30 June 2008

Randomised Controlled Trials are the worst of medicine

Over at spiked-online there is a debate on the Best and Worst of Medicine.  Unsurprisingly, skeptics have nominated homeopathy as one of the worst, but the sheer volume of messages of support for homeopathy managed to get a nomination for best as well.

The debate for the worst of medicine is due on the 17th July.  A clinician sums up the current fundamentalist scientistic backlash against CAM with a damning criticism of the RCT and of those who narrowly support it:

Randomised Controlled Trials are the worst 28 May 2008

The worst thing to happen to medicine is undoubtedly the Randomised Clinical Trial (RCT) – not for the information it does and doesn’t give us but for the way it has been used by government and tunnel visioned researchers to qualify some ridiculous practices under the heading “Evidence Based Medicine”.

As clinicians we are ‘encouraged’ (read ‘forced’) to ignore our clinical skills and acumen in favor of flow chart diagnosis and prescribing. It is virtually never mentioned how much morbidity and mortality modern medicine directly causes – recent analysis in the USA places iatrogenic problems as the country’s third biggest killer!

In addition we are using medicines on complicated people, often with multiple diagnoses and on a variety of drugs – RCTs are conducted in strict (non-clinical) settings using young, relatively fit and healthy people. I am always flabbergasted at the conclusions drawn from these to ‘inform’ normal clinic practice – the information is barely ever transferable!

The best thing to happen to modern medicine is the shake-up of the rigid paradigm that is now being forced on the ‘establishment’ by hoards of patients and practitioners giving a huge range of complementary practices their attention and confidence.

The narrow-minded view taken by a radical few is that we don’t know how these modalities work, therefore they can’t work. This attitude clearly needs to be counterbalanced by the many hundreds of thousands of people who use these treatments and (RCT be damned) find that they work!

Scientific curiosity, informed by actually hearing what people are saying, is the only way forward. Retire any ‘scientist’ who is not actively demonstrating a flexible and curious approach to investigating these complementary therapies, suspending thier predjudice and bias – after all, is this not the DEFINITION of a real scientist?

Geoff Woodin, UK

Edzard Ernst, take note.

26 June 2008

So much homeopathic research evidence should be made widely available ‘for the sake of scientific progression’

Dr Manjir Samanta-Laughton, author of ‘Punk Science’, attended the Scientific Research in Homeopathy Conference hosted by the Complementary Medical Association, held at the University of Westminster on June 18th 2008.

Here are the Complementary Medical Association’s links (some yet to be activated) to the presentations by Dr Alex Tournier, Karin Mont, Dr Rob Verkerk, Oliver Dowding, Claire Haresnape, Dr Lionel Milgrom and Stephen Gordon.

Dr Samanta-Laughtons response to the conference is on her Amazon blog:

I got invited to the most amazing conference last week as a VIP guest courtesy of Jayney Goddard and the Complementary Medical Association. Well it threw me for a loop! I had no idea there were so many RCT trials and evidence of homeopathy. Or that there were real scientific investigations into the actual mechanisms of homeopathy as eloquently demonstrated by Dr Lionel Milgrom, a Fellow of the Royal Society of Chemists. As this was the inaugural conference of its kind, I have one question – where have you been all my life? Why has this information been so hard to find? For the sake of scientific progression, this sort of information should be widely available.”

As she says in ‘Punk Science’: “The paradigm of science has come to a grinding halt. Some are complaining that there are no big discoveries to find. Although technology advances at a rapid pace, these are simply improvements on previous discoveries. There have been no radical changes in the way we see the universe for decades…until now!  The time is right for a change in science; for the next big discovery. This revolution will place consciousness at the very heart of an intelligent universe.”

15 June 2008

Homeopathy, Medicine, Science and Cognitive Dissonance

Given that more and more people globally are using homeopathy with benefit for all kinds of ill-health; its effectiveness in treating epidemics: cholera, influenza (here and here); its integration into the Indian medical system; and the World Health Organisation reporting that it is the number 2 medical system in the world (but you won’t find that report anywhere, it’s been buried), I can only conclude that the reason why conventional medics and scientists might genuinely (rather than wilfully because of love of science itself, self-interest or pharmaceutical allegiances taking priority over the health of patients) refuse to use and investigate homeopathy is because they are suffering from what is termed ‘cognitive dissonance’. www.learningandteaching.info describes it well:

Cognitive dissonance is a psychological phenomenon which refers to the discomfort felt at a discrepancy between what you already know or believe, and new information or interpretation. It therefore occurs when there is a need to accommodate new ideas, and it may be necessary for it to develop so that we become “open” to them. Neighbour (1992) makes the generation of appropriate dissonance into a major feature of tutorial (and other) teaching: he shows how to drive this kind of intellectual wedge between learners’ current beliefs and “reality”.  
Beyond this benign if uncomfortable aspect, however, dissonance can go “over the top”, leading to two interesting side-effects for learning:

  • if someone is called upon to learn something which contradicts what they already think they know — particularly if they are committed to that prior knowledge — they are likely to resist the new learning. Even Carl Rogers recognised this. Accommodation is more difficult than Assimilation, in Piaget’s terms.             
  • and—counter-intuitively, perhaps—if learning something has been difficult, uncomfortable, or even humiliating enough, people are less likely to concede that the content of what has been learned is useless, pointless or valueless. To do so would be to admit that one has been “had”, or “conned”.

Ordeal is therefore an effective — if spurious — way of conferring value on an educational (or any other) experience. “No pain, no gain”, as they say.

  • the more difficult it is to get on a course, the more participants are likely to value it and view it favourably regardless of its real quality.
  • ditto, the more expensive it is.
  • the more obscure and convoluted the subject, the more profound it must be. This has of course been exploited for years to persuade us of the existence of the emperor’s clothes, particularly by French “intellectuals” and “post-structuralists”. (I recently came across the wonderful phrase “intellectual flatulence” which perfectly describes such rubbish.)

It is not, however, so much the qualities of the course which are significant, as the amount of effort which participants have to put in: so the same qualification may well be valued more by the student who had to struggle for it than the student who sailed through.”

As medicine and science is very hard to get into and arduous to study, it seems to fulfill several of the above criteria.

12 June 2008

Homeopathy works – more scientific investigation merited

The Daily Mail reports:

“Homeopathy really does work and doctors should recognise its healing effects, say researchers.

A study found that allergy sufferers who were given homeopathic treatment were ten times more likely to be cured than those given a dummy pill instead.

Doctors should be more positive about the alternative medicine, which is the only complementary therapy available on the NHS, the researchers said.

Their study attempts to settle the controversy over homeopathic treatment, which critics say is not effective because of the tiny level of active substance used in most remedies.

It works on the principle that a substance which in large doses will cause the symptoms of an illness can be used in minute doses to relieve the same symptoms.

Critics argue that the active substance is so diluted that homeopathic remedies have no more effect than placebo or dummy treatment.

The study put homeopathy to the test in 50 patients suffering from nasal allergies. They were given either a homeopathic preparation or a placebo.

Each day for four weeks patients recruited from general practices and a hospital in London measured their nasal air flow and recorded symptoms such as blocked, runny or itchy nose, sneezing or eye irritation.

Both groups reported that they got better – but on average patients who received homeopathy had a 28 per cent improvement in nasal air flow compared with 3 per cent among those in the placebo group.

The study was carried out by doctors in Glasgow, led by Dr David Reilly of the Glasgow Homeopathic Hospital, one of five specialist hospitals in Britain. He said the difference in results from the two treatments was statistically significant.

Dr Reilly said this was the fourth trial carried out by his hospital, all with similar results. In addition, there were positive findings in 70 per cent of a further 180 clinical trials.

‘I hope this will encourage doctors to examine the volume of evidence supporting homeopathy – they might be quite surprised at the positive outcome in many trials,’ he said.

He added that it would take consistent scientific investigation to persuade some doctors, but attitudes were changing.

About 20 per cent of doctors in Scotland have basic homeopathic training compared with one per cent 15 years ago.

‘It isn’t just about the remedies, which can be put to the test in trials, but about a greater holistic approach in encouraging self-healing and self-recovery.'”

Dr Bob Leckridge, president of the Faculty of Homeopathy – the body for doctors, vets, nurses and other health professionals – said: ‘This latest research builds on existing evidence that homeopathy works, something that hundreds of doctors and their patients have known for 200 years.’

6 June 2008

Homeopathy awareness week – Nelson’s Pharmacy open day

From www.londonisfree.com:

Nelson’s Pharmacy in Mayfair will be offering free mini homeopathic consultations as part of National Homeopathy Awareness Week 2008.

You can benefit from one-to-one drop-in consultations on Saturday 14 June from 10am to 5pm as part of a Homeopathy and Natural Health Open Day when homeopaths will be on hand to provide expert advice on a range of ailments.

Taster sessions of other holistic therapies including massage, health testing and reflexology will also be available at Nelson Homeopathic Pharmacy, along with light refreshments and a free goodie bag.

Find out more about National Homeopathy Awareness Week 2008.

To find out more and book an appointment call 020 7079 1282 or email HAW@nelsons.net.

4 June 2008

Edzard Ernst’s uncritical endorsement of EBM is ’empirical quackery’

Dr Michael Fitzpatrick’s review of the book ‘Trick or Treatment’ by Simon Singh and Edzard Ernst at  spiked-online (they say: “an independent online phenomenon dedicated to raising the horizons of humanity by waging a culture war of words against misanthropy, priggishness, prejudice, luddism, illiberalism and irrationalism in all their ancient and modern forms”) makes the following observations and criticisms of interest:

“Despairing of their capacity to engage with serious adversaries or big issues, former left-wingers are inclined to re-fight the battles of the past and to seek out soft targets for their invective: current favourites include neo-fascists, creationists and conservative religionists. Though any small success of these forces is trumpeted as a menace to civilisation, in reality they are as marginal as they have ever been. Exaggerating these threats enables liberals to imagine a return to their glory days, and allows them to evade the real problems of the present.”

“Alternative medicine, the focus of a new critique titled Trick or Treatment? by the science writer Simon Singh and Edzard Ernst, ‘the world’s first professor of complementary medicine’, has become another target of the radical backlash. Following the spectacular success of a series of works promoting militant secularism, a spate of books and blogs now signals a new crusade against alternative medicine.”

“it is light on references”

“My reservations about Trick or Treatment? concern its uncritical endorsement of what the health policy expert Rudolph Klein has characterised as the ‘new scientism’ of ‘evidence-based medicine’ (1), its incoherent advice to doctors on telling the truth and its curiously paternalistic approach towards patients.

According to Singh and Ernst, ‘evidence-based medicine’, a term coined by the epidemiologist David Sackett in 1992, has ‘revolutionised medical practice’. They acknowledge that ‘prior to the development of evidence-based medicine, doctors were spectacularly ineffective’. However, ‘once the medical establishment had adopted such simple ideas as the clinical trial, then progress became swift’. As a result, ‘today’, less than two decades later, according to this remarkable telescoping of the familiar narrative of progress from darkness to enlightenment, ‘the clinical trial is routine in the development of new treatments and medical experts agree that evidence-based medicine is the key to effective health care’.

While it is true that evidence-based medicine (EBM) has made some useful contributions to contemporary medical practice, notably in the systematic use of randomised controlled trials in the study of therapeutic interventions, it is nonsense to claim that it has played a major role in the successes of modern medicine (such as vaccines, antibiotics, steroids, anaesthetics, surgical techniques) which arose from developments in the basic medical sciences.”

“To some of its critics, in its disparagement of theory and its crude number-crunching, EBM marks a return to ‘empiricist quackery’ in medical practice.”

“Why are so many GPs tolerating, promoting or even using bogus treatments?’ is the provocative question posed by Singh and Ernst to my colleagues in primary health care. They consider various possibilities (though they do not seem to apply their commitment to an evidence-based approach to their speculations in this area). Could it be that GPs are simply ignorant of the facts that alternative medicine is useless? They raise the possibility that some GPs may be true believers in alternative therapies, but – understandably – find this too terrifying a subject to investigate further. They believe that many GPs are so inconsiderate towards their patients that this drives them into the sympathetic, empathetic arms of alternative therapists. But for them the most likely explanation is that GPs are simply lazy and respond to their patients’ relentless minor complaints by ‘fobbing them off with placebos’, in the form of ‘bogus remedies’ and referrals to alternative therapists.”

“Singh and Ernst criticise GPs for ‘encouraging patients’ to seek out alternative therapists. In a bizarre parallel with the world of drug addiction, they argue that ‘introducing patients to alternative therapists in relation to a minor condition could act as a gateway to a longer-term reliance’. One taste of a (tasteless) homeopathic pill or twist of an acupuncture needle could lead to a serious habit, and they may end up refusing vaccinations and stopping prescription drugs.

This is getting silly.”

I have received the following further comments from Ralf Jeutter PhD RSHom:

“The quotes from the book presented by Fitzpatrick show how superficial Singh and Ernst’s critique is. It is primarily based on the assumption that EBM is a reliable tool with which to judge treatments, totally ignoring that EBM is far from accepted as that.  Fitzpatrick calls it ‘incoherent advice to doctors’; the ‘founder’ of EBM, Sackett, wrote: ‘EBM … never replaces clinical skills, clinical judgment and clinical experience’, thus refuting in one single sentence everything Ernst claims: that EBM is the most reliable and generally accepted standard for assessing clinical effectiveness.

Ernst is a dramatiser who has lost perspective of real academic/scientific issues when he writes that ‘prior to the development of evidence-based medicine, doctors were spectacularly ineffective.’ If he really means this it is clear that he has an utterly uncritical enthusiasm for what is only the latest fashion in medicine, one that is neither established nor universally accepted. The one appeal it has is its mind numbing simplicity, which totally ignores clinical realities.

The review also highlights how desperate Ernst is to find ANYTHING to discredit CAM: apparently it is habit forming on a par with, well, seriously habit forming things. Rightly Fitzpatrick says: ‘This is silly’.

Ernst loses academic credibility by refusing to acknowledge the real complexity of research into CAM. Moreover he refuses to acknowledge that most conventional treatments and interventions are not evidence based. He has found a way of making headlines by propagating very crude science indeed. His academic status is further undermined by acting much more like a quackbuster of recent years than as somebody who should be encouraging more research (including research methodologies into CAM) to benefit the profession and patients.

It really does not become a Professor of CAM to dismiss such a longstanding and successful practice like homeopathy as ‘bogus’ and ‘nonsense’. As an academic he has had to make a determined effort to ignore the plethora of research which has grown around homeopathy over the last 200 years: pre-clinical fundamental research; fundamental research into physics and chemistry as far as it has a bearing on homeopathy; experiments on plants with ultra-high dilutions; experiments on animals and animal tissue with ultra-high dilutions; in-vitro studies; clinical studies, be they observational or comparative studies; controlled studies of nosological clinical homeopathy to randomised clinical isopathic and epidemiological studies. He has also ignored the dedicated hard work of many researchers into CAM and associated fields: dismissing all of this as useless activity which has yielded nothing and will never yield anything. I think it would suit Prof. Ernst to show more respect to his colleagues and a modicum of modesty.

Ernst has come to the conclusion that homeopathy doesn’t work by cherry-picking what he considers to be state-of-the-art research methodologies, which conflict in many instances with clinical realities.

It appears that it is Ernst’s desire to call a premature end to homeopathy which informs his understanding of ‘science’. Homeopathy has survived many fads, fashions and detractors, and will no doubt survive this latest attempt at discrediting it. In my own modest predicition, Ernst, in all likelihood, will become a footnote in the history of homeopathy, like so many before him.  He is an academic who mistakes scientific models with reality.”

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