usually is that the phenomenon is due to many factors:

  • history,
  • regulation,
  • misinformation,
  • powerful lobby groups,
  • patient demand,
  • homeopathy’s image of being gentle, safe and holistic,
  • patients’ need to believe in something more than ‘just science’,
  • the fact that most German health insurances reimburse it,
  • political support,
  • etc.

But, in fact, the true explanation, as I have learnt recently, might be much simpler and more profane: MONEY!

A German GP gets 4.36 Euros for taking a conventional history.

If he is a homeopath taking an initial homeopathic history, (s)he gets 130 €  according to the ‘Selektivvertrag’.

So, yes, doctors have studied and know that the difference between the two amounts is significant.

On this blog and elsewhere, I have repeatedly criticised the concepts of ‘integrative medicine’ (IM). But criticising is easy, improving would be better. Today, I want to re-visit and revise the idea of IM and propose the concept of a ‘reformed integrated medicine’ (RIM).

Proponents of IM suggest that we should use ‘the best of both worlds’ for the benefit of our patients. This seems to be a progressive and ethical approach to improving healthcare. Therefore, I fully accept this idea. However, I suggest to not stop here; if we are serious about wanting the best for our patients, we must not just integrate, we should also disintegrate! We also need to think about disintegrating (discarding) modalities that are not fit for purpose. This, in a nutshell, is the concept of RIM.

In order to make real progress, we need to have a critical look at all the diagnostic, preventive, therapeutic and rehabilitative practices available to date and:

  1. integrate those into routine care that demonstrably generate more good than harm,
  2. disintegrate those that do not meet this criterion.

THE BEST, AND ONLY THE BEST OF BOTH WORLDS!!!

This means, we use must throw overboard those that are not best. In healthcare ‘best’ can, of course, only mean effective and safe.

I am aware that this is only a very rough sketch of what RIM stands for. But even in this preliminary form, it is easy to see that, although IM and RIM seem to differ only marginally, their effects on healthcare would differ dramatically. Let me demonstrate this by providing 5 examples from my area of expertise:

Iridology embraced by IM discarded by RIM
Homeopathy embraced by IM discarded by RIM
Chiropractic embraced by IM discarded by RIM
Reiki embraced by IM discarded by RIM
Reflexology embraced by IM discarded by RIM

I am sure, you get the gist of it. In RIM, we no longer employ things that don’t work. They are of no real use to patients and possibly even cause harm. RIM not only is the only ethical approach, it also generates progress.

So, RIM – just a tiny adaptation of IM – is the solution.

Gosh, I am proud of my splendid innovation.

Progress at last!

 

 

__________________________________________________________________

Ooops …  I just realised, RIM has one little flaw: it already exists.

It’s called evidence-based medicine.

 

Twenty years ago (5 years into my post at Exeter), I published this little article (BJGP, Sept 1998). It was meant as a sort of warning – sadly, as far as I can see, it has not been heeded. Oddly, the article is unavailable on Medline, I therefore take the liberty of re-publishing it here without alterations (if I had to re-write it today, I would not change much) or comment:

Once the omnipotent heroes in white, physicians today are at risk of losing the trust of their patients. Medicine, some would say, is in a deep crisis. Shouldn’t we start to worry?

The patient-doctor relationship, it seems, is at the heart of this argument. Many patients are deeply dissatisfied with this aspect of medicine. A recent survey on patients consulting GPs and complementary practitioners in parallel and for the same problem suggested that most patients are markedly more happy with all facets of the therapeutic encounter as offered by complementary practitioners. This could explain the extraordinary rise of complementary medicine during recent years. The neglect of the doctor-patient relationship might be the gap in which complementary treatments build their nest.

Poor relationships could be due to poor communication. Many books have been written about communications skills with patients. But never mind the theory, the practice of all this may be less optimal than we care to believe. Much of this may simply relate to the usage of language. Common terms such as ‘stomach’, ‘palpitations’, ‘lungs’, for instance, are interpreted in different ways by lay and professional people. Words like ‘anxiety’, ‘depression’, and ‘irritability’ are well defined for doctors, while patients view them as more or less interchangeable. At a deeper level, communication also relates to concepts and meanings of disease and illness. For instance, the belief that a ‘blockage of the bowel’ or an ‘imbalance of life forces’ lead to disease is as prevalent with patients as it is alien to doctors. Even on the most obvious level of interaction with patients, physicians tend to fail. Doctors often express themselves unclearly about the nature, aim or treatment schedule of their prescriptions.

Patients want to be understood as whole persons. Yet modern medicine is often seen as emphazising a reductionistic and mechanistic approach, merely treating a symptom or replacing a faulty part, or treating a ‘case’ rather than an individual. In the view of some, modern medicine has become an industrial behemoth shifted from attending the sick to guarding the economic bottom line, putting itself on a collision course with personal doctoring. This has created a deeply felt need which complementary medicine is all too ready to fill. Those who claim to know the reason for a particular complaint (and therefore its ultimate cure) will succeed in satisfying this need. Modern medicine has identified the causes of many diseases while complementary medicine has promoted simplistic (and often wrong) ideas about the genesis of health and disease. The seductive message usually is as follows: treating an illness allopathically is not enough, the disease will simply re-appear in a different guise at a later stage. One has to tackle the question – why the patient has fallen ill in the first place. Cutting off the dry leaves of a plant dying of desiccation won’t help. Only attending the source of the problem, in the way complementary medicine does, by pouring water on to the suffering plant, will secure a cure. This logic is obviously lop-sided and misleading, but it creates trust because it is seen as holistic, it can be understood by even the simplest of minds, and it generates a meaning for the patient’s otherwise meaningless suffering.

Doctors, it is said, treat diseases but patients suffer from illnesses. Disease is something an organ has; illness is something an individual has. An illness has more dimensions than disease. Modern medicine has developed a clear emphasis on the physical side of disease but tends to underrate aspects like the patient’s personality, beliefs and socioeconomic environment. The body/mind dualism is (often unfairly) seen as a doctrine of mainstream medicine. Trust, it seems, will be given to those who adopt a more ‘holistic’ approach without dissecting the body from the mind and spirit.

Empathy is a much neglected aspect in today’s medicine. While it has become less and less important to doctors, it has grown more and more relevant to patients. The literature on empathy is written predominantly by nurses and psychologists. Is the medical profession about to delegate empathy to others? Does modern, scientific medicine lead us to neglect the empathic attitude towards our patients? Many of us are not even sure what empathy means and confuse empathy with sympathy. Sympathy with the patient can be described as a feeling of ‘I want to help you’. Empathy, on these terms, means ‘I am (or could be) you’; it is therefore some sort of an emotional resonance. Empathy has remained somewhat of a white spot on the map of medical science. We should investigate it properly. Re-integrating empathy into our daily practice can be taught and learned. This might help our patients as well as us.

Lack of time is another important cause for patients’ (and doctors’) dissatisfaction. Most patients think that their doctor does not have enough time for them. They also know from experience that complementary medicine offers more time. Consultations with complementary practitioners are appreciated, not least because they may spend one hour or so with each patient. Obviously, in mainstream medicine, we cannot create more time where there is none. But we could at least give our patients the feeling that, during the little time available, we give them all the attention they require.

Other reasons for patients’ frustration lie in the nature of modern medicine and biomedical research. Patients want certainty but statistics provides probabilities at best. Some patients may be irritated to hear of a 70% chance that a given treatment will work; or they feel uncomfortable with the notion that their cholesterol level is associated with a 60% chance of suffering a heart attack within the next decade. Many patients long for reassurance that they will be helped in their suffering. It may be ‘politically correct’ to present patients with probability frequencies of adverse effects and numbers needed to treat, but anybody who (rightly or wrongly) promises certainty will create trust and have a following.

Many patients have become wary of the fact that ‘therapy’ has become synonymous with ‘pharmacotherapy’ and that many drugs are associated with severe adverse reactions. The hope of being treated with ‘side-effect-free’ remedies is a prime motivator for turning to complementary medicine.

Complementary treatments are by no means devoid of adverse reactions, but this fact is rarely reported and therefore largely unknown to patients. Physicians are regularly attacked for being in league with the pharmaceutical industry and the establishment in general. Power and money are said to be gained at the expense of the patient’s well-being. The system almost seems to invite dishonesty. The ‘conspiracy theory’ goes as far as claiming that ‘scientific medicine is destructive, extremely costly and solves nothing. Beware of the octopus’. Spectacular cases could be cited which apparently support it. Orthodox medicine is described as trying to ‘inhibit the development of unorthodox medicine’, in order to enhance its own ‘power, status and income’. Salvation, it is claimed, comes from the alternative movement which represents ‘… the most effective assault yet on scientific biomedicine’. Whether any of this is true or not, it is perceived as the truth by many patients and amounts to a serious criticism of what is happening in mainstream medicine today.

In view of such criticism, strategies for overcoming problems and rectifying misrepresentations are necessary. Mainstream medicine might consider discovering how patients view the origin, significance, and prognosis of the disease. Furthermore, measures should be considered to improve communication with patients. A diagnosis and its treatment have to make sense to the patient as much as to the doctor – if only to enhance adherence to therapy. Both disease and illness must be understood in their socio-economic context. Important decisions, e.g. about treatments, must be based on a consensus between the patient and the doctor. Scientists must get better in promoting their own messages, which could easily be far more attractive, seductive, and convincing than those of pseudo-science.These goals are by no means easy to reach. But if we don’t try, trust and adherence will inevitably deteriorate further. I submit that today’s unprecedented popularity of complementary medicine reflects a poignant criticism of many aspects of modern medicine. We should take it seriously

The ‘Schwaebische Tageblatt’ is not on my regular reading list. But this article of yesterday (16/10/2018) did catch my attention. For those who read German, I will copy it below, and for those who don’t I will provide a brief summary and comment thereafter:

Die grün-schwarze Landesregierung lässt 2019 den ersten Lehrstuhl für Naturheilkunde und Integrative Medizin in Baden-Württemberg einrichten. Lehrstuhl für Naturheilkunde und Integrative Medizin

Ihren Schwerpunkt soll die Professur im Bereich Onkologie haben. Strömungen wie Homöopathie oder Anthroposophie sollen nicht gelehrt, aber innerhalb der Lehre beleuchtet werden, sagte Ingo Autenrieth, Dekan der Medizinischen Fakultät in Tübingen am Dienstag der Deutschen Presse-Agentur. «Ideologien und alles, was nichts mit Wissenschaft zu tun hat, sortieren wir aus.»

Die Professur soll sich demnach mit Themen wie Ernährung, Probiotika und Akupunktur beschäftigten. Geplant ist laut Wissenschaftsministerium, die Lehre in Tübingen anzusiedeln; die Erforschung der komplementären Therapien soll vorwiegend am Centrum für Tumorerkrankungen des Robert-Bosch-Krankenhauses in Stuttgart stattfinden. Die Robert-Bosch-Stiftung finanziert die Professur in den ersten fünf Jahren mit insgesamt 1,84 Millionen Euro, danach soll das Land die Mittel dafür bereitstellen.

«Naturheilkunde und komplementäre Behandlungsmethoden werden von vielen Menschen ganz selbstverständlich genutzt, beispielsweise zur Ergänzung konventioneller Therapieangebote», begründete Wissenschaftsministerin Theresia Bauer (Grüne) das Engagement. Sogenannte sanfte oder natürliche Methoden könnten schwere Krankheiten wie etwa Krebs alleine nicht heilen, heißt es in einer Mitteilung des Ministeriums. Wissenschaftliche Ergebnisse zeigten aber, dass sie häufig zu Therapieerfolgen beitragen könnten, da sie den Patienten helfen, schulmedizinische Therapien gut zu überstehen – etwa die schweren Nebenwirkungen von Chemotherapien mindern.

Im Gegensatz zur Schulmedizin gebe es bisher aber kaum kontrollierte klinische Studien zur Wirksamkeit solcher Therapien, ergänzte Ingo Autenrieth. Ihre Erforschung am neuen Lehrstuhl solle Patienten Sicherheit bringen und ermöglichen, dass die gesetzlichen Krankenkassen die Kosten dafür übernehmen.

Hersteller alternativer Arzneimittel loben den Schritt der Politik. «Baden-Württemberg nimmt damit eine Vorreiterrolle in Deutschland und in Europa ein», heißt es beim Unternehmen Wala Heilmittel GmbH in Bad Boll. Die Landesregierung trage mit der Entscheidung dem Wunsch vieler Patienten und Ärzte nach umfassenden Behandlungskonzepten Rechnung.

Auch hoffen die Unternehmen, dass Licht in die oft kritische Debatte um Homöopathie gebracht wird. «Wir sehen mit Erstaunen und Befremden, dass eine bewährte Therapierichtung wie die Homöopathie, die Teil der Vielfalt des therapeutischen Angebots in Deutschland ist, diskreditiert werden soll», sagte ein Sprecher des Herstellers Weleda AG mit Sitz in Schwäbisch Gmünd der Deutschen Presse-Agentur. Deshalb begrüße man den Lehrstuhl: «Es ist gut, dass Forschung und Lehre ausgebaut werden, da eine Mehrheit der Bevölkerung Komplementärmedizin wünscht und nachfragt. Es braucht Ärzte, die in diesen Bereichen auch universitär ausgebildet werden.»

Laut Koalitionsvertrag will Baden-Württemberg künftig eine Vorreiterrolle in der Erforschung der Komplementärmedizin einnehmen. Bisher gab es im Südwesten mit dem Akademischen Zentrum für Komplementäre und Integrative Medizin (AZKIM) zwar einen Verbund der Unikliniken Tübingen, Freiburg, Ulm und Heidelberg, aber keinen eigenen Lehrstuhl. Bundesweit existieren nach Angaben der Hufelandgesellschaft, dem Dachverband der Ärztegesellschaften für Naturheilkunde und Komplementärmedizin, Lehrstühle für Naturheilkunde noch an den Universitäten Duisburg-Essen, Rostock und Witten/Herdecke sowie drei Stiftungsprofessuren an der Berliner Charité.

END OF QUOTE

And here is my English summary:

The black/green government of Baden-Wuerttemberg has decided to create a ‘chair of naturopathy and integrated medicine’ at the university of Tuebingen in 2019. The chair will focus in the area of oncology. Treatments such as homeopathy and anthroposophical medicine will not be taught but merely mentioned in lectures. Ideologies and everything that is not science will be omitted.

The chair will thus deal with nutrition, acupuncture and probiotics. The teaching activities will be in the medical faculty at Tuebingen, while the research will be located at the Robert-Bosch Hospital in Stuttgart. The funds for the first 5 years – 1.84 million Euro – will come from the Robert-Bosch Foundation; thereafter they will be provided by the government of the county.

So-called gentle or natural therapies cannot cure serious diseases on their own, but as adjuvant treatments they can be helful, for instance, in alleviating the adverse effects of chemotherapy. There are only few studies on this, and the new chair will increase patient safety and facilitate the reimbursement of these treatments by health insurances.

Local anthroposophy manufacturers like Wala welcomed the move stating it would be in accordance with the wishes of many patients and doctors. They also hope that the move will bring light in the current critical debate about homeopathy. A spokesperson of Weleda added that they ‘note with surprise that time-tested therapies like homeopathy are being discredited. Therefore, it is laudable that research and education in this realm will be extended. The majority of the public want complementary medicine and need doctors who are also university-trained.’

Baden-Wurttemberg aims for a leading role in researching complementary medicine. Thus far, chairs of complementary medicine existed only at the universities of Duisburg-Essen, Rostock und Witten/Herdecke as well as three professorships at the Charité in Berlin.

END OF MY SUMMARY

As I have occupied a chair of complementary medicine for 19 years, I am tempted to add a few points here.

  • In principle, a new chair can be a good thing.
  • The name of the chair is odd, to say the least.
  • As the dean of the Tuebingen medical school pointed out, it has to be based on science. But how do they define science?
  • Where exactly does the sponsor, the Robert-Bosch Stiftung, stand on alternative medicine. Do they have a track-record of being impractical and scientific?
  • In order to prevent this becoming a unrealistic prospect, it is essential that the new chair needs to fall into the hands of a scientist with a proven track record of critical thinking.
  • Rigorous scientist with a proven track record of critical thinking are very rare in the realm of alternative medicine.
  • The ridiculous comments by Wala and Weleda, both local firms with considerable local influence, sound ominous and let me suspect that proponents of alternative medicine aim to exert their influence on the new chair.
  • The above-voiced notion that the new chair is to facilitate the reimbursement of alternative treatments by the health insurances seems even more ominous. Proper research has to be objective and could, depending on its findings, have the opposite effect. To direct it in this way seems to determine its results before the research has started.
  • I miss a firm commitment to medical ethics, to the principles of EBM, and to protecting the independence of the new chair.

Thus, I do harbour significant anxieties about this new chair. It is in danger of becoming a chair of promoting pseudoscience. I hope the dean of the Tuebingen medical school might read these lines.

I herewith offer him all the help I can muster in keeping pseudoscience out of this initiative, in defining the remit of the chair and, crucially, in finding the right individual for doing the job.

Samuel Hahnemann invented homeopathy about 200 years ago. His placebos were better than (or not as bad as) the ‘heroic’ medicine of his time which frequently was more dangerous than the disease it aimed to cure. Thus, homeopathy took Germany by storm. When, about 100 years ago, medicine finally became scientific and was able to offer more and more effective treatments, the popularity of homeopathy began to wane. Yet, before its natural demise, during the Third Reich, it received a significant boost from Nazi-greats such as Hess and Himmler. After this nightmare was over, German homeopathy went into another slow decline. But when the New Age movement and the current boom in alternative medicine reached Germany, homeopathy seemed to thrive once again.

In the 1990s evidence-based medicine (EBM) grew into one of the central concepts of medicine. In Germany, however, EBM had a relatively hard time to get established. This might be one of the reasons why homeopathy continued to prosper, despite the arrival of ever clearer evidence that highly diluted homeopathic remedies are pure placebos. While, in the UK, we had an increasingly lively debate about the uselessness of homeopathy, Germany remained the promised land of homeopathy. Sales figures of homeopathics continued to increase steadily and reached a level of about half a billion Euros per annum.

The golden age of German homeopathy had dawned:

  • The media, often sponsored by homeopathic interest groups, kept on promoting homeopathy largely unopposed.
  • The mighty Carstens Stiftung worked tirelessly to promote it.
  • Homeopathy became established in many medical schools.
  • Homeopathy was available and often advertised in almost all pharmacies.
  • The public was convinced that homeopathy worked.
  • The Heilpraktiker adopted homeopathy fully.
  • The medical and other conventional healthcare professions embraced it to a large degree.
  • The adult education institutes (Volkshochschulen) offered courses.
  • Politicians were squarely on the side of homeopathy,
  • Health insurances, paid for it.

Of course, there were also some (and always had been) opposing voiced and organisations, such as the GWUP (the German sceptic organisation), for example. But somehow, they remained relatively low-key. When, every now and then, courageous journalists dared to think of a critical take on homeopathy, they had to search far and wide to find a German-speaking expert who was willing or able to tell them the truth: that homeopathy is neither biologically plausible nor evidence-based and therefore an expensive, potentially harmful waste of money that makes a mockery of EBM. During this period, journalists (far too) often asked me for some critical comments. I hardly ever published my research in German, but they nevertheless would find me via my Medline-listed papers. I often felt like a very lone voice in a German desert.

For the German homeopathic industry, I evidently was more than just a lone voice. Unbeknown to me, they clubbed together and financed a PR-man/journalist (at the tune of Euro 30 000/year) to write as many defamatory articles about me as he could muster. First, I was bewildered by his activity, then I tried to communicate with him (only to get mis-quoted), and eventually I ignored his writings. Yet, a German investigative journalist found Fritzsche’s one-sided activities offensive and started investigating. His research and subsequent article disclosed the fact that he was being paid by the homeopathic industry. Once I learn about this scandal, I wrote to some of the financiers directly and asked for an explanation. As a result, they discontinued their sponsorship. Shortly afterwards, Fritzsche committed suicide.

At heart, I have always been an optimist and strongly believe that in medicine the truth, in this case the evidence, will always prevail, no matter what obstacles others might put in its way. Recent developments seem to suggest that I might be right.

In the last few years, several individuals in Germany have, from entirely different angles, taken a fresh look at the evidence on homeopathy and found it to be desperately wanting. Independent of each other, they published articles and books about their research and insights. Here are 5 examples:

Die Homöopathie-Lüge: So gefährlich ist die Lehre von den weißen KügelchenChristian Weymayr, Nicole Heißmann, 2012

In Sachen Homöopathie: Eine Beweisaufnahme, Norbert Aust, 2013

Homöopathie neu gedacht: Was Patienten wirklich hilft, Natalie Grams, 2015

Der Glaube an die Globuli: Die Verheißungen der HomöopathieNorbert Schmacke, Bernd Hontschik, 2015

Der wahrscheinlich teuerste Zucker der Welt: Was Sie über Homöopathie und Alternativmedizin wissen sollten, Oliver Grunau, 2017

Inevitably, these individuals came into contact with each other and subsequently founded several working-groups to discuss their concerns and coordinate their activities. Thus the INH and the Muensteraner Kreis were born. So, now we have at least three overlapping groups of enthusiastic, multidisciplinary experts who voluntarily work towards informing the German public that paying for homeopathy out of public funds is unethical, nonsensical and not in the interest of progress:

  • the GWUP,
  • the INH
  • and the Muensteraner Kreis.

No wonder then, that the German homeopathic industry and other interested parties got worried. When they realised that (presumably due to the work of these altruistic enthusiasts) the sales figures of homeopathics in Germany had, for the first time since many years, started declining, they panicked.

Their reaction was, as far as I can see, similar to their previous response to criticism: they started a media campaign in an attempt to sway public opinion. And just like before, they have taken to employing PR-people who currently spend their time defaming all individuals voicing criticism of homeopathy in Germany. Their prime targets are those experts who are most exposed to activities of responsibly informing the public about homeopathy via lectures, publications social media, etc. All of us currently receive floods of attack, insults and libellous defamations. As before (innovation does not seem to be a hallmark of homeopathy), these attacks relate to claims that:

  • we are incompetent,
  • we do not care about the welfare of patients,
  • we are habitual liars,
  • we are on the payroll of the pharmaceutical industry,
  • we aim at limiting patient choice,
  • we do what we do because we crave the limelight.

So, what is going to happen?

I cannot read tea leaves but am nevertheless sure of a few things:

  • 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.

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