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

survey

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The purpose of this qualitative research was to explore whether pilgrims visiting Lourdes, France had transcendent experiences and to examine their nature.

For this purpose, the researchers traveled to Lourdes and spoke with 67 pilgrims including assisted pilgrims, young volunteers, and medical staff. About two in five reported a transcendent experience: some felt they had communicated or had close contact with a divine presence, while others reported a powerful experience of something intangible and otherworldly.

The authors concluded that visiting Lourdes can have a powerful effect on a pilgrim and may include an “out of the ordinary” transcendent experience, involving a sense of relationship with the divine, or experiences of something otherworldly and intangible. There is a growing focus on Lourdes as a place with therapeutic benefits rather that cures: our analysis suggests that transcendent experiences can be central to this therapeutic effect. Such experiences can result in powerful emotional responses, which themselves may contribute to long term well-being. Our participants described a range of transcendent experiences, from the prosaic and mildly pleasant, to intense experiences that affected pilgrims’ lives. The place itself is crucially important, above all the Grotto, as a space where pilgrims perceive that the divine can break through into normal life, enabling closer connections with the divine, with nature and with the self.

Some people can have powerful effects when they expect something powerful. So what?

To make any sense out of this, we need a controlled experiment. I am glad to tell you that Austrian psychologists recently published a controlled study of this type. They tested the effects of tap water labeled as Lourdes water versus tap water labeled as tap water found that placebos in the context of religious beliefs and practices can change the experience of emotional salience and cognitive control which is accompanied by connectivity changes in the associated brain networks. They concluded that the findings of the present study allow us to draw preliminary conclusions about the placebo effect in the context of religious beliefs and practices. We found that this type of placebo can enhance emotional-somatic well-being, and can lead to changes in rsFC in cognitive control/emotional salience networks of the brain. Future research is warranted to replicate the results. Moreover, future research should investigate whether the observed effects generalize across different religious affiliations. The idea of “holy water” (or blessed water) is common in several religions, from Christianity, Islam, Buddhism to Sikhism.

Placebo can enhance emotional-somatic well-being. Expectation can play all sorts of tricks on us. This makes sense to me – much to the contrary to the ‘qualitative study’ suggesting that transcendental experiences can be central to this therapeutic effect experienced by believers in Lourdes.

The use of so-called alternative medicine (SCAM) is common among cancer patients and it may reflect the individual and societal beliefs on cancer therapy. This paper aimed to evaluate the trends of CAM use among patients with cancer between 2006 and 2018.

The researchers included 2 Cohorts of patients with cancer seen at the Oncology Department at King Abdulaziz Medical City of Ministry of National Guard Health Affairs, Riyadh, KSA, who were recruited for Cohort 1 between 2006 and 2008 and for Cohort 2 between 2016 and 2018. The study is a cross-sectional study obtaining demographic and clinical information and inquiring about the types of SCAM used, the reasons to use them and the perceived benefits. The researchers compared the changes in the patterns of SCAM use and other variables between the two cohorts.

A total of 1416 patients were included in the study, with 464 patients in Cohort 1 and 952 patients in Cohort 2. Patients in Cohort 2 used less SCAM (78.9%) than Cohort 1 (96.8%). Cohort 1 was more likely to use SCAM to treat cancer compared to Cohort 2 (84.4% vs. 73%, respectively, p < 0.0001,); while Cohort 2 used SCAM for symptom management such as pain control and improving appetite among others. Disclosure of SCAM use did not change significantly over time and remains low (31.6% in Cohort 1 and 35.7% for Cohort 2). However, physicians were more likely to express an opposing opinion against SCAM the use in Cohort 2 compared to Cohort 1 (48.7% vs. 19.1%, p < 0.001, respectively).

The authors concluded that there is a significant change in SCAM use among cancer patients over the decade, which reflects major societal and cultural changes in this population. Further studies and interventions are needed to improve the disclosure to physicians and to improve other aspects of care to these patients.

I think that these are interesting findings. Should both patients and conventional healthcare professionally truly become more sceptical about SCAM? It would be good, in my view, but can we be sure?

The answer is NO!

Firstly, we would need data from other countries (SCAM use is known to show marked national differences). Secondly, we would require more up-to-date evidence. The present paper has suggested that, within one decade, SCAM use can change. Therefore, it is only reasonable to assume that it has changed again since 2016/18.

My hope is that progress continues. And by progress, I mean that those forms of SCAM that are demonstrably useful in palliative and supportive cancer care are employed wisely, while all the many bogus alternative cancer ‘cures’ are rapidly falling by the wayside.

This study describes the use of so-called alternative medicine (SCAM) among older adults who report being hampered in daily activities due to musculoskeletal pain. Cross-sectional European Social Survey (EES) Round 7 (2014) data from 21 countries were examined for participants aged 55 years and older, who reported musculoskeletal pain that hampered daily activities in the past 12months. From a total of 35,063 individuals who took part in the ESS study, 13,016 (37%) were aged 55 or older; of which 8183 (63%) reported the presence of pain, with a further 4950 (38%) reporting that this pain hampered their daily activities in any way.

Of the 4950 older adult participants reporting musculoskeletal pain that hampered daily activities, the majority (63.5%) were from the West of Europe, reported secondary education or less (78.2%), and reported at least one other health-related problem (74.6%). In total, 1657 (33.5%) reported using at least one SCAM treatment in the previous year. Manual body-based therapies (MBBTs) were most used, including massage therapy (17.9%) and osteopathy (7.0%). Alternative medicinal systems (AMSs) were also popular with 6.5% using homeopathy and 5.3% reporting herbal treatments. A general trend of higher SCAM use in younger participants was noted.

SCAM usage was associated with

  • physiotherapy use,
  • female gender,
  • higher levels of education,
  • being in employment,
  • living in West Europe
  • having multiple health problems.

The authors concluded that a third of older Europeans with musculoskeletal pain report SCAM use in the previous
12 months. Certain subgroups with higher rates of SCAM use could be identified. Clinicians should comprehensively and routinely assess SCAM use among older adults with musculoskeletal pain.

Such studies have the advantage of large sample sizes, and therefore one is inclined to consider their findings to be reliable and informative. Yet, they resemble big fishing operations where all sorts of important and unimportant stuff is caught in the net. When studying such papers, it is wise to remember that associations do not necessarily reveal causal relationships!

Having said this, I find very little information in these already outdated results (they originate from 2014!) that I would not have expected. Perhaps the most interesting aspect is the nature of the most popular SCAMs used for musculoskeletal problems. The relatively high usage of MBBTs had to be expected; in most of the surveyed countries, massage therapy is considered to be not SCAM but mainstream. The fact that 6.5% used homeopathy to ease their musculoskeletal pain is, however, quite remarkable. I know of no good evidence to show that homeopathy is effective for such problems (in case some homeopathy fans disagree, please show me the evidence).

In my view, this indicates that, in 2014, much needed to be done in terms of informing the public about homeopathy. Many consumers mistook homeopathy for herbal medicine (which btw may well have some potential for musculoskeletal pain), and many consumers had been misguided into believing that homeopathy works. They had little inkling that homeopathy is pure placebo therapy. This means they mistreated their conditions, continued to suffer needlessly, and caused an unnecessary financial burden to themselves and/or to society.

Since 2014, much has happened (as discussed in uncounted posts on this blog), and I would therefore assume that the 6.5% figure has come down significantly … but, as you know:

I am an optimist.

I believe in progress.

Due to polypharmacy and the rising popularity of so-called alternative medicines (SCAM), oncology patients are particularly at risk of drug-drug interactions (DDI) or herb-drug interactions (HDI). The aims of this study were to assess DDI and HDI in outpatients taking oral anticancer drugs.

All prescribed and non-prescribed medications, including SCAMs, were prospectively collected by hospital pharmacists during a structured interview with the patient. DDI and HDI were analyzed using four interaction software programs: Thériaque®, Drugs.com®, Hédrine, and Memorial Sloan Kettering Cancer Center (MSKCC) database. All detected interactions were characterized by severity, risk, and action mechanism. The need for pharmaceutical intervention to modify drug use was determined on a case-by-case basis.

A total of 294 patients were included, with a mean age of 67 years [55-79]. The median number of chronic drugs per patient was 8 [1-29] and 55% of patients used at least one SCAM. At least 1 interaction was found for 267 patients (90.8%): 263 (89.4%) with DDI, 68 (23.1%) with HDI, and 64 (21.7%) with both DDI and HDI. Only 13% of the DDI were found in Thériaque® and Drugs.com® databases, and 125 (2.5%) were reported with a similar level of risk on both databases. 104 HDI were identified with only 9.5% of the interactions found in both databases. 103 pharmaceutical interventions were performed, involving 61 patients (20.7%).

The authors concluded that potentially clinically relevant drug interactions were frequently identified in this study, showing that several databases and structured screening are required to detect more interactions and optimize medication safety.

These data imply that DDIs are more frequent than HDIs. This does, however, not tell us which are more important. One crucial difference between DDIs and HDIs is that the former are usually known to the oncology team who should thus be able to prevent them or deal with them appropriately; in contrast, HDIs are often not known to the oncology team because many patients fail to disclose the fact that they take herbal remedies. Some forget, some do not think of herbals as medicine, others may be worried about their physician’s reaction.

It follows that firstly, conventional healthcare practitioners should always ask about the usage of herbal remedies, and secondly, they need to be informed about which herbal remedy might interact with which drug. The first can easily be implemented into routine history-taking; the second is more problematic, not least because our knowledge about HDIs is still woefully incomplete. In view of this, it might often be wise to tell patients to stop taking herbal remedies while they are on prescription drugs.

The aim of this “multicenter cross-sectional study” was to analyze a cohort of breast (BC) and gynecological cancers (GC) patients regarding their interest in, perception of, and demand for integrative therapeutic health approaches.

The BC and GC patients were surveyed at their first integrative clinic visit using validated standardized questionnaires. Treatment goals and potential differences between the two groups were evaluated.

A total of 340 patients (272 BC, 68 GC) participated in the study. The overall interest in IM was 95.3% and correlated with older age, recent chemotherapy, and higher education. A total of 89.4% were using integrative methods at the time of enrolment, primarily exercise therapy (57.5%), and vitamin supplementation (51.4%). The major short-term goal of the BC patients was a side-effects reduction of conventional therapy (70.4%); the major long-term goal was the delay of a potential tumor progression (69.3%). In the GC group, major short-term and long-term goals were slowing tumor progression (73.1% and 79.1%) and prolonging survival (70.1% and 80.6%). GC patients were significantly more impaired by the side-effects of conventional treatment than BC patients [pain (p = 0.006), obstipation (< 0.005)].

The authors concluded that these data demonstrate a high overall interest in and use of IM in BC and GC patients. This supports the need for specialized IM counseling and the implementation of integrative treatments into conventional oncological treatment regimes in both patient groups. Primary tumor site, cancer diagnosis, treatment phase, and side effects had a relevant impact on the demand for IM in our study population.

This paper is, in my mind, an excellent example of pseudo-research:

  1. The ‘study’ turns out to be little more than a survey.
  2. The sample is small and not representative; therefore the findings cannot be generalized and are meaningless.
  3. The patients surveyed are those who decided to attend clinics of integrative medicine.
  4. These patients had used alternative therapies before and are evidently in favor of alternative medicine.
  5. The most frequently used alternative therapies (exercise, vitamins, trace elements, massage, lymph drainage) are arguably conventional treatments in Germany where the survey was conducted.

I have repeatedly commented on the plethora of useless surveys in so-called alternative medicine (SCAM). But this one might beat them all in its uselessness. The fact that close to 100% of patients attending clinics of integrative medicine are interested in SCAM and use some form of SCAM says it all, I think.

Why do people waste their time on such pseudo-research?

The best answer to this question is that it can be used for promotion. I found the paper by reading what seems to be a press release entitled: “Eine Studie bestätigt Patientenwunsch nach naturheilkundlicher Unterstützung”. This translates into “a study confirms the wish of patients for naturopathic support”. Needless to explain that the survey did not even remotely show this to be true.

What will they think of next?

I suggest a survey run in a BC clinic which amazingly discovers that nearly 100% of all patients are female.

 

 

The purpose of this study was to describe changes in opioid-therapy prescription rates after a family medicine practice included on-site chiropractic services. It was designed as a retrospective analysis of opioid prescription data. The database included opioid prescriptions written for patients seeking care at the family medicine practice from April 2015 to September 2018. In June 2016, the practice reviewed and changed its opioid medication practices. In April 2017, the practice included on-site chiropractic services. Opiod-therapy use was defined as the average rate of opioid prescriptions overall medical providers at the practice.

There was a significant decrease of 22% in the average monthly rate of opioid prescriptions after the inclusion of chiropractic services (F1,40 = 10.69; P < .05). There was a significant decrease of 32% in the prescribing rate of schedule II opioids after the inclusion of chiropractic services (F2,80 = 6.07 for the Group × Schedule interaction; P < .05). The likelihood of writing schedule II opioid prescriptions decreased by 27% after the inclusion of chiropractic services (odds ratio, 0.73; 95% confidence interval, 0.59-0.90). Changes in opioid medication practices by the medical providers included prescribing a schedule III or IV opioid rather than a schedule II opioid (F6,76 = 29.81; P < .05) and a 30% decrease in the daily doses of opioid prescriptions (odds ratio, 0.70; 95% confidence interval, 0.50-0.98).

The authors concluded that this study demonstrates that there were decreases in opioid-therapy prescribing rates after a family medicine practice included on-site chiropractic services. This suggests that inclusion of chiropractic services may have had a positive effect on prescribing behaviors of medical physicians, as they may have been able to offer their patients additional nonpharmaceutical options for pain management.

The authors are correct in concluding the inclusion of chiropractic services MAY have had a positive effect. And then again, it may not!

Cause and effect cannot be established by correlation alone.

CORRELATION IS NOT CAUSATION!

And even if the inclusion of chiropractic services caused the positive effect, it would not prove that chiropractic is effective in the management of pain. It would only mean that the physicians had an option that helped them to write fewer opioid prescriptions. Had they hired a crystal healer or a homeopath or a faith healer or any other practitioner of an ineffective therapy, the findings might have been very similar.

The long and short of it is this: if we want to use fewer opioids, there is only one way to achieve it: we must prescribe less.

 

A substantial proportion of consumers now use healthcare options known as so-called alternative medicine (SCAM). But why? This study aimed to understand the processes and decisional pathways through which chronic illness patients choose treatments outside of regular allopathic medicine.

It employed Charmaz’s constructivist grounded theory methods to collect and analyze data. Using theoretical sampling, 21 individuals suffering from chronic illness and who had used SCAM treatments participated in face-to-face in-depth interviews conducted in Miami/USA.

Seven overarching themes emerged from the data to describe how and why people with chronic illness choose SCAM treatments:

  • influences,
  • desperation,
  • being averse to allopathic medicine and allopathic medical practice,
  • curiosity and chance,
  • ease of access,
  • institutional help,
  • trial and error.

The author concluded that in selecting treatment options that include SCAM, individuals draw on their social, economic, and biographical situations. Though exploratory, this study sheds light on some of the less examined reasons for SCAM use.

There already is a plethora of research on the reasons why people elect to try SCAM. Our own systematic review of 2011 was, in my view, more informative. Here is the abstract:

The aim of this review is to summarize the published evidence regarding the expectations of so-called alternative medicine (SCAM) users. We conducted electronic searches in MEDLINE and a hand search of our own files. Seventy-three articles met our inclusion criteria. A wide range of expectations emerged. In order of prevalence, they included:

  • hope to influence the natural history of the disease;
  • disease prevention and health/general well-being promotion;
  • fewer side effects;
  • being in control over one’s health;
  • symptom relief;
  • boosting the immune system;
  • emotional support;
  • holistic care;
  • improving quality of life;
  • relief of side effects of conventional medicine;
  • good therapeutic relationship;
  • obtaining information;
  • coping better with illness;
  • supporting the natural healing process;
  • availability of treatment.

It is concluded that the expectations of SCAM users are currently not rigorously investigated. Future studies should have a clear focus on specific aspects of this broad question.

As our conclusion stated, the issue is too broad to be easily researchable. The question might need to be narrowed down. And even then, I ask myself, what might such investigations, even if done well, amount to? In what way would the results of such studies benefit anyone? How would they improve the healthcare of the future?

Perhaps someone can help me by suggesting some answers to these questions?

The use of homeopathy in oncological supportive care seems to be progressing. The first French prevalence study, performed in 2005 in Strasbourg, showed that only 17% of the subjects were using it. This descriptive study, using a questionnaire identical to that used in 2005, investigated whether the situation has changed since then.

A total of 633 patients undergoing treatment in three anti-cancer centers in Strasbourg were included. The results of the “homeopathy” sub-group were extracted and studied.

Of the 535 patients included, 164 (30.7%) used homeopathy. The main purpose of its use was to reduce the side effects of cancer treatments (75%). Among the users,

  • 82.6% were “somewhat” or “very” satisfied,
  • 15.5% were “quite” satisfied,
  • 1.9% were “not at all” satisfied.

The homeopathic treatment was prescribed by a doctor in 75.6% of the cases; the general practitioner was kept informed in 87% of the cases and the oncologist in 82%. Fatigue, pain, nausea, anxiety, sadness, and diarrhea were improved in 80% of the cases. Hair-loss, weight disorders, and loss of libido were the least improved symptoms. The use of homeopathy was significantly associated with the female sex.

The authors concluded that with a prevalence of 30.7%, homeopathy is the most used complementary medicine in integrative oncology in Strasbourg. Over 12 years, we have witnessed an increase of 83% in its use in the same city. Almost all respondents declare themselves satisfied and tell their doctors more readily than in 2005.

There is one (possibly only one) absolutely brilliant statement in this abstract:

The use of homeopathy was significantly associated with the female sex.

Why do I find this adorable?

Because to claim that any of the observed outcomes of this study are causally related to homeopathy seems like claiming that homeopathy turns male patients into women.

PS

In case you do not understand my clumsy attempt at humor and satire, rest assured: I do not truly believe that homeopathy turns men into women, and neither do I believe that it improves fatigue, pain, nausea, anxiety, sadness, and diarrhea. Remember: correlation is not causation.

A report just published by the UK GENERAL CHIROPRACTIC COUNCIL (the regulator of chiropractors in the UK) entitled Public perceptions research Enhancing professionalism, February 2021 makes interesting reading. It is based on a consumer survey for which the national online public survey was conducted by djs research in 2020 with a nationally representative sample of 1,002 UK adults (aged 16+). From this sample, 243 UK adults had received chiropractic treatment and were surveyed on their experiences of visiting a chiropractor.

Hidden amongst intensely boring stuff, we find a heading entitled Communicating potential risks. This caught my interest. Here is the unabbreviated section:

The findings show that patients want to understand the potential risks of treatment – alongside information on cost, this is the most important factor for patients considering chiropractic care. In fact, having any risks communicated before embarking on treatment scores 83 out of 100 on a scale of importance.

Many patients report receiving this information from their chiropractor. Seventy per cent of those who have received chiropractic treatment agree that risks were communicated before treatment commenced.

What does that suggest?

  1. Patients want to know about the risks of the treatments chiropractors administer.
  2. 30% of all patients are not being given this information.

This roughly confirms what has long been known:

MANY CHIROPRACTORS DO NOT OBTAIN INFORMED CONSENT FROM THEIR PATIENTS AND THUS VIOLATE MEDICAL ETHICS.

The questions that arise from this information are these:

  1. As the GCC has long known about this situation, why have they not adequately addressed it?
  2. Now that they are reminded of this flagrant ethical violation, what are they planning to do about it?
  3. What measures will they put in place to make sure that all chiropractors observe the elementary rules of medical ethics in the future?
  4. What reprimands do they plan for members who do not comply?

The objective of this survey was to determine the prevalence of Osteopathic Manipulative Treatment (OMT) use, barriers to its use, and factors that correlate with increased use.

The American Osteopathic Association (AOA) distributed its triannual survey on professional practices and preferences of osteopathic physicians, including questions on OMT, to a random sample of 10,000 osteopathic physicians in August 2018 through Survey Monkey (San Mateo, CA). Follow-up efforts included a paper survey mailed to nonrespondents one month after initial distribution and three subsequent email reminders. The survey was available from August 15, 2018, to November 5, 2018. The OMT questions focused on the frequency of OMT use, perceived barriers, and basic demographic information of osteopathic physician respondents. Statistical analysis (including a one-sample test of proportion, chi-square, and Spearman’s rho) was performed to identify significant factors influencing OMT use.

Of 10,000 surveyed osteopathic physicians, 1,683 (16.83%) responded. Of those respondents, 1,308 (77.74%) reported using OMT on less than 5% of their patients, while 958 (56.95%) did not use OMT on any of their patients. Impactful barriers to OMT use included lack of time, lack of reimbursement, lack of institutional/practice support, and lack of confidence/proficiency. Factors positively correlated with OMT use included female gender, being full owner of a practice, and practicing in an office-based setting.

The authors concluded that OMT use among osteopathic physicians in the US continues to decline. Barriers to its use appear to be related to the difficulty that most physicians have with successfully integrating OMT into the country’s insurance-based system of healthcare delivery. Follow-up investigations on this subject in subsequent years will be imperative in the ongoing effort to monitor and preserve the distinctiveness of the osteopathic profession.

What can one conclude from a three-year-old survey with a 17% response rate?

The answer is almost nothing!

Yet, it seems fair to say that OMT-use by US osteopaths is not huge. It might even be fair to speculate that, in reality, it is smaller than 17%. It stands to reason that the non-responders in this survey were the ones who could not care less about OMT. I would argue that this would be a good thing!

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