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.
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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.
The UK ‘COLLEGE OF MEDICINE’ has recently (and very quietly) renamed itself; it now is THE COLLEGE OF MEDICINE AND INTEGRATED HEALTH (COMIH). This takes it closer to its original intentions of being the successor of the PRINCE OF WALES FOUNDATION FOR INTEGRATED MEDICINE (PWFIM), the organisation that had to be shut down amidst charges of fraud and money-laundering. Originally, the name of COMIH was to be COLLEGE OF INTEGRATED HEALTH (as opposed to disintegrated health?, I asked myself at the time).
Under the leadership of Dr Michael Dixon, OBE (who also led the PWFIM into its demise), the COMIH pursues all sots of activities. One of them seems to be publishing ‘cutting-edge’ articles.
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Professor Sonia Williams … explores how integrated oral health needs to consider the whole body, not just the dentition…
Complementary and alternative approaches can also be considered as complementary to ‘mainstream’ care, with varying levels of evidence cited for their benefit.
Dental hypnosis (British Society of Medical and Dental Hypnosis) can help support patients including those with dental phobia or help to reduce pain experience during treatment.
Acupuncture in dentistry (British Society of Dental Acupuncture) can, for instance, assist with pain relief and allay the tendency to vomit during dental care. There is also a British Homeopathic Dental Association.
For the UK Faculty of General Dental Practitioners, holistic dentistry refers to strengthening the link between general and oral health.
For some others, the term also represents an ‘alternative’ form of dentistry, which may concern itself with the avoidance and elimination of ‘toxic’ filling materials, perceived potential harm from fluoride and root canal treatments and with treating dental malocclusion to put patients back in ‘balance’.
In the USA, there is a Holistic Dental Association, while in the UK, there is the British Society for Mercury-free Dentistry. Unfortunately the evidence base for many of these procedures is weak.
Nevertheless, pressure to avoid mercury in dental restorative materials is becoming mainstream.
In summary, integrated health and care in dentistry can mean different things to different people. The weight of evidence supports the contention that the mouth is an integral part of the body and that attention to the one without taking account of the other can have adverse consequences.
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Do I get this right? ‘Holistic dentistry’ in the UK means the recognition that my mouth belongs to my body, and the adoption of a few dubious treatments with w ‘weak’ evidence base?
Well, isn’t this just great? I had no idea that my mouth belongs to my body. And clearly the non-holistic dentists in the UK are oblivious to this fact as well. I am sooooooo glad we got this cleared up.
And what about the alternative treatments used by holistic dentists?
The British Society of Medical and Dental Hypnosis (Scotland) inform us on their website that a trained medical and dental hypnotherapists can help you to deal with a large variety of challenges that you face in your everyday life e.g.
|Anxiety & Stress||Smoking Cessation|
|Weight Problems||Psychosexual Disorders|
|Irritable Bowel||And many other conditions|
I hasten to add that, for most of these conditions, the evidence fails to support the claims.
The British Society of Dental Acupuncture claim on their website that the typical conditions that may be helped by acupuncture are:
- TMJ (jaw joint) problems
- Facial pain
- Muscle spasm in the head and neck
- Stress headaches & Migraine
- Rhinitis & sinusitis
- Dry mouth problems
- Post-operative pain
- Dental anxiety
I hasten to add that, for most of these conditions, the evidence fails to support the claims.
The British Homeopathic Dental Association claim on their website that studies have shown improved bone healing around implants with Symphytum and reduced discomfort and improved healing time with ulcers and beneficial in oral lichen planus.
I hasten to add that none of these claims are not supported by sound evidence.
The COMIH article is entitled “The mouth reflects whole body health – but what does integrated care mean for dentists?’ So, what does it mean? Judging from this article, it means an amalgam (pun intended) of platitudes, bogus claims and outright nonsense.
Pity that they did not change their name to College of Medicine and Integrated Care – I could have abbreviated it as COMIC!
In recent days, journalists across the world had a field day (mis)reporting that doctors practising integrative medicine were doing something positive after all. I think that the paper shows nothing of the kind – but please judge for yourself.
The authors of this article wanted to determine differences in antibiotic prescription rates between conventional General Practice (GP) surgeries and GP surgeries employing general practitioners (GPs) additionally trained in integrative medicine (IM) or complementary and alternative medicine (CAM) (referred to as IM GPs) working within National Health Service (NHS) England.
They conducted a retrospective study on antibiotic prescription rates per STAR-PU (Specific Therapeutic group Age–sex weighting Related Prescribing Unit) using NHS Digital data over 2016. Publicly available data were used on prevalence of relevant comorbidities, demographics of patient populations and deprivation scores. setting Primary Care. Participants were 7283 NHS GP surgeries in England. The association between IM GPs and antibiotic prescribing rates per STAR-PU with the number of antibiotic prescriptions (total, and for respiratory tract infection (RTI) and urinary tract infection (UTI) separately) as outcome. results IM GP surgeries (n=9) were comparable to conventional GP surgeries in terms of list sizes, demographics, deprivation scores and comorbidity prevalence.
Statistically significant fewer total antibiotics were prescribed at NHS IM GP surgeries compared with conventional NHS GP surgeries. In contrast, the number of antibiotics prescribed for UTI were similar between both practices.
The authors concluded that NHS England GP surgeries employing GPs additionally trained in IM/CAM have lower antibiotic prescribing rates. Accessibility of IM/CAM within NHS England primary care is limited. Main study limitation is the lack of consultation data. Future research should include the differences in consultation behaviour of patients self-selecting to consult an IM GP or conventional surgery, and its effect on antibiotic prescription. Additional treatment strategies for common primary care infections used by IM GPs should be explored to see if they could be used to assist in the fight against antimicrobial resistance.
The study was flimsy to say the least:
- It was retrospective and is therefore open to no end of confounders.
- There were only 9 surgeries in the IM group.
Moreover, the results were far from impressive. The differences in antibiotic prescribing between the two groups of GP surgeries were minimal or non-existent. Finally, the study was financed via an unrestricted grant of WALA Heilmittel GmbH, Germany (“approx. 900 different remedies conforming to the anthroposophic understanding of man and nature”) and its senior author has a long track record of publishing papers promotional for anthroposophic medicine.
Such pseudo-research seems to be popular in the realm of CAM, and I have commented before on similarly futile projects. The comparison, I sometimes use is that of a Hamburger restaurant:
Employees by a large Hamburger chain set out to study the association between utilization of Hamburger restaurant services and vegetarianism. The authors used a retrospective cohort design. The study population comprised New Hampshire residents aged 18-99 years, who had entered the premises of a Hamburger restaurant within 90 days for a primary purpose of eating. The authors excluded subjects with a diagnosis of cancer. They measured the likelihood of vegetarianism among recipients of services delivered by Hamburger restaurants compared with a control group of individuals not using meat-dispensing facilities. They also compared the cohorts with regard to the money spent in Hamburger restaurants. The adjusted likelihood of being a vegetarian was 55% lower among the experimental group compared to controls. The average money spent per person in Hamburger restaurants were also significantly lower among the Hamburger group.
To me, it is obvious that such analyses must produce a seemingly favourable result for CAM. In the present case, there are several reasons for this:
- GPs who volunteer to be trained in CAM tend to be in favour of ‘natural’ treatments and oppose synthetic drugs such as antibiotics.
- Education in CAM would only re-inforce this notion.
- Similarly, patients electing to consult IM GPs tend to be in favour of ‘natural’ treatments and oppose synthetic drugs such as antibiotics.
- Such patients might be less severely ill that the rest of the patient population (the data from the present study do in fact imply this to be true).
- These phenomena work in concert to generate less antibiotic prescribing in the IM group.
In the final analysis, all this finding amounts to is a self-fulfilling prophecy: grocery shops sell less meat than butchers! You don’t believe me? Perhaps you need to read a previous post then; it concluded that physicians practicing integrative medicine (the 80% who did not respond to the survey were most likely even worse) not only use and promote much quackery, they also tend to endanger public health by their bizarre, irrational and irresponsible attitudes towards vaccination.
What is upsetting with the present paper, in my view, are the facts that:
- a reputable journal published this junk,
- the international press has a field-day reporting this study implying that CAM is a good thing.
The fact is that it shows nothing of the kind. Imagine we send GPs on a course where they are taught to treat all their patients with blood-letting. This too would result in less prescription of antibiotics, wouldn’t it? But would it be a good thing? Of course not!
True, we prescribe too much antibiotics. Nobody doubts that. And nobody doubts that it is a big problem. The solution to this problem is not more CAM, but less antibiotics. To realise the solution we do not need to teach GPs CAM but we need to remind them of the principles of evidence-based practice. And the two are clearly not the same; in fact, they are opposites.
The Royal London Homeopathic Hospital, recently re-named as the Royal London Hospital for Integrated Medicine (RLHIM), has been one of the most influential homeopathic hospitals in the world. It was founded in 1849 by Dr Frederick Foster Hervey Quin. In 1895, a new and larger hospital was opened on its present site in Great Ormond Street. Many famous homeopaths have worked there, including Robert Ellis Dudgeon, John Henry Clarke, James Compton Burnett, Edward Bach, Charles E Wheeler, James Kenyon, Margaret Tyler, Douglas Borland, Sir John Weir, Donald Foubister, Margery Blackie and Ralph Twentyman. In 1920, the hospital received Royal Patronage from the Duke of York, later King George VI, who also became its president in 1924, and in 1936, the Hospital was honoured by the Patronage of His Majesty the King gaining its ‘Royal’ prefix in 1947. Today, Queen Elizabeth II is the Hospital’s Patron.
On 18 June 1972, 16 of the hospital’s doctors and colleagues on board were killed in a plane crash. During the following years, several reductions in size and income took place. From 2002 to 2005, the hospital underwent a £20m redevelopment and, in 2010, its name was changed to Royal London Hospital for Integrated Medicine.
The hospital just published a new brochure for patients. It contains interesting information and therefore, I will quote directly from this document.
START OF QUOTES
The Royal London Hospital for Integrated Medicine (RLHIM) is part of University College London Hospitals NHS Foundation Trust and accepts all NHS referrals. GP referrals are by letter or via Choose and Book. Patients can also be referred by their NHS hospital consultant.
NHS Choices provides information and an opportunity to provide feedback about our service at www.nhs.uk
The General Medicine Service is led by three consultant physicians. The team also includes other doctors and nurses, a dietitian, a physiotherapist, an occupational therapist and a psychotherapist. The service sees patients with chronic and complex conditions. The team is trained in many areas of complementary medicine. These are used alongside orthodox treatment, allowing them to offer a fully integrated General Medicine service. The General Medicine Service offers a full range of diagnostic tests as well as a variety of treatments and advice on orthodox treatment.
From 3rd April 2018, The Royal London Hospital for Integrated Medicine (RLHIM) will no longer be providing NHS-funded homeopathic remedies for any patients as part of their routine care. This is in line with the funding policy of Camden Clinical Commissioning Groups, the local NHS body that plans and pays for healthcare services in this area.
Should you choose you will be able to purchase these medicines from the RLHIM pharmacy, while other homeopathic pharmacies may also be able to supply the medicines. You can speak to your clinician or the RLHIM pharmacy at your next visit about this…
Conditions commonly seen include:
- Recurrent infections, such as colds, sore throats, cystitis, thrush, chest infections and bacterial infections
- Some persistent symptoms where tests have not revealed a serious underlying disorder
- Asthma or chronic obstructive pulmonary disease (COPD)
- Digestive disorders, for example acid reflux, Irritable Bowel Syndrome and inflammatory bowel disease
- Endocrine (glandular) disorders such as under-active thyroid
- Type II diabetes
- Some types of heart disease, high blood pressure and palpitations (requiring no orthodox treatment)
- Chronic headache such as migraine or tension-type headache
- Side effects of prescribed medications
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Clearly, the big news here is that the RLHIM has been forced to stop providing NHS-funded homeopathics. This could be indicative of what might soon happen throughout NHS England.
But there are other items that I find remarkable: “The General Medicine Service offers a full range of diagnostic tests as well as a variety of treatments and advice on orthodox treatment.” Call me a nit-picker, but this is not INTEGRATED! Integrated medicine means employing both alternative as well as conventional therapies in parallel. The best of BOTH worlds and all that…
In the same vein is the statement that they treat “some types of heart disease, high blood pressure and palpitations (requiring no orthodox treatment)” I am sorry, but this again is not INTEGRATED MEDICINE! I ask myself, is it ethical to mislead patients, colleagues, NHS officials and everyone else pretending to deliver ‘integrated medicine’, while in fact all they seem to offer is ‘alternative medicine’?
The RLHIM has recently dropped the term HOMEOPATHY from its name. Soon it might have to also abandon the term INTEGRATED, because it does not seem to be able to provide a safe level of conventional medicine.
How shall we then call it?
Doctor Jonas is an important figure head of US ‘Integrative Medicine’. As we discussed in a recent post, he pointed out that many US hospital doctors fail to answer the following questions relating to their chronically ill patients:
- “What matters most for this patient?
- What is the person’s lifestyle like – their nutrition, movement and sleep?
- How does that patient manage their stress?
- Does that patient have a good support system at home?
- What supplements does that patient take? Has your patient seen any CAM practitioners to cope with their condition?
- Why do they want to get well?”
In my previous post, I tried to explain that this is embarrassing – embarrassing for doctor Jonas, I meant.
But Jonas also claims that most US hospital doctors he addressed during his lecture tour, were unable to answer these questions. And that might be embarrassing not for Jonas, but for those physicians. Let’s consider this possibility for a moment.
The way I see it, the doctors in question might not have answered to Jonas for the following reasons:
- They felt that the questions were simply too daft to bother.
- They were too polite to tell Jonas what they think of him.
- They were truly unable to answer the questions.
Here I want to briefly deal with the last category.
I do not doubt for a minute that this category of physician exists. They have little interest in what matters to their patients, don’t ask the right questions, have no time and even less empathy and compassion. Yet nobody can deny that medical school teaches all of these qualities, skills and attitudes. And there is no doubt that good doctors practice them; it is not a choice but an ethical and moral imperative.
So, what went wrong with these doctors?
Probably lots, and I cannot begin to tell you what exactly. However, I can easily tell you that those doctors are not practicing good medicine. Similarly, I can tell you what these doctors ought to do: re-train and be reminded of what medical school has once taught them.
And what about those physicians who advocate ‘integrated medicine’ reminding everyone of the core values of healthcare?
Aren’t they fabulous?
No, they aren’t!
Because they too have evidently forgotten what they should have learnt at medical school. If not, they would not be able to pretend that ‘integrative medicine’ has a monopoly on core values of all healthcare. Their messages are akin to a new ‘school’ of ship-building insisting that it is beneficial to build ships that do not leak.
What I am trying to say in my clumsy way is this:
DOCTORS WHO PRACTICE BAD MEDICINE SHOULD RE-TRAIN – TOGETHER WITH THOSE PHYSICIANS WHO ADVOCATE ‘INTEGRATIVE MEDICINE‘, BECAUSE THEY BOTH HAVE FORGOTTEN WHAT THEY LEARNT AT MEDICAL SCHOOL.
Yesterday, I received a ‘LETTER FROM DR JONAS’ (the capital lettering was his) – actually, it was an email, and not a very personal one at that. Therefore I feel it might be permissible to share some of it here (you do remember Jonas, don’t you? I did mention him in a recent post: “Considering the prominence and experience of Wayne Jonas, the 1st author of this paper, such obvious transgression is more than a little disappointing – I would argue that is amounts to overt scientific misconduct.”)
Here we go:
As part of my book tour, I spent last month visiting hospitals and medical schools, talking to the doctors, nurses and students. I tell them to think of a chronically ill patient, and I ask:
“What matters most for this patient? What is the person’s lifestyle like – their nutrition, movement and sleep? How does that patient manage their stress? Does that patient have a good support system at home? What supplements does that patient take? Has your patient seen any CAM practitioners to cope with their condition? Why do they want to get well?”
Most can’t answer these questions. Providers may know the diagnosis and treatments a patient gets, but few know their primary determinants of health. They know ‘what’s the matter’, but not ‘what matters.’ …
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Let’s have a closer look at those items of which Jonas thinks they matter:
- What is the person’s lifestyle like – their nutrition, movement and sleep? Depending on the condition of the patient, these issues might indeed matter. And if they do, any good doctor will consider them. There is nothing new about this; it is stuff I learnt in medical school all those years ago.
- How does that patient manage their stress? The question supposes that all patients suffer from stress. I know it is fashionable to ‘have stress’, but not every patient suffers from it. If the patient does suffer, it goes without saying that a good doctor would consider it.
- Does that patient have a good support system at home? Elementary, my dear Watson! If a doctor does not know about this, (s)he has slept through medical school (where did you go to medical school Wayne, and what did you do during these 6 years?).
- What supplements does that patient take? That’s a good one. I suppose Jonas would ask it to see what further nonsense he might recommend. Most rational doctors would ask this question to see what (s)he must advise the patient to discontinue.
- Has your patient seen any CAM practitioners to cope with their condition? As above.
- Why do they want to get well? Most patients would assume we are pulling their leg, if we really asked this. Instead of a response, they might return a question: Why do you ask, do you think being ill is fun?
So, doctor Jonas’ questions might do well during lectures to a self-selected audience, but in reality they turn out to be a mixture of embarrassing re-discoveries from conventional medicine, platitudes and outright nonsense. “My goal is for integrative healthcare to become the standard of care…” says Jonas towards the end of his ‘LETTER’. I suppose, this explains it!
Thus Jonas’ ‘LETTER’ turns out to be yet another indication to suggest that the reality of ‘integrative medicine’ consists of little more than re-discoveries from conventional medicine, platitudes and outright nonsense.
Yesterday, I heard my ‘good friend’ Dr Michael Dixon (see here, here and here, for example) talk on the BBC about the “new thing” in healthcare: social prescribing. He explained, for instance, that social prescribing could mean treating a diabetic not with medication but with auto-hypnosis and other alternative therapies. At that moment, I wasn’t even entirely sure what the term ‘social prescribing’ meant, I have to admit – so I did some reading.
What is social prescribing?
The UK ‘Social Prescribing Network‘ defines it thus:
Social Prescribing is a means of enabling GPs and other frontline healthcare professionals to refer patients to a link worker – to provide them with a face to face conversation during which they can learn about the possibilities and design their own personalised solutions, i.e. ‘co-produce’ their ‘social prescription’- so that people with social, emotional or practical needs are empowered to find solutions which will improve their health and wellbeing, often using services provided by the voluntary and community sector. It is an innovative and growing movement, with the potential to reduce the financial burden on the NHS and particularly on primary care.
Does social prescribing work?
The UK King’s Fund is mildly optimistic:
There is emerging evidence that social prescribing can lead to a range of positive health and well-being outcomes. Studies have pointed to improvements in areas such as quality of life and emotional wellbeing, mental and general wellbeing, and levels of depression and anxiety. For example, a study into a social prescribing project in Bristol found improvements in anxiety levels and in feelings about general health and quality of life. In general, social prescribing schemes appear to result in high levels of satisfaction from participants, primary care professionals and commissioners.
Social prescribing schemes may also lead to a reduction in the use of NHS services. A study of a scheme in Rotherham (a liaison service helping patients access support from more than 20 voluntary and community sector organisations), showed that for more than 8 in 10 patients referred to the scheme who were followed up three to four months later, there were reductions in NHS use in terms of accident and emergency (A&E) attendance, outpatient appointments and inpatient admissions. The Bristol study also showed reductions in general practice attendance rates for most people who had received the social prescription.
However, robust and systematic evidence on the effectiveness of social prescribing is very limited. Many studies are small scale, do not have a control group, focus on progress rather than outcomes, or relate to individual interventions rather than the social prescribing model. Much of the evidence available is qualitative, and relies on self-reported outcomes. Researchers have also highlighted the challenges of measuring the outcomes of complex interventions, or making meaningful comparisons between very different schemes.
Determining the cost, resource implications and cost effectiveness of social prescribing is particularly difficult. The Bristol study found that positive health and wellbeing outcomes came at a higher cost than routine GP care over the period of a year, but other research has highlighted the importance of looking at cost effectiveness over a longer period of time. Exploratory economic analysis of the Rotherham scheme, for example, suggested that the scheme could pay for itself over 18–24 months in terms of reduced NHS use….
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Is there no harder evidence at all?
The only Medline-listed controlled study seems to have been omitted by the King’s Fund – I wonder why. Perhaps because it fails to share the optimism? Here is its abstract:
Social prescribing is targeted at isolated and lonely patients. Practitioners and patients jointly develop bespoke well-being plans to promote social integration and or social reactivation. Our aim was to investigate: whether a social prescribing service could be implemented in a general practice (GP) setting and to evaluate its effect on well-being and primary care resource use. We used a mixed method evaluation approach using patient surveys with matched control groups and a qualitative interview study. The study was conducted in a mixed socio-economic, multi-ethnic, inner city London borough with socially isolated patients who frequently visited their GP. The intervention was implemented by ‘social prescribing coordinators’. Outcomes of interest were psychological and social well-being and health care resource use. At 8 months follow-up there were no differences between patients referred to social prescribing and the controls for general health, depression, anxiety and ‘positive and active engagement in life’. Social prescribing patients had high GP consultation rates, which fell in the year following referral. The qualitative study indicated that most patients had a positive experience with social prescribing but the service was not utilised to its full extent. Changes in general health and well-being following referral were very limited and comprehensive implementation was difficult to optimise. Although GP consultation rates fell, these may have reflected regression to the mean rather than changes related to the intervention. Whether social prescribing can contribute to the health of a nation for social and psychological wellbeing is still to be determined.
So, there is a lack of evidence for social prescribing. Yet, this is not why I feel uneasy about the promotion of this “new thing”. The more i think about it, the more I realise that social prescribing is just good care and decent medicine. It is what I was taught at med school 40 years ago. It therefore seems like a fancy name for something that should be obvious.
But why my unease?
The way I see it, it will be (and perhaps already is) used to smuggle bogus alternative therapies into the mainstream. In this way, it could turn out to serve the same purpose as did the boom in integrative/integrated medicine/healthcare: a smokescreen to incorporate treatments into medical routine which otherwise would not pass muster. If advocates of this approach, like Michael Dixon, subscribe to it, the danger of this happening is hard to deny.
The disservice to patients (and medical ethics) would then be obvious: diabetics unquestionably can benefit from a change of life-style (and to encourage them is part of good conventional medicine), but I very much doubt that they should replace their anti-diabetic medications with auto-hypnosis or other alternative therapies.
The Society of Homeopaths (SoH) has launched a campaign to inform the public that, despite everything non-homeopaths may say and despite the undeniable facts about homeopathy, their remedies are highly effective. This article provides a detailed account of their incompetence.
I saw the image below first on Twitter. It is part of their current campaign and summarises ‘POSITIVE MESSAGES ABOUT HOMEOPATHY’ as the SoH proclaim them. Presumably, they did this piece of work to help their members finding the right arguments when defending the indefensible.
I am not usually prone to laughing fits, but this had me in stiches! It is hilarious, I think; a true masterpiece of comedy.
The masterpiece is almost too perfect to tarnish with my comments; however, I cannot resist. Sorry!
I will take the arguments in turn going clockwise and starting with
‘HOMEOPATHY MEDICINES ARE TESTED SAFELY AND EFFECTIVELY ON HEALTHY HUMANS’
Should this not be ‘homeopathic medicines’? In any case, the remedies (medicines seems too strong a word) are tested in so-called ‘provings’ – yes, safely because they normally contain no active ingredient… and effectively? I cannot see why provings might be ‘effective’; they are pure fantasy.
HOMEOPATHY MAKES A POSITIVE CONTRIBUTION TO INTEGRATED HEALTHCARE
No, as we have discussed often on this blog, adding cow pie to apple pie is not a positive contribution to anything.
HOMEOPATHY HAS BEEN AVAILABLE ON THE NHS SINCE 1948
Appeal to tradition = fallacy.
Appeal to authority = fallacy.
HOMEOPATHY PUTS THE PATIENT AT THE CENTRE OF THEIR HEALTHCARE
This too is false logic, because all good medicine puts the patient at the centre; in addition it is grammatically false English (if I as a non-native speaker may be so bold).
HOMEOPATHY IS USED BY 15% OF UK CITIZENS
I doubt it. But even if this figure is correct, an appeal to popularity is a fallacy and not a logical argument.
HOMEOPATHY IS USED BY 450 MILLION PEOPLE WORLDWIDE
I doubt it. But even if this figure is correct, an appeal to popularity is a fallacy and not a logical argument.
HOMEOPATHY IS A SYSTEM OF NATURAL HEALTHCARE THAT HAS BEEN USED WORLDWIDE FOR 200 YEARS
What is ‘natural’ in endlessly diluting things like ‘Berlin Wall’ and pretending it is a medicine? In any case, the appeal to tradition is yet another fallacy.
HOMEOPATHY DOES NOT CONTRADICT SCIENTIFIC PROGRESS, IT IS PART OF IT
This is where I almost fell off my chair; homeopathy is the opposite of progress, it is a dogma and a belief-system.
HOMEOPATHY IS HOLISTIC
All good medicine is holistic; arguably, homeopathy is not holistic.
HOMEOPATHY IS EFFECTIVE IN BOTH ACUTE AND CHRONIC ILLNESS
Yes, this is what homeopaths believe, but it is not true.
To conclude what better than quoting the person who, a long time ago, said: “HOMEOPATHS ARE THE CLOWNS AMONGST THE HEALTHCARE PROFESSIONALS” ?
In their now famous 1998 NEJM editorial about alternative medicine, Angell and Kassirer concluded that “It is time for the scientific community to stop giving alternative medicine a free ride. There cannot be two kinds of medicine — conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted. But assertions, speculation, and testimonials do not substitute for evidence. Alternative treatments should be subjected to scientific testing no less rigorous than that required for conventional treatments.”
Then and today, I entirely agree(d) with these sentiments. Years later, the comedian Tim Minchin brought it to the point: “You know what they call alternative medicine that’s been proved to work? – Medicine.” So, comedians have solved the terminology problem, but we, the experts, have not managed to get rid of the notion that there is another type of medicine. Almost 20 years after the above editorial, we still struggle to find the ideal name.
Despite their desperate demand ‘THERE CANNOT BE TWO KINDS OF MEDICINE’, Angell and Kassirer still used the word ALTERNATIVE MEDICINE. On this blog, I usually do the same. But there are many terms, and it is only fair to ask: which one is the most suitable?
- ALTERNATIVE MEDICINE is strictly speaking an umbrella term for modalities (therapy or diagnostic technique) employed as a replacement of conventional medicine; more commonly the term is used for all heterodox modalities.
- CHARLATANERY treatment by someone who professes to have expertise that he does not have.
- COMPLEMENTATY MEDICINE is an umbrella term for modalities usually employed as an adjunct to conventional healthcare.
- COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM) an umbrella term for both 1 and 3 often used because the same alternative modality can be employed either as a replacement of or an add-on to conventional medicine.
- COMPLEMENTARY AND INTEGRATIVE MEDICINE (CIM) a nonsensical term recently created by authors of an equally nonsensical BMJ review.
- DISPROVEN MEDICINE is an umbrella term for treatments that have been shown not to work (as proving a negative is usually impossible, there are not many such therapies).
- FRINGE MEDICINE is the term formerly used for alternative medicine.
- HETERODOX MEDICINE is the linguistically correct term for unorthodox medicine (this could be the most correct term but has the disadvantage that consumers are not familiar with it).
- HOLISTIC MEDICINE is healthcare that emphasises whole patient care (as all good medicine is by definition holistic, the term seems problematic).
- INTEGRATED MEDICINE describes the use of treatments that allegedly incorporate ‘the best of both worlds’, i.e. the best of alternative and conventional healthcare (integrated medicine can be shown to be little more than a smokescreen for adopting bogus treatments in conventional medicine).
- INTEGRATIVE MEDICINE is the same as 10 (10 is more common in the UK, 11 is more common in the US).
- NATURAL MEDICINE is healthcare exclusively employing the means provided by nature for treating disease.
- QUACKERY is the deliberate misinterpretation of the ability of a treatment or diagnostic technique to treat or diagnose disease (quackery exists in all types of healthcare).
- TRADITIONAL MEDICINE is healthcare that has been in use before the scientific era (the assumption is that such treatments have stood the test of time).
- UNCONVENTIONAL MEDICINE is healthcare not normally used in conventional medicine (this would include off-label use of drugs, for instance, and therefore does not differentiate well).
- UNORTHODOX MEDICINE the linguistically incorrect but often used term for healthcare that is not normally used in orthodox medicine.
- UNPROVEN MEDICINE is healthcare that lacks scientific proof (many conventional therapies fall in this category too).
These terms and explanations (mostly my own) are meant to bring out clearly that:
- none of them is perfect,
- none has ever been clearly defined,
- none describes the area completely,
- none is without considerable overlap to other terms,
- none is really useful.
My conclusion, after pondering about these terms for many years (it can be an intensely boring issue!), is that the best solution would be to abandon all umbrella terms (see Angell and Kassirer above). Alas, that hardly seems practical when running a blog on the subject. I think therefore that I will continue to (mostly) use the term ALTERNATIVE MEDICINE (consumers understand it best, in my experience) … unless, of course, someone has a better idea.
I have been alerted to the fact that my former medical school in Munich at one of Germany’s highest-ranked universities is currently running an elective course in homeopathy. For those who do not read German (the original announcement [apparently posted all over Munich university hospitals] is copied below), it teaches the use of homeopathy in/for:
- INTERNAL MEDICINE
- RECURRENT OTITIS MEDIA
- PALLIATION OF RESPIRATORY PROBLEMS
- PROSTATE CANCER
- POST-TRAUMATIC SYNDROMES
- BIPOLAR DISEASE
- MULTIMORBID PATIENTS WITH UVEITIS
- DISEASES OF THE FEMALE BREAST
- SUPPORTIVE CANCER CARE
- PAEDIATRIC ASTHMA
The course is being organised by Dr. med. Sigrid Kruse, von Haunersches Kinderspital des Klinikums der Universität München in co-operation with the ‘Landesverband Bayern des Deutschen Zentralvereins homöopathischer Ärzte’. The lecturers of this course seem to be mostly homeopaths from practices in and around Munich.
This article provides further explanations:
The project „Homeopathy in pediatrics“ was established in the Dr. von Hauner’s Children’s Hospital University of Munich in 1995 to integrate homeopathy into a university hospital. Selected children (outpatients and in the wards) are treated conventionally and homeopathically. The Karl and Veronica Carstens-Foundation initially financed the project over six years. An association of parents, whose children were treated for cancer, funded the project for one year. Since 2002, for the first time in Germany, the National Health Insurance is providing the financial background for two consultants for Homeopathy at this University hospital.
Who are we?
Dr. Mira Dorcsi-Ulrich, who initiated the project and carries out the supervision. She is a pediatrician in her own practice with 23 years of experience.
Dr. Sigrid Kruse has managed to integrate homeopathy into the clinic, starting at first in 1995 as a resident for pediatrics. Now she fulfills the requests of doctors and parents in the wards demanding concomitant homeopathic treatment.
Dr. Christian Lucae mainly treats the outpatients while focussing on his research project with children showing attention-deficit-hyperactivity-syndrome (ADHS).
Concomitant homeopathic therapy was successful in the following cases: intracerebral bleeding 3rd degree in premature babies, drug withdrawal in neonates addicted mothers, epilepsy, handicapped children, ADHS, migraine, tic, recurrent infections, asthma and atopic eczema, complications in wound healing and other problems. Homeopathic treatment of children parallel to conventional methods is particularly well accepted in the treatment of cancer. The side effects of oncological treatment like vomiting and stomatitis can be relieved, aggressions and anxiety intercepted and life quality improved.
END OF QUOTE
Which journal with a modicum of self-respect or rigor allows a homeopath to publish anything like the last paragraph without providing a jot of evidence? The answer is the ‘ALLGEMEINE HOMOEOPATHISCHE ZEITUNG’ – no further explanation needed, I think.
Courses like the one above, run at university level, make me first a little speechless and then more than a little angry. Medical schools should have other roles than teaching impressionable students things that fly in the face of science and evidence. They should guide them to become responsible doctors not misguide them to turn into irresponsible quacks. The fact that this comes from the medical school where I, many years ago, studied, graduated, worked and made both my MD and PhD theses renders the whole thing painfully sad for me personally.
But let’s not get depressed… ‘always look on the bright side of life’!!!
Luckily, there are glimpses of a bright side here. For instance, the fact that doctor Quak is one of the lecturers of this course (see below) is not without jollity, I must admit. Also amusing – at least to me – is be the vision of Dr. med. Mira Dorcsi-Ulrich (see below) standing in front of her students explaining the findings of one of the few RCT of individualised homeopathy for paediatric asthma. This study from my team found no evidence that “adjunctive homeopathic remedies, as prescribed by experienced homeopathic practitioners, are superior to placebo in improving the quality of life of children with mild to moderate asthma in addition to conventional treatment in primary care.”
Here is the German original announcement of the course:
RINGVORLESUNG IM WINTERSEMESTER 2016/2017
HOMÖOPATHIE VON DER THEORIE ZUR PRAXIS MIT PRAXISBEISPIELEN UND PATIENTENVORSTELLUNGEN
1. 20.10.2016 … IN DER INNEREN MEDIZIN: MÖGLICHKEITEN UND GRENZEN Dr. med. Ulf Riker
2. 27.10.2016 … IN DER NEONATOLOGIE: IKTERUS, ASPHYXIE UND UNRUHE Dr. med. Monika Grasser
3. 03.11.2016 … BEI PATIENTEN MIT SINUSITIS Dr. med. Michael Schreiner
4. 10.11.2016 … BEI KINDERN MIT REZIDIVIERENDER OTITIS MEDIA Dr. med. Christian Lucae
5. 17.11.2016 … BEI SCHLAFSTÖRUNGEN Dr. med. Brigitte Seul
6. 24.11.2016 … BEI PALLIATIV-PATIENTEN MIT RESPIRATORISCHEN PROBLEMEN Herbert Michalczyk
7. 01.12.2016 … IN DER BEGLEITUNG VON PATIENTEN MIT EINEM PROSTATA-CARCINOM Uwe Kraemer-Hoenes
8. 08.12.2016 … BEI POSTTRAUMATISCHER BELASTUNGS-STÖRUNG Dr. med. Ingrid Pfanzelt
9. 15.12.2016 … BEI EINER PATIENTIN MIT BIPOLARER AFFEKTIVER STÖRUNG Dr. med. Stephan Gerke
10. 12.01.2017 … BEI EINEM MULTIMORBIDEN PATIENTEN MIT UVEITIS Dr. med. Thomas Quak
11. 19.01.2017 … BEI PATIENTEN MIT HUSTEN Dr. med. Renate Grötsch
12. 26.01.2017 … BEI ERKRANKUNGEN DER WEIBLICHEN BRUST Dr. med. Ute Bullemer
13. 02.02.2017 … IN DER BEGLEITUNG VON KREBSPATIENTEN MIT Q-POTENZEN Miclós Takács
15. 09.02.2017… BEI KINDERN MIT ASTHMA BRONCHIALE Dr. med. Mira Dorcsi-Ulrich
Organisation: Dr. med. Sigrid Kruse, Dr. von Haunersches Kinderspital des Klinikums der Universität München
E-Mail: email@example.com in Zusammenarbeit mit dem Landesverband Bayern des Deutschen Zentralvereins homöopathischer Ärzte,