Homeopathy4health

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.

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19 Comments »

  1. […] admin wrote an interesting post today onHere’s a quick excerptOver 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 […] […]

    Pingback by Random Controlled Trials are the worst of medicine — 30 June 2008 @ 8:09 am

  2. You are quite right, it does look like there is a grossly disproportionate amount of messages supporting homeopathy compared to other topics. Was there an organised campaign to lobby Spiked/Wellcome in this manner?

    Having said that there are some deeply weird arguments in the ‘Worst of Medicine’ section. Epidemiology? BMI? Chemical fears? WTF? I suppose with the abolition of primitive and harmful treatments and theories like bloodletting and humourism homeopathy is one of the few utterly unbelievable treatment modalities left. Personally I’m a little surprised to see that drug company manipulation of data is not on the list, in all honesty that concerns me more than homeopathy does.

    Comment by gimpy — 30 June 2008 @ 9:03 am

  3. Retire any ‘scientist’ who is not actively demonstrating a flexible and curious approach to investigating these complementary therapies, suspending thier [sic] predjudice [sic] and bias – after all, is this not the DEFINITION of a real scientist?

    Personally, I would fire any scientist who thought themselves capable of “suspending their prejudice [or] bias”. No human can do that. That’s why we randomise groups, use controls, and blind examiners in studies: to ensure that people’s inevitable prejudices and biases cannot interfere with the results. People’s judgement isn’t perfect, so we withhold from them any information which we’d rather they didn’t base decisions on.

    RCTs performed on healthy people are done to assess safety. Efficacy is tested on volunteers with the condition, usually with a positive control for ethical reasons. Woodin is therefore quite wrong to suggest that the information from these trials is not transferable, although of course in practice every patient is different, which he acknowledges when he says

    As clinicians we are ‘encouraged’ (read ‘forced’) to ignore our clinical skills and acumen in favor of flow chart diagnosis and prescribing.

    This is also wrong: clinical trials have repeatedly shown that penicillin is effective, but for certain people it can be lethal, and spotting things like that won’t come from a flow-chart. “Clinical skills and acumen” can mean a whole range of things, some of which must be encouraged but others of which are really just hunches, prejudices and biases. When patients’ health is at stake, clinicians have a duty of care to act in accordance with the current best evidence, taking into account their own expertise and judgement, considering the patient’s wishes also. (I am not a clinician, however I just recently completed a course on evidence based medicine — specifically dentistry — at Manchester University, so I feel qualified to talk about this. And I have a cheap inkjet certificate which feels the same way.) The results of trials should be used to inform, not in lieu of, a clinician’s skills and acumen.

    RCTs are an incredibly powerful experimental design, and the only people who ever doubt their validity practice medicinal techniques which RCTs routinely fail to validate. None of these people has ever provided a good argument as to how such a robust methodology could be inapplicable to certain forms of treatment — despite some fantastically elaborate sophistry from the likes of Lionel Milgrom.

    Comment by Andrew — 30 June 2008 @ 4:31 pm

  4. gimpy ‘Personally I’m a little surprised to see that drug company manipulation of data is not on the list, in all honesty that concerns me more than homeopathy does.’

    Can you quantify the effects of drug company manipulation of data versus homeopathic anything (e.g. number of deaths, public and private money involved). Does that correlate with your published concerns in any way?

    Comment by auquai — 9 July 2008 @ 5:46 pm

  5. auquai, what drug companies do and what homeopaths do are two entirely different and non-comparable practices. Yes, drug companies have been caught out suppressing data, this is a bad thing and should be condemned. Yes, homeopaths have a fantastical concept of medicine and ignore the realities of physics, chemistry and biology, this is a bad thing and should be condemned. Only a fool would pretend that because drug companies do the occasional bad thing then this proves that homeopathy works/is safe.

    Comment by gimpy — 10 July 2008 @ 9:02 am

  6. You know I didn’t suggest any equivalence, gimpy. Your bluster indicates you regret your startling admission, as does your backtrack. Suppression of inconvenient evidence is not ‘occasional’, and not confined to drug companies, but permeates the medicalised state at all levels –
    http://www.nybooks.com/articles/21578

    Blumsohn is on target, as usual –
    http://scientific-misconduct.blogspot.com/2007/05/on-decorum-in-medicine.html

    Comment by auquai — 11 July 2008 @ 10:50 am

  7. auquai, this isn’t bluster, this is confrontationalism. We all know that drug companies have been caught out manipulating data, and we all know that it is something that is well publicised generally, which is why I was surprised to see it didn’t feature in the Spiked/Wellcome debate. But we also know that homeopaths often cite the deaths caused by drugs vs the deaths caused by homeopathy as an argument somehow in support of homeopathy, I was merely seeking to preempt that argument. Given that you claim you were not making this argument, what was your point?

    PS linking to hatchet jobs against Richard Doll proves nothing.

    Comment by gimpy — 11 July 2008 @ 1:54 pm

  8. I don’t think there’s been a backtrack.

    In any competitive field, people will cheat. That’s people being people; can’t be stopped (although that doesn’t mean it should be tolerated). The fact remains that evidence-based medicine is built upon a good evidence base (hence the name) — the whole system is designed to that even if people are the biased, fallible, stupid liars and crooks that we assume they will be the system has enough fail-safes and redundancies that it will cope.

    There’s an interesting discussion to be had in this kind of context about whether drug companies are “worse” in any particular way than homeopaths peddling harmless but ineffective pills and potions, but I think that discussion would be pretty pointless except for scoring cheap points, since the two are wholly unconnected.

    In any case, it’s safe to assume that both are, by any reasonable measure, infinitely worse than a randomised controlled trial — a robust and highly effective test of pretty well anything you care to point it at.

    Comment by Andrew — 11 July 2008 @ 2:25 pm

  9. My point, gimpy: As someone not involved in the debates pro and contra homeopathy, nutritionists, magic water etc I am fed up to the back teeth reading your mob’s attacks. Reminds me of the gutter press recycling endless stories on benefit fraud, while turning a blind eye to the huge amount lost through tax evasion, especially corporation tax. I respect bloggers like Blumsohn with the guts to stand up to gigantic vested interests, not dogs who do their witchhunting in packs.

    Gayle’s letter was hardly a hatchet job, just a reminder that Doll’s disgusting collusion with powerful liars would get him my ‘worst of medicine’ nomination if he were still alive
    http://www.wsws.org/articles/2007/jan2007/doll-j09.shtml

    (COI – an uncle who died of leukemia aged 40, 20 years after being forced by the British Navy to stand on deck in the Pacific during an atomic test. No family history.)

    Comment by auquai — 12 July 2008 @ 5:09 pm

  10. Andrew, EBM is an aspirational slogan at best.

    Comment by auquai — 12 July 2008 @ 5:14 pm

  11. Andrew, EBM is an aspirational slogan at best.

    It amuses me greatly that you would assert that with no evidence.

    You really have no irony filter, do you?

    Comment by Andrew — 12 July 2008 @ 8:32 pm

  12. auquai, the problem with homeopathy, nutritionists and many other unscientific practices is that they, in collusion with some aspects of the media, actively harm the publics understanding of science and medicine and cause in increase in health risks. They breed distrust and fear by promoting spurious and quite often malicious scaremongering and untruths relating to scientific and medical matters that actively harms the health of society. Look at the declining vaccination rates and concurrent rise in diseases that once were though to be on their way out thanks to one man’s discredited (and false) science being accepted as fact by legions of uneducated journalists and alternative health practitioners.
    You may argue that drug companies have also harmed societies health by the odd dodgy trial and drug retractions but the companies suffer over this through fines, a loss of reputation and increased scrutiny. In some cases the punishment may be weak and ineffectual but nevertheless they are being held responsible for their actions. Do we see any punishment for alt-health practitioners for promoting dangerous and ineffective treatments for autism, arguing against vaccination or undermining evidence based medicine? Certainly not from their so called professional regulators. On occasion a death or permanent crippling will result in a criminal prosecution but there is no drive from within the profession to impose some standards of reason and decency on practices. Is it any wonder that outsiders feel compelled to do this for them?

    Comment by gimpy — 13 July 2008 @ 8:21 am

  13. http://www.cmaj.ca/cgi/content/full/163/7/837#R33-14

    “Although agreeing that evidence-based medicine makes good sense in theory, its critics have quite appropriately demanded evidence for whether it improves patient out-comes.33 *No such evidence is available from randomized trials* [my emphasis] because no investigative team has yet overcome the problems of sample size, contamination and blinding that such a trial raises. Moreover, it is questionable whether withholding access to evidence from the control arm in such a trial would be ethical. However, outcomes researchers consistently document that patients who receive proven efficacious therapies have better outcomes than those who do not.34,35,36 ”

    So you accept outcomes research? But not for quack therapies, of course. Now where did I leave my irony filter?

    Comment by auquai — 14 July 2008 @ 10:18 am

  14. gimpy, your weak apology for corporate lying about harms may be a first for you, but it doesn’t begin to address the issues raised by Blumsohn (link in my first post above). And the corporate sector is installed in the state to the very top. So we’ll leave it there, if you don’t mind, as I don’t think a partisan health blog (of either side) is the the right place for this.

    Comment by auquai — 14 July 2008 @ 10:30 am

  15. http://www.cmaj.ca/cgi/content/full/163/7/837#R33-14

    So you accept outcomes research? But not for quack therapies, of course. Now where did I leave my irony filter?

    Well first of all that paper does nothing to support your rather brash assertion that “EBM is an aspirational slogan at best”. Nobody ever said the system was perfect, and that paper is aimed at identifying the flaws, not discrediting evidence based medicine entirely. That’s probably why you’ve quietly changed your accusation to “you have double standards” — which I don’t. I don’t recall ever refusing to accept outcomes research for any modality at all. The issue is with poor study design. You’ve just made up an opinion, assigned it to me, then found one single paper, assumed I support its conclusions entirely, then berated me because the two opinions you’ve invented and attributed to me are at odds with each other.

    Did you really think I wouldn’t spot that?

    Comment by Andrew — 14 July 2008 @ 5:22 pm

  16. auquai, why would I have to apologise for corporate lying? I am not working in the private sector, nor have I ever worked in the private sector or received payment from them so I have no compunction to address issues raised against them. I have my own opinions on these matters but I will not discuss them here, here I would like to talk about why I hold the opinions I do on CAM in general and homeopathy in particular.

    PS
    I also think that your statement that “the corporate sector is installed in the state to the very top” is a bit too conspiracy theorist for me to take seriously.

    Comment by gimpy — 15 July 2008 @ 3:44 pm

  17. “Andrew, EBM is an aspirational slogan at best”

    Sounds likes an excellent aspiration to me. Find out what treatments work and then apply what you have discovered to clinical practice. What other alternative is there ….?

    Comment by LeeT — 25 July 2008 @ 9:11 pm

  18. I am not sure why the homeopathy community is so against randomized double blind trials. For what I have seen, many of them are in favor of homeopathy. Randomized double blind large trials should be done with homeopaths and skeptics both on board. Any successful homeopathic trial that happens, skeptics always say researcher bias or the sampling was too small. Unsuccessful trials that happen seem to have issues that homeopaths are not please with. I rather get it right with proper trials with both homeopaths and skeptics on board.

    Comment by Sanjib Sarkar — 26 July 2008 @ 5:40 am

  19. Sanjib

    I would be to know about the trials the showed up positive results for homeopathy. Where we can read them?

    Lee

    Comment by leet01 — 26 July 2008 @ 1:59 pm


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