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

patient choice

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Low back pain must be one of the most frequent reasons for patients to seek out some so-called alternative medicine (SCAM). It would therefore be important that the information they get is sound. But is it?

The present study sought to assess the quality of web-based consumer health information available at the intersection of LBP and CAM. The investigators searched Google using six unique search terms across four English-speaking countries. Eligible websites contained consumer health information in the context of CAM for LBP. They used the DISCERN instrument, which consists of a standardized scoring system with a Likert scale from one to five across 16 questions, to conduct a quality assessment of websites.

Across 480 websites identified, 32 were deemed eligible and assessed using the DISCERN instrument. The mean overall rating across all websites 3.47 (SD = 0.70); Summed DISCERN scores across all websites ranged from 25.5-68.0, with a mean of 53.25 (SD = 10.41); the mean overall rating across all websites 3.47 (SD = 0.70). Most websites reported the benefits of numerous CAM treatment options and provided relevant information for the target audience clearly, but did not adequately report the risks or adverse side-effects adequately.

The authors concluded that despite some high-quality resources identified, our findings highlight the varying quality of consumer health information available online at the intersection of LBP and CAM. Healthcare providers should be involved in the guidance of patients’ online information-seeking.

In the past, I have conducted several similar surveys, for instance, this one:

Background: Low back pain (LBP) is expected to globally affect up to 80% of individuals at some point during their lifetime. While conventional LBP therapies are effective, they may result in adverse side-effects. It is thus common for patients to seek information about complementary and alternative medicine (CAM) online to either supplement or even replace their conventional LBP care. The present study sought to assess the quality of web-based consumer health information available at the intersection of LBP and CAM.

Methods: We searched Google using six unique search terms across four English-speaking countries. Eligible websites contained consumer health information in the context of CAM for LBP. We used the DISCERN instrument, which consists of a standardized scoring system with a Likert scale from one to five across 16 questions, to conduct a quality assessment of websites.

Results: Across 480 websites identified, 32 were deemed eligible and assessed using the DISCERN instrument. The mean overall rating across all websites 3.47 (SD = 0.70); Summed DISCERN scores across all websites ranged from 25.5-68.0, with a mean of 53.25 (SD = 10.41); the mean overall rating across all websites 3.47 (SD = 0.70). Most websites reported the benefits of numerous CAM treatment options and provided relevant information for the target audience clearly, but did not adequately report the risks or adverse side-effects adequately.

Conclusion: Despite some high-quality resources identified, our findings highlight the varying quality of consumer health information available online at the intersection of LBP and CAM. Healthcare providers should be involved in the guidance of patients’ online information-seeking.

Or this one:

Background: Some chiropractors and their associations claim that chiropractic is effective for conditions that lack sound supporting evidence or scientific rationale. This study therefore sought to determine the frequency of World Wide Web claims of chiropractors and their associations to treat, asthma, headache/migraine, infant colic, colic, ear infection/earache/otitis media, neck pain, whiplash (not supported by sound evidence), and lower back pain (supported by some evidence).

Methods: A review of 200 chiropractor websites and 9 chiropractic associations’ World Wide Web claims in Australia, Canada, New Zealand, the United Kingdom, and the United States was conducted between 1 October 2008 and 26 November 2008. The outcome measure was claims (either direct or indirect) regarding the eight reviewed conditions, made in the context of chiropractic treatment.

Results: We found evidence that 190 (95%) chiropractor websites made unsubstantiated claims regarding at least one of the conditions. When colic and infant colic data were collapsed into one heading, there was evidence that 76 (38%) chiropractor websites made unsubstantiated claims about all the conditions not supported by sound evidence. Fifty-six (28%) websites and 4 of the 9 (44%) associations made claims about lower back pain, whereas 179 (90%) websites and all 9 associations made unsubstantiated claims about headache/migraine. Unsubstantiated claims were made about asthma, ear infection/earache/otitis media, neck pain,

Conclusions: The majority of chiropractors and their associations in the English-speaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue.

The findings were invariably disappointing and confirmed those of the above paper. As it is nearly impossible to do much about this lamentable situation, I can only think of two strategies for creating progress:

  1. Advise patients not to rely on Internet information about SCAM.
  2. Provide reliable information for the public.

Both describe the raison d’etre of my blog pretty well.

As often mentioned in previous posts, the ‘Heilpraktiker’ is a recognized healthcare professional in Germany that was established during the Third Reich. Despite the fact that a Heilpraktiker doesn’t necessarily undergo any meaningful medical training, they are permitted to do almost all the treatments a medically trained practitioner can carry out. This situation has created a two-tier healthcare system in Germany which many experts find unacceptable. Reports of patients being seriously harmed are reported with depressing regularity.

It has been reported that a German woman suffering from cancer discontinued her conventional oncological treatments and had herself treated with preparations made from snake venom. After she died of her cancer, the practitioner of so-called alternative medicine (SCAM), a Heilpraktiker, was ordered to pay compensation for pain and suffering. The practitioner must now pay 30,000 Euros in compensation for pain and suffering to her son. This was decided by a court in Munich in a landmark ruling on Thursday. The boy’s father had originally demanded 170,000 Euros.

The deceased patient had been suffering from cervical cancer with a good prognosis. She decided to abandon radiation and chemotherapy and instead opted for preparations made from snake venom, which she received from her SCAM practitioner.

“The defendant did not actively advise her patient to discontinue the life-saving radiation therapy,” the court found, but “she did not oppose her decision, which as a Heilpraktiker would have been her duty.” In the court’s view, the Heilpraktiker should have advised her patient to resume chemotherapy. “This continued omission by the defendant over a period of weeks was irresponsible and, from the point of view of a responsible healthcare practitioner, utterly incomprehensible.” In addition to damages for pain and suffering, the Heilpraktiker was ordered to pay damages for lost child support, among other things. The court did not allow an appeal against the verdict.

The case seems unusual in that the court found a SCAM practitioner guilty not because of administering a bogus or harmful treatment, but because of failing to provide essential advice. This could have consequences for many legal cases in the future.

If I understand it correctly, it means that, according to German law, healthcare practitioners can be held responsible not just for what they were doing, but also for what they were not doing, and that this form of neglect extends not just to treatments and procedures, but also to advice. If that is true, a German homeopath treating an asthma patient, for instance, could be sued if he fails to advise that his patient also takes essential conventional medications.

It would be valuable to have the opinion of legal experts on this point and on the question of how the law in other counties would apply in such matters.

The COMPLEMENTARY AND NATURAL HEALTHCARE COUNCIL describe themselves as follows:

We were set up by the government to protect the public. We do this by providing an independent UK register of complementary healthcare practitioners. Protection of the public is our sole purpose.

We set the standards that practitioners need to meet to get onto and then stay on the register. All CNHC registrants have agreed to be bound by the highest standards of conduct and have registered voluntarily. All of them are professionally trained and fully insured to practise.

We investigate complaints about alleged breaches of our Code of Conduct, Ethics and Performance. We impose disciplinary sanctions that mirror those of the statutory healthcare regulators.

We make the case to government and a wide range of organisations for the use of complementary healthcare to enhance the UK’s health and wellbeing. We raise awareness of complementary healthcare and seek to influence policy wherever possible to increase access to the disciplines we register.

At present, the CNHC are looking for new board members:

Are you interested in setting standards in the public interest? CNHC is the independent regulatory body for complementary healthcare practitioners, established in 2008 with support and funding from the Department of Health. Our public register of over 6,300 qualified therapists provides confirmation that individuals have met UK standards for safe and competent practice.

The Board meets for a half-day four times a year. In normal circumstances meetings are held in London. There is no remuneration but travel costs are reimbursed.

We have vacancies for one Lay and two Registrant Board members.

Although not essential, CNHC are particularly interested in applications from individuals with a background in financial management or accounting.

Deadline for applications is 26 March 2021. Interviews for a Lay member will be held via Zoom on 15 April and for Registrant members on 14 April.

Full information about the work of CNHC is available on our website.

I think it would be desirable for new members to be rational thinkers. I, therefore, encourage all skeptics and rationalists to apply via their website … but expect the job to be a challenge!

The fact that the NHS England has stopped reimbursing homeopathy in 2018 is probably quite well known. France followed more recently, and then Germany too reported trouble for homeopaths on various levels. About two years ago, the manufacturer of homeopathic products, Hevert (Germany),  threatened legal action against several German critics of homeopathy for expressing the fact that highly diluted homeopathic remedies do not work beyond placebo. Crucially, the medical associations of many regions in Germany have – one after the next – discontinued their training in and recognition of homeopathy.

Now similar difficulties are being felt also by Austrian homeopaths. In 2019, the Vienna medical school closed its course on homeopathy because students had filed a complaint about its unethical content. And recently, it was reported by the Austrian ‘Initiative für Wissenschaftliche Medizin‘ that at a secret webinar run by lobbyists in Vienna things were reported to no longer going well for homeopathy. Faced with such problems, the lobbyist, Dr. Jens Behnke, recommended in the above-mentioned secret webinar an alliance of all so-called alternative medicine (SCAM):

“…..and if we do not form this broad alliance now, in order to make appropriate professional PR and lobbying … then everything will fall apart….”

Now a union of pseudomedicine and politics is being forged with the aim of stopping the decline of quackery and paving the way for pseudomedicine in Austria. A resolution has been tabled in the Austrian parliament with the following demands:

  1. Institutionalising of the field of “Complementary Medicine” as “Integrative Medicine” in the academic education at all medical schools.
  2. Appropriate support for and funding of complementary medicine research, especially in the university sector.
  3. Establishment of a broad range of complementary medicine in the hospital sector, in outpatient but also inpatient healthcare.
  4. Promotion of active knowledge transfer in the area of integrative and complementary medicine within the Austrian medical profession.
  5. Securing of complementary diplomas by the Austrian Medical Association.

The motion was introduced by the Freedom Party (FPÖ, the Austrian far-right party) on 21.12.2020, forwarded to the Health Committee for consultation, and is now scheduled for consultation there. The application was introduced by the FPÖ-Nationalratsabgeordnete Mag. Gerhard Kaniak (Chairman of the Health Committee of Parliament, pharmacist), Peter Wurm (entrepreneur), Dr. Dagmar Belakowitsch (physician), and “other deputies”. It is supported by members of the “Initiative Complementary Medicine at Austrian Universities” of the Austrian Society for Homeopathic Medicine. The list of signatories of the motion reads like the “Who’s Who” of pseudo-medicine procedures in Austria – foremost homeopathy, but also anthroposophic medicine, ozone therapy, functional myo-diagnostics (= kinesiology), Ayurvedic medicine, orthomolecular medicine, TCM, etc. It almost goes without saying that it also includes Prof Michael Frass (a prominent member of THE ALTERNATIVE MEDICINE HALL OF FAME), who regular readers of my blog would have met several times before.

__________________________

Instead of a comment (other than I sincerely wish that reason prevails in Austria and the motion is going to be defeated), I think I will quote the concluding phrases from my memoir (which incidentally also covers my most turbulent time in Vienna):

When science is abused, hijacked, or distorted in order to serve political or ideological belief systems, ethical standards will inevitably slip. The resulting pseudoscience is a deceit perpetrated on the weak and the vulnerable. We owe it to ourselves, and to those who come after us, to stand up for the truth, no matter how much trouble this might bring.

 

 

 

Yes, I have just published a new book! Its title is ‘Alternativmedizin – was hilft, was schadet: Die 20 besten, die 20 bedenklichsten Methoden’ (Alternative medicine – treatments that help and treatments that harm: The 20 best and the 20 most worrying methods). Yes, it is in German, and somehow I doubt that there will be an English version of it. Therefore I take the liberty of translating a short section for those who do not read German.

But first, let me tell you about the book’s concept.

Some people who read this blog seem to have the impression that I am dead against so-called alternative medicine (SCAM) – my friend Dana Ullman, for instance, is convinced of it. This, however, is not quite correct (Dana rarely is). The truth is that I am

  • FOR evidence-based medicine,
  • FOR a level playing field in all areas of healthcare,
  • FOR critically evaluating all options.

This also means, of course, that I am against misleading consumers about the value of SCAM. And therefore I am FOR any SCAM that demonstrably does more good than harm.

This attitude should have been clear from all my books. However, it seems to be difficult to understand for those who are on the more fanatical end of the SCAM spectrum. And because it is not that obvious, I decided to write a book that analyses (understandably yet analytically [including ~300 references of the original science]) the evidence for 20 SCAMs that are supported by reasonably sound evidence together with 20 for which this is not the case. My hope is that, with this approach, I might reach more consumers who are in favour of SCAM.

There is a risk, of course. Chances are that, instead of reaching more people from the pro-camp, I will merely offend both the sceptics as well as the enthusiasts.

We shall see.

Anyway, here is the promised bit that I translated for you. It is the postscript of the book, and I hope it gives you a flavour of what it is all about. Here we go:

 

In the first chapter of the book, I promised that I would neither uncritically hype alternative medicine nor unfairly condemn it. I have taken great pains to keep this promise.

Have I succeeded?

I fear there will be many who answer this question in the negative. And I can’t even blame my critics! Who likes to be criticized for something in which he deeply believes? Who likes to hear that his prejudices against everything called alternative medicine are wrong and counter-productive? Who doesn’t mind an ugly fact that destroys his beautiful theory? Both the dogmatic naysayers and the naive believers will be dissatisfied with my book (or at least parts of).

That’s a shame, but ultimately it is irrelevant. My point was not to take the word of one camp or another in the endless trench warfare that is alternative medicine. My main concern was to present the evidence as up-to-date, understandable, and objective as possible, and to serve those who are seriously interested in facts.

The book is thus not for dogged trench warriors; rather, it is aimed at ordinary consumers with an interest in their health. After all, the vast majority of the population is not among the unteachables of one camp or the other. Most people don’t want ideology, they want effective medicine. And most of them are baffled by the unmanageable variety of alternative medicine on offer, the grandiose promises of healing, and the vehement emotions that it all triggers.

In the area of alternative medicine, there is undoubtedly a lot of nonsense, charlatanry, and danger. But there are also some things that demonstrably do more good than harm. In order to separate the wheat from the chaff, consumers don’t need creeds. What they need above all is reliable evidence!

You can read about this evidence in my book. How you then deal with it is solely your decision. I do not want to tell anyone what to do with my presentation of the facts. But I know that the abundance of misinformation in the field of alternative medicine causes great damage and that the consumer and reader of my book, deserve better than to be led up the garden path.

If this book helps readers to make wise treatment decisions, my efforts will have been worthwhile. And if they get half as much pleasure from reading it as I did from writing it, my goal has been achieved.

THE END

(If by any chance you do read German and are in the position to publish a book review, please let me know and I will see that you get a free review copy of my book)

The amount of different so-called alternative medicines (SCAMs) that are being tried or promoted against COVID-19 is legion. Anything really from vitamins to herbal remedies, homeopathics to chiropractic. In fact, it is hard these days to find a SCAM that is not touted for COVID-19.

This study aimed to evaluate if a dietary supplement of quercetin (a polyphenol contained in many fruit and vegetables), vitamin C and bromelain (a proteolytic enzyme contained in pineapple) could be protective against coronavirus infections.

In the verum group, a supplement containing

  • 500mg of quercetin,
  • 500mg of vitamin C,
  • 50mg of  bromelain (QCB)

was administered daily in 2 divided doses for 71 healthcare workers working in areas with high risk of COVID-19, whereas 42 were the control group who received no supplements. The maximum period of follow-up was 120 days. Termination of QCB use prematurely or having a coronavirus infection was the end of a volunteer’s study participation. A rapid diagnostic test was used to detect immunoglobulin positivity.

Graphic demonstrated survival without COVID-19 during follow up time between groups

Graphic demonstrated survival without COVID-19 during follow up time between groups

A total of 113 persons were included. No significant difference were detected between groups at baseline. Mean age of QCB group was 39.0 ± 8.8 years and control group was 32.9 ± 8.7. Average follow-up period for the QCB group was 113 days, and for the control group, 118 days. During the follow-up period, 1 healthcare worker in the QCB group and 9 out in 42 in control group contracted COVID-19. One case was asymptomatic, while others were not. Transmission risk hazard ratio of participants who did not receive QCB was 12.04 (95% Confidence interval= 1.26-115.06, P = 0.031). No significant effect of gender, smoking, antihypertensive medication exposure and having chronic disease on rate of transmission. The authors concluded that this study revealed that QCB was protective for healthcare workers.

The sudy is so poorly written and reported that I had trouble making sense of it. In fact, I first thought it was a fake. Then I saw this note:

Preprints with The Lancet is part of SSRN´s First Look, a place where journals identify content of interest prior to publication. Authors have opted in at submission to The Lancet family of journals to post their preprints on Preprints with The Lancet. The usual SSRN checks and a Lancet-specific check for appropriateness and transparency have been applied. Preprints available here are not Lancet publications or necessarily under review with a Lancet journal. These preprints are early stage research papers that have not been peer-reviewed. The findings should not be used for clinical or public health decision making and should not be presented to a lay audience without highlighting that they are preliminary and have not been peer-reviewed.

If the results are for real (because of the small sample size, the lack of a placebo-control, dozens of potential confounders, etc., the findings could easily false-positive), they would merit urgent replication in a larger, more rigorous trial.

And meanwhile?

Meanwhile I would be very sceptical about the validity of the results. The paper (it really is just a submission for publication in the Lancet; I am not even sure that it will be officially published and I don’t quite see why it is being made available to the public in this way) is too flimsy for words. Despite these warnings, it is likely that many consumers will fall for the claim that QCB was protective for healthcare workers. 

One of my last posts re-ignited the discussion about the elementary issue of informed consent, specifically about informed consent for chiropractors. As it was repeatedly claimed that, in Australia, informed consent is a legal requirement for all chiros, I asked on Wednesday 11 November 2020 at 07:12

FOUR QUESTIONS TO DC + CRITICAL CHIRO (CC):

1) what does the law say about informed consent for Australian chiros?
2) what info exactly do you have to provide?
3) who monitors it?
4) what published evidence do we have about compliance?

CC then posted this reply:

Here we go again you demand evidence while providing little if any for your own assumptions (poor case studies do not count. The pleural of anecdote does not equal evidence whether it’s from chiro’s or you).
We have been over this many times over many years, I cite research/provide links yet you still find it challenging to take it onboard. It is human nature to feel obligated once making a public statement to defend it no matter how much evidence is sent your way. So not surprising.

“1) what does the law say about informed consent for Australian chiros?”
It is all freely available on the national regulators website (as you know and as I have referenced in the past):
https://www.chiropracticboard.gov.au/Codes-guidelines/Code-of-conduct.aspx
https://www.chiropracticboard.gov.au/Search.aspx?q=Informed+consent
Some research by chiropractors on this topic (cited many times in the past):
Risk Management for Chiropractors and Osteopaths. Informed consent
A Common Law Requirement (2004):
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051308/
Quick advanced PubMed with filters set to “Chiropractic” AND “Informed consent”.
https://www.ncbi.nlm.nih.gov/pmc/?term=(Chiropractic)+AND+Informed+consent
Not rocket science
Latest paper that you wrote an ill informed blog on and the comments were not going as you expected (So I expected you to double down like Donald Trump with a new blog within days. Your getting predictable).
https://chiromt.biomedcentral.com/articles/10.1186/s12998-020-00342-5
This paper questions the legal implications of vertebral subluxations with high powered legal input and is a broadside by evidence based chiropractors against vitalistic chiropractors. You respond a snide fantasy informed consent dialogue when you should be supporting the authors:
https://edzardernst.com/2020/11/informed-consent-why-chiropractors-dont-like-it/

“2) what info exactly do you have to provide?”
“4) what published evidence do we have about compliance?”
We have discussed this as well. It is a common law requirement for every profession and is checked upon re-registration by AHPRA every year and by the professional indemnity insurers every year. No informed consent, no registration and no professional indemnity insurance.
Checked AHPRA’s panel decisions and went back 5 YEARS and found ONE decision relating to informed consent:
https://www.ahpra.gov.au/Publications/Panel-decisions.aspx

“3) who monitors it?”
Another of your tired old arguments that we have discussed many times over the years.
In the UK there is the “‘Chiropractic Reporting and Learning System’ (CRLS)” but this is set up by the association representing chiropractors and not the registration board that advocates for patients. Right idea and step in the right direction, wrong organization.
Here years ago there was a trial of an adverse event reporting system in a Melbourne emergency department systematically collected relevant AE information on all professions which was sent to the relevant board for investigation.
It was supported by doctors and chiropractors while physio’s were not involved. A doctor involved told me it was killed off by ER doctors who “snivelled” about the extra paperwork.
There is no AE reporting system for physio’s, chiro’s, osteo’s, GP’s in private practice etc.
Over the years you have harped on and on about this topic as if it is a failing purely of the chiropractic profession when we have supported initiatives for its implementation.
You have also kept up with the research even commenting on an chiropractic researcher on AE’s Charlotte Leboeuf-Yde (who you highly regard) yet ignored until you could take issue with two sentences written in a blog then you wrote this hatchet blog:
https://edzardernst.com/2017/04/we-have-an-ethical-legal-and-moral-duty-to-discourage-chiropractic-neck-manipulations/
So you are asking for evidence yet willfully ignore an author who “I have always thought highly of Charlotte’s work”.

Stop the cynical cherry picked blogs and start supporting the researchers and reformers otherwise you are just someone standing on the sidelines blindly throwing grenades. You do not care who you hit or the damage you do to the chiropractors leading the reform you demand yet consistently fail to support.

____________________________________

I thought the tone of this response was oddly aggressive and found that CC had failed to understand some of my questions. Yet the link to the chiro’s code of conduct https://www.chiropracticboard.gov.au/Codes-guidelines/Code-of-conduct.aspx was useful. This is what it says about informed consent:

3.5 Informed consent
Informed consent is a person’s voluntary decision about healthcare that is made with knowledge and understanding of the benefits and risks involved. A useful guide to the information that chiropractors need to give to patients is available in the National Health and Medical Research Council (NHMRC) publication General guidelines for medical practitioners in providing information to patients.3 The NHMRC guidelines cover the information that chiropractors should provide about their proposed management or approach, including the need to provide more information where the risk of harm is greater and likely to be more serious, and advice about how to present information. Good practice involves:
a) providing information to patients in a way they can understand before asking for their consent
b) providing an explanation of the treatment/care recommended, its likely duration, expected benefits and cost, any alternative(s) to the proposed care, their relative risks/benefits, as well as the likely consequences of no care
c) obtaining informed consent or other valid authority before undertaking any examination or investigation, providing treatment/care (this may not be possible in an emergency) or involving patients in teaching or research, including providing information on material risks
 d) consent being freely given, without coercion or pressure
 e) advising patients, when referring a patient for investigation or treatment/ care, that there may be additional costs, which they may wish to clarify before proceeding
 f) obtaining (when working with a patient whose capacity to give consent is or may be impaired or limited) the consent of people with legal authority to act on behalf of the patient, and attempting to obtain the consent of the patient as far as practically possible
 g) being mindful of additional informed consent requirements when supplying or prescribing products not approved or made in Australia, and
h) documenting consent appropriately, including considering the need for written consent for procedures that may result in serious injury or death.
_______________________________________
This does indeed clarify some of my questions. Related to the fictional patient with neck pain who consults a chiropractor in my previous post, this means the chiro must inform the patient that:
  • the chiro suggests a manipulation of the neck;
  • this often involves forcing a spinal joint beyond its physiological range of motion;
  • the treatment will be short but needs repeating several times during the coming weeks;
  • the expected benefits are a reduction of pain and improvement of motion;
  • the total cost of the treatment series will be xy;
  • there are many other treatment options for neck pain;
  • most of these have a better risk/benefit profile than neck manipulation;
  • having no treatment for neck pain at all is likely to lead to full resolution of the problem over time.

Apart from any doubts that chiropractors would actually comply with these requirements, the question remains: is the listed information sufficient? Does it outline a truly a fully informed consent? I think that essential aspects of informed consent are missing.

  • The code does not explicidly require an explanation about the possible harms of spinal manipulation (i.e. 50% of all patients will suffer mild to moderate adverse effects lasting 2-3 days, and occasionally patients will have a stroke of which some have died).
  • Moreover, the code mentions EXPECTED benefits, but not benefits supported by evidence. Chiros may well EXPECT their treatment to work, but what does the evidence show? As often discussed on this blog, the evidence is negative or very week, depending how you want to interpret it. The code does not require a chiro to inform his patients about this fact.

So, the way I see it, the code does not expressedly demand the chiro to explain his patient that the treatment he is being asked to consent to is

  1. not supported by sound evidence for effectiveness,
  2. nor that the treatment is burdened with significant risks.

And what about the other questions listed above? An Australian chiropractor who will remain anonymous gave me the following answers:

Who monitors Informed Consent?
 
The short answer here is nobody monitors informed consent.  Typically informed consent is a side issue whenever a negligence claim is made.  Similarly, clinical records are a side issue as well.   Thus, when a patient alleges they were injured a complaint is lodged.  As part of the investigation consideration is given regarding the consent process.  If the analysis determines that the adverse outcome was maloccurence rather than negligence  but valid consent was not obtained, the practitioner will still face disciplinary action. 
 
As we are all too well aware, the Boards show little or no desire to be proactive.  I have yet to see any results from the pilot advertising audit project which began approximately 2 years ago.
 
What published evidence have we ab​out compliance?
 
Good question.  To my knowledge Langworthy & Flemming’s 2005 paper is the only one looking at compliance.  Their results suggest that the majority of respondents would be unable to successfully defend a negligence in consent liability charge.  In my experience providing expert opinions in Australian cases, valid consent was not obtained in a single case.  The most bizarre case had the practitioner their expert argue that consent obtained 7 years prior to the injury was still valid.  
 
Langworthy J.M., Cambron J. Consent: its practices and implications in United Kingdom and the United States chiropractic practice. J Manip Physiol Ther. 2007;(6):419–431.

_____________________________________

Yet, Australian chiropractors claim that they abide by the ethical imperative of informed consent. Are they taking the Mickey?

Perhaps not. Perhaps they are merely trying to make sure they do not lose the majority of their clientele. As I already pointed out in my previous post, fully informed consent would make most chiropractic patients turn round and run a mile.

This study assessed the patterns of dietary supplement usage among cancer survivors in the United States in a population-based setting. National Health and Nutrition Examination Survey (NHANES) datasets (1999-2016) were accessed, and adult respondents (≥ 20 years old) with a known status of cancer diagnosis and a known status of dietary supplements intake were included. Multivariable logistic regression analysis was then used to assess factors associated with dietary supplements intake. Moreover, and to evaluate the impact of dietary supplements on overall survival among respondents with cancer, multivariable Cox regression analysis was conducted.

A total of 49,387 respondents were included in the current analysis, including a total of 4,575 respondents with cancer. Among respondents with cancer, 3,024 (66.1%) respondents reported the use of dietary supplements; while 1,551 (33.9%) did not report the use of dietary supplements. Using multivariable logistic regression analysis, factors associated with the use of dietary supplements included:

  • older age (OR: 1.028; 95% CI: 1.027-1.030);
  • white race (OR for black race vs. white race: 0.67; 95% CI: 0.63-0.72);
  • female gender (OR for males vs. females: 0.56; 95% CI: 0.53-0.59),
  • higher income (OR: 1.13; 95% CI: 1.11-1.14),
  • higher educational level (0.59; 95% CI: 0.56-0.63),
  • better self-reported health (OR: 1.36; 95% CI: 1.17-1.58),
  • health insurance (OR: 1.35; 95% CI: 1.27-1.44),
  • history of cancer (OR: 1.20; 95% CI: 1.10-1.31).

Using multivariable Cox regression analysis and within the subgroup of respondents with a history of cancer, the use of dietary supplements was not found to be associated with a difference in overall survival (HR: 1.13; 95% CI: 0.98-1.30).

The authors concluded that dietary supplement use has increased in the past two decades among individuals with cancer in the United States, and this increase seems to be driven mainly by an increase in the use of vitamins. The use of dietary supplements was not associated with any improvement in overall survival for respondents with cancer in the current study cohort.

Many cancer patients, when they first get diagnosed, are tested for vitamin D levels and found to be low or borderline. Consequently, they get a prescription for supplements. Other than this, there is rarely an indication to take any vitamins or other dietary supplements. Yet, cancer patients take them because they think these ‘natural’ preparations can do no harm (and because the industry can be persuasive [there is big money at stake] and the odd breed of ‘integrated’ oncologists might even recommend them). Sadly, this assumption is not correct. The biggest danger, in my view, is the possibility of supplements to interact with one of the many drugs that cancer patients need to take. So, in a way, it is reassuring that, on average, there is no detrimental effect on overall survival.

The paper will probably also reignite the perennial discussion about the effects of vitamin C on the natural history of cancer. My understanding is that there is none (and this verdict seems to be supported by the findings reported here). But I am, of course, aware that this is a ‘hot potato’ and that some readers will think differently. To them I say: please show me the evidence.

It would be interesting, I thought, to get some information on what type of books on so-called alternative medicine (SCAM) are being most frequently sold and read in different countries. In particular, it would be relevant to see how many of them are books that one might recommend.

But how would one go about researching this?

The simplest solution, I guessed, would be to go on the Amazon sites of various countries and have a look. And that’s precisely what I did a few days ago. I decided to scan the first 100 books that are listed under ‘alternative medicine’ and pick out the ones that are non-promotional, factual or critical. I did this little research in 4 countries: USA, UK, France and Germany.

Here are my findings:

1 USA

Not one of the 100 books seems to offer a critical assessment of SCAM. That means the percentage of what I might call recommendable books (books that do not promote unproven or disproven SCAMs to the unsuspecting public) seems to be precisely zero.

2 UK

On place 6, I was delighted to find my recent book Alternative Medicine: A Critical Assessment of 150 Modalities. On place 14 was You Are the Placebo: Making Your Mind Matter. And on place 70 Trick or Treatment?: Alternative Medicine on Trial.

That makes the percentage 3.

3 FRANCE

Surprisingly, there are hardly any books in French listed in the SCAM category. Place 4 is my SCAM: So-Called Alternative Medicine, place 7 More Harm than Good?: The Moral Maze of Complementary and Alternative Medicine, place 9 Trick or Treatment: The Undeniable Facts about Alternative Medicine, and place 64 Killing Us Softly: The Sense and Nonsense of Alternative Medicine.

The percentage is thus 4.

4 GERMANY

Not a single book met the inclusion criteria which makes the percentage a proud zero.

____________

In 1998, we assessed for the first time books on SCAM ( Int J Risk Safety Med 1998, 11: 209-215. [the article is not Medline-listed]). We chose a random sample of 6 such books published in 1997, and assessed their contents according to pre-defined criteria. The findings showed that the advice given in these volumes was frequently misleading, not based on good evidence and often inaccurate. If followed, it would have caused significant harm to patients.

In 2006, we conducted a similar investigation which we then reported in the first and second editions of our book THE DESKTOP GUIDE TO COMPLEMENTARY AND ALTERNATIVE MEDICINE (now out of print, but the German and French translations are still available, I think). This time, we selected 7 best-sellers in SCAM and scrutinised them in much the same way. Our findings showed that almost every form of SCAM was recommended for almost every condition. There was no agreement between the 7 books which SCAM might be effective for which condition. Some treatments were even named as indications for a certain condition in one book, while, in other books, they were listed as contra-indications for the same problem. A bewildering plethora of treatments was recommended for most conditions, for instance:

  • addictions: 120 different SCAMs
  • arthritis: 131 different SCAMs
  • asthma: 119 different SCAMs
  • cancer: 133 different SCAMs
  • etc. etc.

Even though, it included a much larger range of SCAM books, I do not consider my new investigation into this area to be a reliable piece of research. There are many reasons why, it can provide merely a very rough impression, e.g.:

  • The lists included lots of misclassifications, i. e. books that have nothing to do with SCAM.
  • Nobody seems to know by what rank order Amazon lists these books; I had hoped that it would be by sales figures, but I am not sure that this is so.
  • Amazon is just one of many book sellers.
  • My categorising can be criticised for being highly subjective.

Nonetheless, this little exercise, together with my previous research, might tell us something valuable after all. There are now between 30 000 and 60 000 SCAM books listed on the national Amazon sites, and even the most useless forms of SCAM are thus being promoted as though they were evidence-based forms of healthcare. Consumer demand for SCAM books is evidently substantial. The vast majority of these books are dangerously uncritical.

I believe that consumers deserve better.

In this second part of my series ‘Heedless Homeopathy‘, I want to introduce you to some remedies that are based on mother tinctures which might be viewed as less than appetising by some of the more faint-hearted of my readers. Some time ago, we had already discussed that the urethral discharge of a male patient suffering from gonorrhoea is used to make a popular remedy sold under the name of Medorrhinum. But in the ‘revolting range’, homeopathy has more – much more – to offer. Here is a selection of my personal favourites:

Did I put you off homeopathy, because you find these substances disgusting?

Sorry (perhaps some Nux vomica C30?)! But you really need not worry: as with practically all homeopathic remedies, there will be not a single molecule of what it says on the bottle left in the remedy you buy.

Or did I put you off homeopathy, because you find such remedies ridiculous?

No, I am not sorry for that!

In fact, I think it is time that the public learn how silly homeopathy truly is.

 

 

PS

I do hope they pay a good salary to the man who has to collect the tiger urine!

 

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