Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Appropriate evidence required in complementary medicine evaluation
- Jon L Wardle (14 October 2008)
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Chiropractic Assertiveness
- Richard Bartley (15 October 2008)
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The prose and the cons
- David B Todd (16 October 2008)
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Inappropriate hierarchies
- Stephen J Gordon (18 October 2008)
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Protection from the "enemies of reason"
- Peter R Mansfield (18 October 2008)
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Complementary Confusion.
- Noel B Thomas (20 October 2008)
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Change the libel laws
- Neville W Goodman (20 October 2008)
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Re: Inappropriate hierarchies
- Leslie B Rose (20 October 2008)
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Homeopathy: the game is up
- David Colquhoun (20 October 2008)
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March on, evidence-based medicine !
- Alexander S D Spiers (21 October 2008)
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Hierarchies of Evidence
- Stephen J Gordon (22 October 2008)
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Alternative medicine
- Terry J Hamblin (22 October 2008)
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Time to think again?
- Andrew A G Morrice (23 October 2008)
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Support
- Ann C Homer (26 October 2008)
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Dissonance Theory
- Amanda Jones (28 October 2008)
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Removing the cancer
- Dylan Evans (28 October 2008)
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Jon L Wardle, Research Scholar School of Population Health, University of Queensland, Herston, Qld, 4006
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Sometimes the complementary medicine industry quite rightly comes under fire for the unscrupulous actions of those within it. However, this also unfairly taints many in the industry who exhibit far less nefarious behaviour. In many cases institutional or commercial interests do not represent those of the majority in the complementary medicine sector. I recently submitted a report to the Australian government which suggested that complementary therapists are overwhelmingly in favour of greater regulation of their industry and tighter restrictions on this type of behaviour1. This is in spite of opposition from industry and professional associations. My report also suggests that complementary practitioners also want more collaboration and more research, not less, but simply desire consultation in this process. Ernst suggests that complementary therapists should accept the fact that medicine has judged their treatments to be ineffective. Often this is not the issue at hand. One of the major criticisms coming from the complementary medicine industry is that many of the evaluation techniques used do not accurately represent clinical practise2, 3 – a common criticism not isolated to complementary medicines4, 5. The scientific community continues to argue that these medicines need to be evaluated like any other. Both these arguments are valid. Much of the research performed by those with intimate knowledge of the therapies lacks scientific rigour. But much of the research performed by those without this intimate knowledge but expertise in research methodology or other health professions may not accurately evaluate the way these therapies are used in practice. A noteworthy example is Echinacea. Whilst professional herbal texts do not recommend its use as a treatment for acute cold and flu due in part to its significant lead in-period6-8, most evaluation has focused upon this use9 – most probably as this is what it has been marketed for by the commercial interests of this sector. This has resulted in a wealth of research data gained at great expense that is of little actual clinical use to anyone. And it tells us no more than a herbalist could have had they been properly consulted. The solution seems an obvious one. Researchers and complementary therapists need to collaborate and formulate research designs that can appropriately evaluate these medicines. Ernst has previously suggested that those who promote the use of complementary medicine should not be involved in its evaluation10. I contend that this argument when applied to complementary therapists is as ludicrous as suggesting that medical doctors should be barred from medical research. More research and evaluation of complementary medicine is certainly required – but to ensure this research accurately reflects the way complementary medicines are used the practitioner community needs to be appropriately engaged. 1. Wardle J. Regulation of complementary medicines: A brief report on the regulation and role of complementary medicines in Australia. Brisbane: The Naturopathy Foundation; 2008 [cited 2008 October 15] Available from: http://www.norphcam.org/cmregreport/cmregreport.pdf 2. Mason S, Tovey P, Long AF. Evaluating complementary medicine: methodological challenges of randomised controlled trials. BMJ 2002;325(7368):832-834. 3. Tonelli M, Callahan T. Why alternative medicine cannot be evidence -based. Acad Med. 2001;76:1224-1225. 4. Bagshaw S, Bellomo R. The need to reform our assessment of evidence from clinical trials: A commentary. Philosophy, Ethics and Humanities in Medicine. 2008;3(1):23. 5. Bellomo R, Bagshaw S. Evidence-based medicine: classifying the evidence from clinical trials--the need to consider other dimensions. Crit Care. 2006;10(5):232. 6. Braun L, Cohen M. Herbs & Natural Supplements: An Evidence- Based Guide. Sydney: Elsevier; 2007. 7. Scientific Committee of the British Herbal Medical Association. British Herbal Pharmacopoeia. 2nd ed. Bournemouth: British Herbal Medicine Association; 1996. 8. Mills SM, Bone K. Principles and Practice of Phytotherapy. Edinburgh: Churchill Livingstone; 2000. 9. Linde K, Barrett B, Wölkart K, Bauer R, Melchart D. Echinacea for preventing and treating the common cold. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD000530. DOI: 10.1002/14651858.CD000530.pub2 10. Ernst E. Complementary and alternative medicine. Lancet. 2001;357(9258):802-803. Competing interests: None declared |
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Richard Bartley, Physiotherapist LL16 3ES
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UK physiotherapists can undergo post-graduate training in spinal manipulation (in addition to passive mobilisation techniques taught at under-graduate level). There are inherent dangers in the inappropriate use of spinal manipulation and thus training and clinical reasoning need to be of an exceptionally high standard. In the US, chiropractors have appealed to the higher courts to prevent American physiotherapists (physical therapists) from practising spinal manipulation on the spurious grounds that such techniques are only applicable to 'chiropractic subluxations' (whatever these are). As only chiropractors use this diagnostic definition, they argue that any physiotherapist attempting spinal manipulation (however well qualified to do so) is applying treatment for a chiropractic condition and is therefore unlawful. This is a good example of non-evidence based practice encroaching on the clinical autonomy of other professions. One only hopes that this practice doesn't cross the pond. Competing interests: None declared |
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David B Todd, Sports Physician Student University of Bath BA2 7AY
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I take some interest (although a non-prescriber in another speciality) in complementary medicine.
RCTs in acupuncture and homeopathy (as a broad generalisation) are of the order of "50% pro" and "50% anti", and are of the poor quality one would expect in a targetted-therapy area such as this.
Lest such figures be thought a dreadful indightment, (the starting point to do them down), absolutely exactly the same such evidence is found in huge-spending areas such as methadone prescribing.
I read the British Journal of Anaesthesia online today; its header is a quote from Montaigne, the gist of which is to talk (positively) about those things you know about. I am mystified why Professor Ernst would want his own job: his conclusions are negative and he has the air of someone that thinks he needs to add to the general negative professional belief in complementary practice. I think his complaints against intellectual challenge are ridiculous, although I do agree that Prince Charles has undue influence in healthcare. Competing interests: None declared |
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Stephen J Gordon, Homeopathy Practitioner Norfolk Clinic. Norwich NR3
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I find it interesting this letter is published on the same day as comments from the head of NICE Prof. Sir Mathew Rawlins to the effect that RCTs are placed on an 'undeserved pedestal' at the top of the evidence hierarchy and that other forms of research such as 'observational studies' should be taken more seriously in medical research. These comments are certainly appropriate for complementary medicine. Unfortunately Ernst and his co-author Singh both worship at the alter of the RCT and have used it to justify their conventionally critical positions of CAM. They are working from what Sir Michael calls "Hierarchies that attempt to replace judgment with an over-simplistic, pseudo-quantitative, assessment of the quality of the available evidence,'. If Prof. Ernst was to have a more open attitude to what constitutes 'evidence' he would have been able to have a more reasonable dialogue with CAM researchers and practitioners and could have engaged helpfully with them instead of giving himself a hard time and feeling 'got at'. Competing interests: I am a practising homeopath. |
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Peter R Mansfield, Director Healthy Skepticism Inc, .. 34 Methodist St, Willunga SA 5172, Australia
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One option that provides partial protection from the "enemies of reason" is to join Healthy Skepticism Inc: www.healthyskepticism.org
Competing interests: I am the Director of Healthy Skepticism Inc. |
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Noel B Thomas, Part time NHS GP Bron y Garn Surgery, Maesteg, Wales, CF34 9AL
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One of the reasons it is so depressingly difficult to have a friendly dialogue between the pro and anti parties is that we cannot always agree on what our choice of words conveys, and more importantly, whether we have chosen the correct words ourselves. Those who are upset at the claims made by chiropractors should remember what was first pointed out by James Cyriax 50 years ago, and still applies today. People in pain from spinal problems frequently have chest and adominal symptoms that mimic, for instance ,'grumbling' appendicitis, pleurisy, biliary and renal colic. Doctors make these incorrect diagnoses, and then fail to remove their patients' pain. The patients go to someone who manipulates their spine, cures them, and both parties assume that manipulation cures biliary colic , or whatever. Thus does confusion, and worse, arise. Whenever we wish to criticise another, be sure we are talking about the same thing. Often we are not. Competing interests: I have used homeopathy and spinal manipulation as a GP, for NHS patients, for many years |
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Neville W Goodman, Retired Anaesthetist Bristol, BS9 3LW, UK
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People who feel that their integrity or livelihood is threatened will always react, and sometimes unpleasantly. We can never stop such people writing letters, or conducting media campaigns, but reform of this country's libel laws would go a long way to taking much of the sting out of their efforts. Competing interests: None declared |
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Leslie B Rose, Clinical science consultant Salisbury, UK, SP2 8NJ
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While I might take issue with Sir Michael Rawlins' use of language, what he actually said bears some examination. He did not recommend ditching RCTs. He did question their generalisability, and on that I agree with him. Now what happens with orthodox medicines is that they are registered on the basis of RCT data, which have to show efficacy or no such registration is granted. After that, questions might be raised as experience is gained in the general population. What happens with CAM for the most part is that we don't see any good quality RCT data to support its claims. What we do see are claims based on uncontrolled observational data, and poor quality RCTs. This is a fundamental difference - RCTs are the bedrock, on which we build an edifice of evidence from other sources. The problem with most CAM is that it lacks foundations - one puff and it falls over. I am sure that Rawlins will agree that the controlled experiment is one of the key tools on which all of science is based. It is how we have learned what we know about the universe. The RCT is just one type of controlled experiment. If we say it isn't appropriate for whatever we are claiming, what does that say about our claim? Homeopaths presumably claim that an ultra-dilute (ie beyond Avogadro's number) solution has measurable therapeutic effects. Hardly anything could be easier to test, and has been so tested, with generally negative or inconclusive results. This is science. Competing interests: None declared |
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David Colquhoun, Research professor of pharmacology UCL WC1E 6BT
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I find quite astonishing the vituperation that is poured on Professor Ernst, simply because he assesses evidence with scrupulous fairness. The only people who would want to do that are those who don't like scrupulous fairness when it threatens to harm their income. Perhaps the homeopath, Stephen Gordon, should listen to what Michael Rawlins actually says, rather than the parody of it that has appeared in the media. He was referring to treatments that had already passed RCTs and saying that they should be followed up in the wider population of patients to see if they lived up to their initial promise. Homeopathic treatments have failed to show any initial promise when they have been tested properly. They can fairly be called the most discredited of all the widespread branches of CAM (I exclude crystal therapy and dowsing). For homeopaths, the game is up. That being the case it is not surprising that those who make a living from it have to resort to grasping at straws. I don't want to ban homeopaths, crystal therapists or any other sort of delusion, as long as they do no harm by pretending they can cure malaria or AIDS. I'm with Goldacre on this: these sorts of witchcraft can be thought of as a voluntary tax on the scientifically-illiterate Competing interests: None declared |
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Alexander S D Spiers, Professor of Medicine (retired). N/A.
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I applaud Professor Ernst for his courage and his outspoken denunciation of treatments that are not supported by proper scientific evidence. Indeed, when subjected to proper evaluation, such treatments are usually laughed out of court. Medical practice, and thus people's health, are under constant attack by unorthodox practices, treatments, and medications. A few of the many examples are as follows. ALTERNATIVE MEDICINE is particularly dangerous. Unproven therapy is recommended and orthodox therapies (e.g. for cancer or AIDS) are described as dangerous or inferior. The patient may decline orthodox treatment and may remain ill or even die. COMPLEMENTARY MEDICINE is less dangerous but is cynically dishonest. A variety of substances and treatments - usually expensive - are recommended to be used in addition to conventional treatment. This approach does not dissuade patients from receiving proper treatment, but defrauds them of significant amounts of money. IMPROPER USE OF THE TITLE "DOCTOR" is illegal in some jurisdictions and should be illegal everywhere. A "DOCTOR" should have a university degree at doctoral level, or in the case of holders of the MB;BS the title is a civil one conferred by law. Improper use of the title is outright fraud and can delude many innocent people. UNPROVEN PHARMACY is rife everywhere. Shelves full of "remedies" with dubious or no credentials can be found in a great many pharmacies. Magazines and the Internet are full of advertisements for such nostrums. Unfortunately, when medical professionals speak out against cancer quackery, acupuncture, reflexology, iridology, chiropractic, homeopathy, naturopathy or extraordinary dietetic measures they are apt to be accused of arrogance, cant, bias, blindness, or sheer financial self interest. In fact, individuals like Professor Ernst are stoutly defending the public interest. Competing interests: None declared |
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Stephen J Gordon, Homeopathy Practitioner Norfolk Clinic. Norwich NR3
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Homeopathy's arch sceptics Colquhoun, Ernst an Singh and others who cry 'EBM" make their attacks from within a large glass house. The quality of the evidence base for much of what is practised daily in the NHS is pretty poor. As the British BMJ Clinical Evidence so succinctly points out 'of around 2500 treatments covered 13% are rated as beneficial, 23% likely to be beneficial, 8% as trade off between benefits and harms, 6% unlikely to be beneficial, 4% likely to be ineffective or harmful, and 46%, the largest proportion, as unknown effectiveness' and ' most decisions about treatments still rest on the individual judgements of clinicians and patients.' (http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp) The NHS homeopathic hospital treatment centres that Colquhoun, Ernst an Singh are so desperate to close down are all staffed by medically qualified personnel. Furthermore, no patient attends those hospitals without referral from an NHS GP who has considered all the diagnostic and treatment options in front of him before doing so. Both categories of conventionally trained and qualified health practitioner together with their patients daily make the kind of clinical decisions that Prof. Sir Micheal Rawlins is calling for based on a range of unhierarchised evidence. There is a range of observational and experimental evidence for homeopathy which is very positive, admittedly RCT evidence is more difficult to establish. This is because RCT's are highly appropriate for the one drug-one disease/symptom approach of pharmaceutical medicine, the whole-patient individualised medicinal treatment approach of homeopathy is more difficult to research in the same manner though some good trials exist. I am sure that not for one moment did Sir Michael think he was defending homeopathy when he wrote and gave his speech but either the fundamental message he gave is appropriate for assessing all forms of treatment or it is not, I believe it is . Competing interests: I am a practising homeopath |
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Terry J Hamblin, Visiting Professor of Haematology University of Southampton SO16 6YD
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It seems to me strange that cancer patients who wish to pay for potentially effective treatments that have not yet been approved by NICE are charged for their NHS chemotherapy, while cancer patients who wish to pay for their definitely ineffective complementary treatment are encouraged to do so and retain their right to NHS chemotherapy. Competing interests: None declared |
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Andrew A G Morrice, GP and Homoepathic Physician St Chad's Surgery, Midsomer Norton BA3 2UH, and Bristol Homeopathic Hospital BS6 6JU
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The last three years have seen a constant stream of articles and books stating categorically that there is no evidence for homeopathy. Edzard Ernst is not the only one feeling frustrated and upset by this sterile and overblown debate, but at least he can comfort himself that he has helped to set its terms. Those of us who have also read the evidence but happen not to agree are also feeling frustrated: that our points seem hard to get across inthe professional and lay media. By contrast, the wilder and more unpleasant responses of anti-science members of the (non- medical) homeopathic community are noted and cited with great care by Goldacre, Ernst and their fellow travellers. This current period of anti-CAM and anti-homeopathy campaigning began with the Shand et al paper in 2005 (1). This was intriguingly presented to the press as the “first” systematic review of homeopathy. The original study design was useful, but the final analysis was arrived at on unspecified grounds, comparing unidentified trials and should surely be treated with caution. These flaws were obvious to anyone who didn’t assume a-priori, that its findings must be correct. It is surprising to see self styled defenders of science and objectivity basing categoric statements on such a foundation, whilst simultaneously ignoring the mixed findings of the meta-analyses that preceded it. (2, 3, 4, 5, 6) It can only be a matter of time before detailed analysis of the problems with the Shand et al study appear in the research literature. Dare we hope this will lead to at very least a toning down of the rhetoric that characterises this debate? There are deep seated problems besetting medicine at present, and such challenges cannot be met by reverting to simplistic and entrenched positions on anyone’s part. It can only be hoped that we will soon see a broadening of the polarising agenda set by Professor Ernst and many of those who agree with him (many are rapid responders to, or cited in, his letter). Only when this occurs can we have a fruitful discussion of placebo, CAM, integrated care, and the challenges of creating and interpreting evidence relevant to the wide ranging needs of our patients. 1) Shang A, Huwiler-Müntener K, Nartey L, et al. Are the clinical effects of homeopathy placebo effects? Comparative study of placebo- controlled trials of homoeopathy and allopathy. Lancet 2005; 366: 726-32. 2) Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997; 350: 834-43 3) Cucherat M, et al. Evidence of clinical efficacy of homeopathy. A meta- analysis of clinical trials. Eur J Clin Pharmacol 2000; 56: 27-33. 4) Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy. Br Med J 1991; 302: 316-23 5) Linde K, Melchart D. Randomized controlled trials of individualized homeopathy: a state-of-the-art review. J Alter Complement Med 1998;4: 371- 88 6) Boissel JP, Cucherat M, Haugh M, Gauthier E. Critical literature review on the effectiveness of homoeopathy: overview of data from homoeopathic medicine trials. Homoeopathic Medicine Research Group. Report to the European Commission. Brussels 1996, 195-210. A list of reference of papers on homeopathy research can be found at http://www.trusthomeopathy.org/case/res_toc Competing interests: I don't consider practicing both as a GP and as a homeopathic physician to be competing interests, but I declare them anyway! |
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Ann C Homer, GP Newcombes, Crediton EX17 2AR
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It is not right that Professor Ernst is bullied for providing some clear-sighted evaluation of CAM. I rely on his assessments to know what might help and what is not safe for patients to carry on with. Who would do this if he did not? His work, and those who challenge unsupportable claims, deserve our support. Competing interests: None declared |
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Amanda Jones, Consultant Obstetyrician & Gynaecologist and Foundation Programme Director Pennine Acute Trust M8 6RB
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Self justification drives us all. It is why, whether you are an alternative practitioner or traditional physician, you will believe that, since you are a kind and caring person, what you do is in the best interest of your patient. I recommend everyone to read 'Mistakes were made (but not by me)' by Carol Tavris and Elliott Aronson. It explains the response by alternative practitioners, and also all of us who justify what we are doing, when at times what we do does not have the evidence base to support it. But we KNOW that it helps our patients! Competing interests: None declared |
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Dylan Evans, Lecturer School of Medicine, University College Cork, Ireland
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The cavalier attitude towards evidence adopted by so many of the proponents of Complementary and Alternative Medicine (CAM), and which Professor Ernst has documented, is a cancer that must be removed from the body physic. The attitude of some proponents of CAM seems to be that, if certain forms of alternative therapy are not proven to be effective, the problem must lie, not in the therapies themselves, but in the standard methods of scientific research. If clinical trials cannot prove that acupuncture is no better than a placebo, then there must be a problem with the methodology of clinical trials. Perhaps the effects of acupuncture and other alternative methods are too ‘subtle’ for the ‘reductionist approach’ of orthodox medical research. Sometimes, this argument takes on almost mystical overtones, in which the materialist approach of Western medicine is contrasted unfavourably with the spiritual sensitivity of the various alternatives. The implication is that people holding different different views cannot engage in rational debate. Doctors and alternative therapists must simply agree to differ, because they work in different paradigms. Evidence and argument are completely abandoned. Clearly, this is not a recipe for progress. If we wish to heal the rift between orthodox and complementary medicine, we must begin by finding some common ground, and the methodology of the clinical trial is the perfect candidate. Contrary to what some have claimed, the clinical trial is not ‘biased’ towards any particular school of thinking in medicine. It is grounded in very basic ideas about evidence that would, in any other context, hardly be in dispute. The principles of the clinical trial are really just common sense writ large. Whether applied to tasting tea or testing medicine, they involve no special commitment to any particular ‘paradigm’. I was greatly heartened by Professor Ernst's letter to the BMJ. I hope he keeps up the good work, and doesn't let the harassment get him down. Competing interests: None declared |
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