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

experience

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[If you do not like black humour or sarcasm, please do NOT read this post!!!]

Donald Trump just announced that, at Easter, he wants to see churches packed, his way of saying the lock-down is over because it is damaging the economy. Many others have put forward similar arguments and have pointed out that caring for the vulnerable, sick, old, etc. creates an economic burden that might eventually kill more people than it saves (see for instance ‘Economic crash could cost more lives than coronavirus, study warns‘).

Many people have also argued that homeopathy is unjustly vilified because it is truly a wholesome and safe medicine that should be used routinely. The notion here is that, alright, the evidence is not brilliant, but 200 years of experience and millions of fans cannot be ignored.

I have been wondering whether these two lines of thinking could not be profitably combined. Here is my suggestion based on the following two axioms.

  1. The economy is important for all our well-being.
  2. Homeopaths have a point in that the value of experience must not be ignored.

What follows is surprisingly simple: in view of the over-riding importance of the economy, let’s prioritise it over health. As it would look bad to deny those poor corona victims all forms of healthcare, let’s treat them homeopathically. This would make lots of people happy:

  • those who think the economy must take precedent,
  • those who fear the huge costs of saving corona patients (homeopathy is very cheap),
  • those who argued for decades that we never gave homeopathy a fighting chance to show its worth.

There is a downside, of course. There would be a most lamentable mortality rate. But, to paraphrase Dominic Cummings, if a few oldies have to snuff it, so be it!

Once we get used to this innovative approach – I suggest we call it integrative medicine – we might even consider adopting it for other critical situations. When we realise, for instance, that the pension pots are empty, we could officially declare that homeopathy is the ideal medicine for anybody over 60.

What do you think?

 

Boris Johnson said we should take the coronavirus ‘on the chin’ and count on ‘herd-immunity’. This, he claimed, is what his scientific advisers recommended.

I find this very hard to believe and have many doubts and questions.

To start with, I doubt that this is what Johnson’s scientific advisers recommend – it is a solution that SOME of his scientific advisers recommend. And it is a solution that seems easy to follow. It is, however, by no means the only strategy for tacking the pandemic; it is just one of several options.

The fact that all other countries have opted for other solutions, suggests to me that it is an unusual path to go down to. The modellers who obviously like it had to make a number of assumptions; that’s what modellers always have to do and rarely tell us about. But what if not all of these assumptions are correct?

The herd-immunity strategy counts on the fact that, once a certain percentage of the population has taken the infection ‘on the chin’, it is immune and therefore the transmission of the virus within such a population will be dramatically reduced or even zero. The percentage of the population needed for that to happen depends on how contagious the virus is. For the measles virus, herd immunity requires 90% of the population to be immune. For the coronavirus, the figure is said to be 60 – 70%. Is that an assumption or a fact? If it is a current fact, would the figure change, if the virus mutates? Could it be that a mutated virus can re-infect formerly immune people?

But let’s postulate that the herd-immunity assumption is both correct and stable. Johnson’s herd-immunity strategy would thus require that about 40 million Brits get infected with the virus to generate the required herd-immunity. Assuming a mortality rate of 1 – 2%, this means that Johnson is cheerfully accepting 400 000 – 800 000 fatalities.

But, as I said, this scenario is based on wild assumptions. It applies only if the virus does not mutate. And it only applies, if we do not run out of intensive care (IC) beds. However, running out seems possible, perhaps even likely, considering that we have only about half of the French and just one third of the German IC capacity. Sod’s law has it that both might happen. In this case, we might easily have far in excess of 800 000 fatalities. How should we take that ‘on the chin’, Mr Johnson?

Sadly, this is not all; I have further doubts about our PM’s ideas.

The present strategy regarding diagnosis of coronavirus cases is to self-isolate once suspicious symptoms start. Even if someone is seriously ill (with high fever etc.), they are told to stay at home and sit it out. This means we will never know whether these patients had or had not suffered from a coronavirus infection. How then can we ever be sure that the 60% target of infection has been reached? And if we are uncertain about it, how can we be sure that herd-immunity will work in the way the modellers predicted?

Moreover, we now know that people who caught the virus are infective BEFORE they develop symptoms. If that is so, the strategy of self-isolation will be far less effective than predicted. And, given this fact, are we not much more likely to have a sharp peak of cases early on which would make us run out of IC capacity? When that happens, even the pessimistic death rates might turn out to be too optimistic.

It seems to me that Johnson’s herd-immunity strategy is risky to the point of being reckless. It also seems to me that there are very good reasons why other countries have not adopted it.

But what is the solution?

In my view, the solution cannot be to uncritically adopt the theories and assumptions of modellers. This is not a computer game; we are talking about human lives, many human lives!

I wish I new what the best solution is – but I don’t. I merely fear that ‘taking it on the chin’ is not a solution at all. In any case, a wise move for Johnson and his team might be to consider that foreigners might be at least as clever as they are. Subsequently they could carefully study the actions of those countries which managed to bring down their death-rates despite being attacked by the coronavirus.

Today is a momentous and desperately sad day. Allow me therefore to deviate from my usual subject and write a very personal post (I promise, it won’t happen often).

This post is not about SCAM but about something that is even closer to my heart.

 

I first moved to the UK in 1979. The reason was simple, I had fallen in love with Danielle, the woman who now is my wife. I only stayed for about 3 years. However, as luck would have it, this short time would become the most formative period of my life, both privately and professionally. After a brief and unhappy stint as a doctor in a psychiatric hospital, I got a job under John Dormandy who opened my eyes to the wonderous world of science.

I nonetheless went back to Germany because I felt I had to complete my clinical training. In 1987, became a professor first in Hannover and then in Vienna. Even though the Vienna post was grand (to say the least), I soon became unhappy with it (no need to go into details here; if you need to know, read this or this). I thus started looking for other opportunities, ideally in the UK.

Why the UK?

It wasn’t because of the weather.

It also was not because of the food.

Nor was it because of the huge salary (the move roughly halved my previous income).

It was because of the beautiful memories. And it was because of my deep appreciation of the people. I had grown to admire their humour, their tolerance, their openness, their way of life, their way of dealing with problems, their politeness, their understatement, their honesty, their fair play.

Much has been written about my time at Exeter. Not everything was smelling of roses. But, on the whole and despite all the problems encountered, I had a really good time – mainly because my initial judgement of the people was being confirmed over and over again. I began to feel British and, in 2000, I became British. All my life, I had felt the burden of the recent German past weighing heavily on my shoulders. I had never managed to be proud of being a German. Now I was proud to be British, and I had a passport to prove it!

When Cameron announced the ‘in/out referendum’, I was baffled by the sheer stupidity of the move. How could anyone want to get out of the EU? It never made sense to me. The EU had given us peace for decades and was a guarantor that we Europeans would never again start killing each other. Why was that not pointed out in the run-up to the referendum? Most families had lost sons in the last two European wars. Why did hardly anyone use such arguments? Why was the remain campaign fought so half-heartedly? The other side was campaigning with (mostly vile and primitive) emotions; why did we not use positive and ethical ones?

I remember being in tears when I heard the results of the vote.

I remember fighting tears when acquaintances asked my wife (she is French and has, like I, a British passport) and me: ‘are you now going to go home?

Since the referendum, I have observed in utter horror and bewilderment how the county that I now call my home has changed.

What happened to the tolerance that I so admired?

What happened to the openness of the people?

What about honesty and fair play?

What happened even to humour?

During our 8 years in Germany, my wife and I had to witness our fair share of xenophobia. I despised my fellow Germans for it. Now I see it in Britain, and I feel nauseous.

What is happening to the county I love?

Carl Sagan was a giant in critical thinking and has inspired many, including myself. His book THE DEMON HAUTED WORLD is a classic. In it, he published his ‘BALONEY DETECTION KIT’. As it relates to SCAM and so much more that troubles us today, I today take the liberty of citing it here.

  1. Wherever possible there must be independent confirmation of the “facts.”
  2. Encourage substantive debate on the evidence by knowledgeable proponents of all points of view.
  3. Arguments from authority carry little weight — “authorities” have made mistakes in the past. They will do so again in the future. Perhaps a better way to say it is that in science there are no authorities; at most, there are experts.
  4. Spin more than one hypothesis. If there’s something to be explained, think of all the different ways in which it could be explained. Then think of tests by which you might systematically disprove each of the alternatives. What survives, the hypothesis that resists disproof in this Darwinian selection among “multiple working hypotheses,” has a much better chance of being the right answer than if you had simply run with the first idea that caught your fancy.
  5. Try not to get overly attached to a hypothesis just because it’s yours. It’s only a way station in the pursuit of knowledge. Ask yourself why you like the idea. Compare it fairly with the alternatives. See if you can find reasons for rejecting it. If you don’t, others will.
  6. Quantify. If whatever it is you’re explaining has some measure, some numerical quantity attached to it, you’ll be much better able to discriminate among competing hypotheses. What is vague and qualitative is open to many explanations. Of course there are truths to be sought in the many qualitative issues we are obliged to confront, but finding them is more challenging.
  7. If there’s a chain of argument, every link in the chain must work (including the premise) — not just most of them.
  8. Occam’s Razor. This convenient rule-of-thumb urges us when faced with two hypotheses that explain the data equally well to choose the simpler.
  9. Always ask whether the hypothesis can be, at least in principle, falsified. Propositions that are untestable, unfalsifiable are not worth much. Consider the grand idea that our Universe and everything in it is just an elementary particle — an electron, say — in a much bigger Cosmos. But if we can never acquire information from outside our Universe, is not the idea incapable of disproof? You must be able to check assertions out. Inveterate skeptics must be given the chance to follow your reasoning, to duplicate your experiments and see if they get the same result.

As I said, this is a good book; I warmly recommend it to you.

I have reported previously about the tragic death of John Lawler. Now after the inquest into the events leading to it has concluded, I have the permission to publish the statement of Mr Lawler’s family:

We were devastated to lose John in such tragic and unforeseen circumstances two years ago. A much-loved husband, father and grandfather, he continues to be greatly missed by all of us. Having to re-live the circumstances of his death has been particularly difficult for us but we are grateful to have a clearer picture of the events that led to John’s death. We would like to take this opportunity to thank the coroner’s team, our legal representatives and our wider family and friends for their guidance, empathy and sensitivity throughout this process.

There were several events that went very wrong with John’s chiropractic treatment, before, during, and after the actual manipulation that broke his neck.

Firstly, John thought he was being treated by a medically qualified doctor, when he was not. Furthermore, he had not given informed consent to this treatment.

The chiropractor diagnosed so-called ‘vertebral subluxation complex’ which she aimed to treat by manipulating his neck. We heard this week from medical experts that John had ossified ligaments in his spine, where previously flexible ligaments had turned to bone and become rigid. This condition is not uncommon, and is present in about 10% of those over 50. It would have showed on an X-ray or other imaging technique. The chiropractor did not ask for any images before commencing treatment and was seemingly unaware of the risks of doing a manual manipulation on an elderly patient.

It has become clear that the chiropractor did the manipulation incorrectly, and broke these rigid ligaments during a so-called ‘drop table’ manipulation, causing discs in the cervical spine to rupture and the spinal cord to become crushed. Although these manipulations are done frequently by chiropractors, we have heard that the force applied to his neck by the chiropractor would have had to have been “significant”.

Immediately John reported loss of sensation and paralysis in his arms. At this stage the only safe and appropriate response was to leave him on the treatment bed and await the arrival of the paramedics, and provide an accurate history to the ambulance controller and paramedics. The chiropractor, in fact, manhandled John from the treatment bed into a chair; then tipped his head backwards and gave “mouth to mouth” breaths. She provided an inaccurate and misleading history to the paramedic and ambulance controller, causing the paramedic to treat the incident as “medical” not “traumatic” and to transport John downstairs to the ambulance without stabilising his neck. If the paramedics had been given the full and accurate story, they would have stabilised his neck in situ and transported him on a scoop stretcher – and he would have subsequently survived.

The General Chiropractic Council decided not to suspend the chiropractor from practicing in September 2017. They heard evidence from the chiropractor that she had “not touched the neck during the appointment” and from an expert chiropractor that it would be “physically impossible” for the treatment provided to cause the injury which followed. We have heard this week that this is incorrect. The family was not allowed to attend or give evidence at that hearing, and we are waiting – now 2 years further on – for the GCC to complete their investigations.

We hope that the publicity surrounding this event will highlight the dangers of chiropractic, especially in the elderly and those with already compromised spines. We would again urge the regulator to take immediate measures to ensure that the profession is properly controlled: that chiropractors are prevented from styling themselves as medical professionals; that patients are fully informed and consent to the risks involved; that imaging is done before certain procedures and on high risk clients; and that the limits of the benefits chiropractic can provide are fully explored.

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Before someone comments pointing out that this is merely a single case which does not amount to evidence, let me remind you of the review of cervical manipulation prepared for the Manitoba Health Professions Advisory Council. Here is the abstract:

Neck manipulation or adjustment is a manual treatment where a vertebral joint in the cervical spine—comprised of the 7 vertebrae C1 to C7—is moved by using high-velocity, low-amplitude (HVLA) thrusts that cannot be resisted by the patient. These HVLA thrusts are applied over an individual, restricted joint beyond its physiological limit of motion but within its anatomical limit. The goal of neck manipulation, referred to throughout this report as cervical spine manipulation (CSM), is to restore optimal motion, function, and/or reduce pain. CSM is occasionally utilized by physiotherapists, massage therapists, naturopaths, osteopaths, and physicians, and is the hallmark treatment of chiropractors; however the use of CSM is controversial. This paper aims to thoroughly synthesize evidence from the academic literature regarding the potential risks and benefits of cervical spine manipulation utilizing a rapid literature review method.

METHODS Individual peer-reviewed articles published between January 1990 and November 2016 concerning the safety and efficacy of cervical spine manipulation were identified through MEDLINE (PubMed), EMBASE, and the Cochrane Library.

KEY FINDINGS

  • A total of 159 references were identified and cited in this review: 86 case reports/ case series, 37 reviews of the literature, 9 randomized controlled trials, 6 surveys/qualitative studies, 5 case-control studies, 2 retrospective studies, 2 prospective studies and 12 others.
  • Serious adverse events following CSM seem to be rare, whereas minor adverse events occur frequently.
  • Minor adverse events can include transient neurological symptoms, increased neck pain or stiffness, headache, tiredness and fatigue, dizziness or imbalance, extremity weakness, ringing in the ears, depression or anxiety, nausea or vomiting, blurred or impaired vision, and confusion or disorientation.
  • Serious adverse events following CSM can include the following: cerebrovascular injury such as cervical artery dissection, ischemic stroke, or transient ischemic attacks; neurological injury such as damage to nerves or spinal cord (including the dura mater); and musculoskeletal injury including injury to cervical vertebral discs (including herniation, protrusion, or prolapse), vertebrae fracture or subluxation (dislocation), spinal edema, or issues with the paravertebral muscles.
  • Rates of incidence of all serious adverse events following CSM range from 1 in 10,000 to 1 in several million cervical spine manipulations, however the literature generally agrees that serious adverse events are likely underreported.
  • The best available estimate of incidence of vertebral artery dissection of occlusion attributable to CSM is approximately 1.3 cases for every 100,000 persons <45 years of age receiving CSM within 1 week of manipulative therapy. The current best incidence estimate for vertebral dissection-caused stroke associated with CSM is 0.97 residents per 100,000.
  • While CSM is used by manual therapists for a large variety of indications including neck, upper back, and shoulder/arm pain, as well as headaches, the evidence seems to support CSM as a treatment of headache and neck pain only. However, whether CSM provides more benefit than spinal mobilization is still contentious.
  • A number of factors may make certain types of patients at higher risk for experiencing an adverse cerebrovascular event after CSM, including vertebral artery abnormalities or insufficiency, atherosclerotic or other vascular disease, hypertension, connective tissue disorders, receiving multiple manipulations in the last 4 weeks, receiving a first CSM treatment, visiting a primary care physician, and younger age. Patients whom have experience prior cervical trauma or neck pain may be at particularly higher risk of experiencing an adverse cerebrovascular event after CSM.

CONCLUSION The current debate around CSM is notably polarized. Many authors stated that the risk of CSM does not outweigh the benefit, while others maintained that CSM is safe—especially in comparison to conventional treatments—and effective for treating certain conditions, particularly neck pain and headache. Because the current state of the literature may not yet be robust enough to inform definitive prohibitory or permissive policies around the application of CSM, an interim approach that balances both perspectives may involve the implementation of a harm-reduction strategy to mitigate potential harms of CSM until the evidence is more concrete. As noted by authors in the literature, approaches might include ensuring manual therapists are providing informed consent before treatment; that patients are provided with resources to aid in early recognition of a serious adverse event; and that regulatory bodies ensure the establishment of consistent definitions of adverse events for effective reporting and surveillance, institute rigorous protocol for identifying high-risk patients, and create detailed guidelines for appropriate application and contraindications of CSM. Most authors indicated that manipulation of the upper cervical spine should be reserved for carefully selected musculoskeletal conditions and that CSM should not be utilized in circumstances where there has not yet been sufficient evidence to establish benefit.

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Just three points which, in my view, sand out most in relation to Mr Lawler’s death:

  1. Mr Lawler had no proven indication (and at least one very important contra-indication)  for neck manipulation.
  2. He did not give infromed consent.
  3. The neck manipulation was not within the limits of the physiological range of motion.

“Maybe it is as simple as: I enjoyed that treatment, it was worth the amount I spent on it and I feel better.”

This argument between the fans and the critics of so-called alternative medicine (SCAM) might be the key to understanding the two opposing positions. It applies across the board to all the SCAMs that lack solid evidence (which, of course, is most).

  1. The sceptic asks for evidence of effectiveness and finds none that is convincing. He concludes that the SCAM is not evidence-based.
  2. The SCAM enthusiast cannot argue with the evident lack of evidence, but says (as Angela did in a recent comment): “Maybe it is as simple as: I enjoyed that treatment, it was worth the amount I spent on it and I feel better.”

Both positions may well be correct. And both are held with total conviction. Thus, many consumers who are not deeply into SCAM are confused or even bewildered.

So, how can we make sense of this situation?

Let me start with the argument of the SCAM enthusiast. She is, of course, right to sate that she enjoyed reflexology, or aromatherapy, or crystal therapy. She might also enjoy having her hair done, or soaking in a bath, or drinking a glass of champagne. There is nothing wrong with that, and we should all be happy for her.

Enjoying something is often good for you – often but not always. Enjoying a fag isn’t. Enjoying a bottle of whiskey per evening isn’t. Enjoying a drive at neck-breaking speed on a public motorway isn’t. Enjoying sending out hate-mail isn’t. But innocent treats like a foot massage by an aromatherapist probably is!

But none of these things can be considered to be a THERAPY. Feeling better is not necessarily a therapeutic aim.

So, the situation might not be so confusing after all: enjoyments are enjoyments. They are usually fine, and they are often very personal. Some people enjoy being massaged, others don’t. But enjoyments are not therapies. This means that all would be fine, if we stopped calling aromatherapy, reflexology, crystal therapy THERAPIES, and if we stopped calling aromatherapists, etc. THERAPISTS.

Therapies are medical interventions, and as such they need evidence to back them up, evidence that they do something positive to our health. Therapists are healthcare professionals who make therapeutic claims that need evidence to back them up. If that is missing, sceptics are entirely correct to criticise them. In fact, they fulfil a public service when criticising bogus therapies or claims.

So, the confusion mentioned above mainly arises from mislabelling enjoyments as therapies. Lets call aromatherapists, etc. by different names, and the confusion disappears. Let’s stop aromatherapists, etc. making therapeutic claims, and there is no more reason for sceptics to criticise.

Burning mouth syndrome (BMS) is a rare but potentially debilitating condition. So far, individualised homeopathy (iHOM) has not been evaluated or reported in any peer-reviewed journal as a treatment option. Here is a recently published case-report of iHOM for BMS.

At the Centre of Complementary Medicine in Bern, Switzerland, a 38-year-old patient with BMS and various co-morbidities was treated with iHOM between July 2014 and August 2018. The treatment involved prescription of individually selected homeopathic single remedies. During follow-up visits, outcome was assessed with two validated questionnaires concerning patient-reported outcomes. To assess whether the documented changes were likely to be associated with the homeopathic intervention, an assessment using the modified Naranjo criteria was performed.

Over an observation period of 4 years, an increasingly beneficial result from iHOM was noted for oral dysaesthesia and pains as well as for the concomitant symptoms.

The authors concluded that considering the multi-factorial aetiology of BMS, a therapeutic approach such as iHOM that integrates the totality of symptoms and complaints of a patient might be of value in cases where an association of psychological factors and the neuralgic complaints is likely.

BMS can have many causes. Some of the possible underlying conditions that can cause BMS include:

  • allergies
  • hormonal imbalances
  • acid reflux
  • infections in the mouth
  • various medications
  • nutritional deficiencies in iron or zinc
  • anxiety
  • diabetes

Threatemnt of BMS consists of identifying and eliminating the underlying cause. If no cause of BMS can be found, we speak of primary BMS. This condition can be difficult to treat; the following approaches to reduce the severity of the symptoms are being recommended:

  • avoiding acidic or spicy foods
  • reducing stress
  • avoiding any other known food triggers
  • exercising regularly
  • changing toothpaste
  • avoiding mouthwashes containing alcohol
  • sucking on ice chips
  • avoiding alcohol if it triggers symptoms
  • drinking cool liquids throughout the day
  • smoking cessation
  • eating a balanced diet
  • checking medications for potential triggers

The authors of the above case-report state that no efficient treatment of BMS is known. This does not seem to be entirely true. They also seem to think that iHOM benefitted their patient (the post hoc ergo propter hoc fallacy!). This too is more than doubtful. The natural history of BMS is such that, even if no effective therapy can be found, the condition often disappears after weeks or months.

The authors of the above case-report treated their patient for about 4 years. The devil’s advocate might assume that not only did iHOM contribute nothing to the patient’s improvement, but that it had a detrimental effect on BMS. The data provided are in full agreement with the notion that, without iHOM, the patient would have been symptom-free much quicker.

 

I am not usually a vulgar person, and I do apologise for the title of this post. But, in view of todays’ subject, some vulgarity seems almost unavoidable. This post is about homeopathic provings. In my book, I explain them in some detail:

The term ‘proving’ is a mis-translation of Hahnemann’s term ‘Pruefung’ which means ‘a test’. The English term wrongly implies that some fact is being proven. According to the International Dictionary of Homeopathy, provings (also known as ‘homeopathic pathogenetic trials’ or ‘Arzneimittelpruefung’ as Hahnemann called them), are defined as the process of determining the medicinal properties of a substance; testing in material dose, mother tincture or potency, by administration to healthy volunteers, to elicit effects from which the therapeutic potential, or material medica of the substance may be derived.

In order to individualise their treatment according to the ‘like cures like’ principle, homeopaths need to know what symptoms, or ‘artificial disease’, can be caused by the substances they prescribe. If they treat a patient who suffers from running eyes and nose, for instance, they would be looking for a substance that causes runny eyes and nose in healthy individuals. This is why remedies based on onion might be used to treat conditions like the common cold or hay fever.

But most patients’ complaints are usually a lot more complex. For instance, a person might suffer from frequently runny eyes and nose together with a whole host of other symptoms, many of which might seem trivial or irrelevant to conventional doctors but, for a homeopath, all complaints and patient characteristics are potentially important.

The first proving in the history of homeopathy was Hahnemann’s quinine experiment, which convinced him that he had discovered that this malaria cure causes the symptoms of malaria when taken by a healthy individual. From this observation he deduced that any substance causing symptoms in a healthy person could be used to cure these same symptoms when they occur in a patient.

Provings are normally conducted by administering a mother tincture or a low potency to healthy volunteers who subsequently note in minute detail all sensations, symptoms, emotions and thoughts that occur to them while taking it. These are then carefully registered and eventually form the ‘drug picture’ of that substance.

As a day goes by, we all experience, of course, all sorts of sensations without apparent reason, whether we have taken a medicine or not. Therefore, simple provings are not reliable and might not describe the specific symptoms caused by the substance in question. Realising this problem, most homeopaths now advocate conducting provings in a placebo-controlled manner hoping that this method might generate only symptoms which are specific to the tested substance.

Today thousands of provings have been carried out; most of them are of very low methodological quality. Their results have been published in reference books called ‘repertories’. Homeopaths, once they have noted the full range of characteristics of a patient, can look up the optimal remedy for each individual case. To ease this process even further, sophisticated computer programs are available.

So, essentially, homeopathic provings are experiments where homeopaths give a (often highly diluted/potentised) substance to healthy volunteers and ask them to monitor all sensations that follow. These symptoms are then recorded and eventually form the ‘drug picture’ of a homeopathic remedy. When prescribing a remedy, homeopaths essentially try to match the patient’s symptoms with the drug picture. This is why provings and drug pictures are so very important to classical homeopaths.

Now, imagine that you have just swallowed a substance and start paying attention to all the sensations you feel. As I am writing these lines, I would note all of the following:

  • mild mental irritation,
  • impatience,
  • neck pain,
  • back pain,
  • heavy feet,
  • hot feet,
  • slight ringing in right ear,
  • pressure on abdomen,
  • tickling nose,
  • sweaty hands,
  • acid taste in mouth,
  • need to pass urine,
  • feeling of need to wash hands,
  • itchy scalp,
  • acidity in stomach,
  • itch over right eyebrow.

These are just some of the sensations that come and go with everyday life; they are devoid of any medical meaning or importance. In homeopathy, however, they are elevated to something of fundamental relevance. As I have just had a cup of coffee, the above list could even be seen as a proving of coffea and a contribution to its drug picture. In turn, this would then determine how homeopaths prescribe homeopathic coffea. If others generated similar symptoms after coffee, some of the symptoms listed above might become the part of the accepted drug picture of coffea.

Many of the homeopathic provings are indeed based on little more than that. Modern provings are often conducted a little more rigorously, but there are tens of thousands of different remedies and the drug pictures of many are hardly different from my above-described proving of coffea. If you find this hard to believe, see what two homeopaths noted during a homeopathic proving of another remedy:

Domination and abuse are so intense that they lead to total suppression of oneself. The person develops intense hatred towards  the dominant person, as though they are being tortured. The intensity of the suppressed emotions produces other emotional, mental and physical symptoms: suicidal thoughts, aversion to company, panic attacks with lot of anxiety, low self confidence, arrested mental development, heart palpitations with anxiety, indisposed to talk, aversion to work, compulsive disorder of work, etc.

Low self-esteem and low self-confidence are associated with dependency and fear of failure.There is intense fear of failure and inadequacy, which leads to complete helplessness. This remedy also has aversion to self and a low self image. In this remedy, there are dreams/ thoughts of toilets.

Other symptoms include:

  • Ailments from sexual abuse and rape
  • Mind; colors; charmed by; golden/ colors; desires; golden
  • Delusion or image that body parts/ arms/ legs are smaller, and shortened
  • Dreams lascivious/ seduction/ necked people/ prostitution/ violent sex; Dreams; lascivious, voluptuous; partner, frequent change of/ voluptuous; perverse; girls, about little)
  • Dreams of dogs/ cats, felines
  • Fastidious; appearance, about; personal
  • Music; desires; drums

Believe it or not, the above text is taken from a published proving of excrementum canium – yes: dog shit!

This leads me to conclude that homeopathic provings (and, as provings are the basis for all homeopathy, with it the entire field of homeopathy) are BS.

Autologous whole blood (AWB) therapy is a treatment where a patients blood is first drawn from a vein and then (unmodified or treated in various bizarre ways) reinjected intra-muscularly. This sounds barmy, not least because there is no remotely plausible mode of action. Nonetheless, the therapy is popular in some countries (like Germany, where it is practised by many doctors and Heilpraktikers) and recommended for all sorts of illnesses, particularly for strengthening the immune system and fend off infections.

I have personally used it quite a bit and even conducted the first but very small double-blind, placebo-controlled RCT of AWB therapy which showed promising results. Now two systematic reviews of AWB therapy have become available almost simultaneously.

The first systematic review included our plus 7 more clinical studies. The authors included all prospective controlled trials concerning intra-muscular AWB therapy with the exception of trials using oxygenated, UV radiated or heated blood. Information was extracted on the indication, design, additions to AWB and outcome. Full texts were screened for information about the effector mechanisms.

Eight trials met their inclusion criteria. In three controlled trials with patients suffering from atopic dermatitis and urticaria, AWB therapy showed beneficial effects. In five randomized controlled trials (RCTs), two of which concerned respiratory tract infections, two urticaria and one ankylosing spondylitis, no efficacy could be found. A quantitative assessment was not possible due to the heterogeneity of the included studies. The authors found only 4 controlled trials with sample sizes bigger than 37 individuals per group. Only one study investigated the effector mechanisms of AWB.

The German authors concluded that there is some evidence for efficacy of AWB therapy in urticaria patients and patients with atopic eczema. Firm conclusions can, however, not be drawn. We see a great need for further RCTs with adequate sample sizes and for investigation of the effector mechanisms of AWB therapy.

The second systematic review had a slightly different focus in that it assessed AWB therapy as well as autologous serum therapy (AST) for patients suffering from chronic spontaneous urticaria (CSU). Its authors managed to include 8 clinical trials. AST was not more effective than the placebo treatment in alleviating CSU symptoms at the end of treatment (p = .161), and AWB injection was also not more effective in response rates than the placebo at the end of follow-up (p = .099). Furthermore, the efficacy of AST or AWB injection for CSU and the ASST status were not significantly related. No remarkable adverse events were recorded during therapy.

The Taiwanese authors concluded that their meta-analysis suggested that AWB therapy and AST are not significantly more effective in alleviating CSU symptoms than the placebo treatment.

These somewhat contradictory conclusions will confuse most readers. Personally, I think that caution is well-justified. The trials are mostly flawed, and even our positive study (which received the highest possible quality marks by the authors of the first review) can in no way be definitive, because it was far too small for allowing firm conclusions.

Yet, despite all this, I do think that AWB therapy merits further study.

 

I recently saw a tweet by a German homeopath stating that ‘homeopathy is 100% experienced based medicine’. It made me think and realise that there is not just one EBM, there are, in fact, at least three EBMs!

  1. Experience based medicine
  2. Eminence based medicine
  3. Evidence based medicine

I will start with the type which I encountered first when studying medicine all those years ago.

EMINENCE BASED MEDICINE

German healthcare was at the time – 1970s – deeply steeped in this variety of EBM. What the professor said was right, and there was no discussion about it. I don’t even know how my teachers would have reacted, if we had challenged their wisdom, because nobody ever did; it just did not occur to us.

Personally, I never got along too well with this type of EBM. I found it stifling, and this feeling might have contributed to my first ‘escape’ to England in 1979. In the UK, I felt, things were refreshingly different (see also my recent obituary of my former boss).

EXPERIENCE BASED MEDICINE

So-called alternative medicine (SCAM) is almost entirely based on this type of EBM. Practitioners of SCAM pride themselves of their experience and are convinced that it outweighs evidence any time. They rarely miss an occasion to stress that their treatment as stood the test of time. And as such it does not require evidence; if SCAM did not work, it would not have survived all these years.

Little do they know that the appeal to tradition is a logical fallacy. And little do they care that the long tradition of their SCAMs might just signal how obsolete their treatments truly are. Hundreds (homeopathy) or thousands (acupuncture) of years ago, we had little knowledge about physiology, pathology, etc., and clinicians had to make do with the little that got. Seen in this light, experience based medicine is a negative label that indicates the fact that the treatments are likely to be obsolete and out-dated.

EVIDENCE BASED MEDICINE

Providers of SCAM have a deeply rooted dislike for the word evidence. The reason is simple: their SCAMs are usually very shy on evidence; little wonder that they like to focus on experience instead. Yet, try to explain the concept of evidence to someone neutral like a barman, for instance – whenever I made this attempt, I was interrupted by him saying: ‘Hold on, are you saying that before EBM you did not depend on evidence? This is frightening! What on earth did you rely on then?’

It is indeed not logical to rely on eminence or on experience, in my view. And therefore, I have stopped explaining EBM to people who have common sense, like my barman. Let’s try something else instead: imagine you are seriously ill and are able to chose between three clinician who are each the leading head in their type of EMB.

THE EMINENCE IS A PROFESSOR MANY TIMES OVER AND SIMPLY KNOWS THAT HE IS ALWAYS RIGHT

Personally, I would run a mile. I have seen too many of those blundering through the wards of university hospitals. He never makes a mistake, except that things do go wrong quite often; and when they do, it is the fault of some underling, of course.

THE EXPERIENCED CLINICIAN WITH YEARS OF PRACTICE WHO HAS SEEN IT ALL AND HAS ALL THE ANSWERS

With a bit of bad luck, he might be a homeopath. He will tell you endlessly of cases that were similar to yours. Occasionally, there was an aggravation (which, of course, is a good sign in his view), but in the end he cured them all with his treatments that had stood the test of time. He has excellent bedside manners, a lot of charisma, and is a good listener. Who was it that said: “the three most dangerous words in medicine are IN MY EXPERIENCE”?

Yes, you guessed it: run and don’t turn back!

THE CLINICIAN WHO KNOWS WHAT THE CURRENT BEST EVIDENCE HAS TO OFFER

He might not be all that charismatic, perhaps he even is a bit abrupt. But he will know the latest developments and weigh the risks of all therapeutic options against their benefits.

But hold on, my barman would interrupt at this point, this is not either or. One can have both experience and evidence!

I told you my barman was clever. The definition of evidence based medicine is not healthcare based on up-to date knowledge, it is the integration of best research evidence with clinical expertise and patient values. It thus rests on three pillars: external evidence, ideally from systematic reviews, the clinician’s experience, and the patient’s preferences.

Therefore, my barman and I agree that eminence based medicine is highly questionable, experience based medicine can be outright dangerous, and evidence based medicine is the only EBM version that does make sense.

 

 

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