Assaulting alternative medicine: worthwhile or witch hunt?
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e1075 (Published 15 February 2012) Cite this as: BMJ 2012;344:e1075All rapid responses
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We all agree that the placebo effect exists. This is one important reason for doing well designed randomised control trials – to try to detect an effect greater than the placebo effect, as well as to eliminate in one study other biases such as selecting patients more favourably for a treatment and minimising the effects of chance.
The paradox is that to benefit from a placebo effect, the patient has to believe that it is not just a placebo effect. This requires an element of deception or ignorance, which open and honest people find distasteful. They also find deception on the part of those who purposely exaggerate the benefit of drugs that do better than placebo equally distasteful.
So the real question to my mind is an answer to a paradox: Can a benefit be provided by using a placebo effect that depends on an element of deception or ignorance without involving deception or ignorance?
Competing interests: No competing interests
David Colquhoun's ad hominem response to my input here not only misrepresents me, but would suggest he lacks reasoned and substantive response to my arguments.
I do not work "on behalf of companies producing Complementary Medicines". As disclosed, "I have been paid for GP education (most RACGP approved) on behalf of companies producing Complementary Medicines".
These are very different. Education has to be funded, whether from the public purse (in the case of Prof Colquhoun) or from a sponsor (in my case, working in private practice). CM companies who do not support independent education are bitterly criticised. Now those that do are similarly criticised.
On the statement, "I can see no evidence of his activities in PubMed", David has been less than thorough! Although a GP, I have 4 original, peer-reviewed papers to my credit in PubMed, including one widely discussed a few years back in the BMJ regarding evidence-based medicine.
And regarding the final statement, "Judging by the quality of the evidence produced by the companies that support his web site, it seems he hasn't been very successful", I can only say that no companies support my web site. How David managed to judge the quality of evidence of non-existent companies escapes me.
Further, I believe I have a reasonable claim for success in terms of formal RACGP feedback of doctors attending the workshops and lectures I have provided over those years.
David's inexperience in clinical medicine may underpin his poor understanding of how patients respond to treatment, much of which is minimally evidence-based. Clinicians have been taking credit for ineffective and sometimes harmful treatments for centuries, and the practice continues with unnecessary antibiotics, antidepressants and much of surgery to this day.
We are all working towards better care of our patients. EBM is not a goal in itself. It is a method. A tool. Evidence-based practice (EBP) is a collaboration between practitioner and patient, informed by EBM, but not a slave to it.
As clinicians, we need a broad education of all available modalities in order to engage with the patients who increasingly request advice on non-orthodox modalities. Denying the right of those modalities to exist within Universities and the research community will not make them disappear. It will drive them from the University to shadier places to the detriment of all.
EBM is not the only tool, David.
Competing interests: I have been paid for GP education (most RACGP approved) on behalf of companies producing Complementary Medicines. I am a director of CEBCoM (the Centre for Evidence-Based Complementary Medicine) in Sydney, Australia
In the current scientific context it is well established that a situation of initiative is health enhancing, while in adverse situations it is pathogenic to be in a state of submission when typically fighting or fleeing are impossible. Resorting to alternative medicine is to put oneself in a state of initiative. It is usually associated with the belief that the chosen modality of alternative medicine is valuable (belief that may be shared by the practitioner). It is therefore easy to explain how the combination of state of initiative and placebo effect can have positive effects undetectable via randomised controlled trials.
Competing interests: No competing interests
I have already written an extensive review in Advances in Psychiatry 2009 on the subject of 'natural remedies'. It is easy to find on Google and is entitled The Natural Health Service: natural does not mean safe.
Competing interests: No competing interests
I have been practising treatment of some diseases with honey for about 12 years. I have no idea about other forms of alternative or complementary treatments. I have come to the following conclusions:
1. Why do people seek alternative treatment? We have to acknowledge that modern medicine has failed to heal many diseases. Healing means cure and not just alleviation of symptoms. Cure means getting rid of an ailment or ailments leaving an intact body. Intact body means intact anatomy and function. Not all treatments are healers but all curatives are healers. We have to admit that modern treatments are not curatives in all cases.
2. Modern medicine does not admit or recognise anything which is not evidence based. This is right. However what is the mechanism or mechanisms underlying the so called “a placebo effect of a drug”? What is the physical pathway for its expression? Nobody knows.
3. Based on my personal experience of using honey as an alternative treatment, I have found that most patients will also need the modern medicine for treating their symptoms. A very common example is fever. Although the duration of a febrile illness might have been shortened with honey yet the fever may have initially increased. Therefore most parents request prescribing antipyretics and others do not tolerate such initial reaction and shift to the traditional (modern) medicine.
4. A lot of money has been spent on investigating the effect of a drug through different phases of trials. Ultimately a drug has been proved effective and relatively safe; but for how long? After years of using a drug, we discover that this drug is toxic.
In conclusion: “Not everything should be materialistic; otherwise we should see the electrons”
Competing interests: No competing interests
Sir,
As Ray Moynihan’s article says, university departments where complementary (please, don’t call them ‘alternative’) therapies can be properly taught and studied are the proper base for the kind of critical practice and evaluation they so obviously need. Though it takes time to grow research capacity and build bridges between disciplines, unless we succeed how will science come to accept (or finally reject) the potential of complementary therapies?
David Colquhoun and Sense About Science rightly emphasise complementary therapies’ obvious limitations, and remind us that any poorly educated practitioner (though not only the complementary sort) is a danger to the public. Fifteen years ago Westminster was one of the first universities to take complementary therapies seriously, and to explore how they might augment (rather than replace) everyday medical care. This entails educating a high calibre of practitioners who can think critically, practice safely and engage with the wider scientific and medical community.
It seems Australia’s Friends of Science in Medicine believe that David Colquhoun’s very personal campaign against UK universities teaching complementary therapies has forced them to close their complementary therapy degrees. Ironic then, that his recent Telegraph article trumpeting responsibility appeared on very day when news broke that as tuition fees kick in, and with the economy in a tailspin, applications across all English university courses have dropped by 10%.
It is tempting to reduce complex phenomena – whether health or university recruitment - to oversimplified basics, and then apply single solutions. The pharmaceutical industry – like Professor Colqhoun no friend of the complementary therapies – could be accused of doing just that. These negative campaigns are giving complementary therapies a bad name, but to whose benefit? Surely their popularity should make us curious about medicine’s deficits and downsides, ready to ask some important questions about medicine’s sustainability, and how doctors can better support health and resilience. At a time when conventional healthcare is struggling with soaring costs and adverse events, unable to cure a pandemic of chronic disease, and arguable faces a declining commitment to traditional values of care and the art of medicine, these are matters of real significance.
Professor David Peters
Clinical Director
School of Life Sciences
University of Westminster
115 New Cavendish St
London W1W 6UW
Competing interests: I am a medical doctor, researcher and an osteopath working in a university department where complementary therapies are taught and researched
Whether we like it or not, there is always likely to be a demand for Complementary and Alternative Medicine (CAM). Anecdotally at least, many patients feel they gain benefit, and since this is usually privately funded, I generally have little objection. Things have moved forward in the UK in recent years with the majority at least now having some statutory regulation. Some of these practitioners study in private institutions, and some in universities. The question raised is whether they should be allowed to study in university.
The instigators of this so called witch hunt presumably feel that this lends false credence to what they feel are entirely unscientific non-evidence based approaches. However whether this makes any difference to the users of CAM is debatable. Many of the users of CAM may well care little about scientific principles and university degrees. However it could be argued that by incorporating these courses into universities as academic degrees, the courses will at least be based on some scientific principles, the students and faculty will be exposed to other academic disciplines, and faculty and students are more likely to engage in academic debate, and perhaps even question their own approaches. Surely this is better than simply attempting to marginalise them academically, which I suspect will have little influence.
Competing interests: The author practiced as an osteopath prior to training in medicine.
It's hard to understand the relevance of the comment by Ron Law. In case he hasn't noticed, medicine has moved on since 1542 (though herbalism has changed remarkably little).
SSRIs seem to be almost ineffective for mild/moderate depression, but they are still thought to be useful in serious depression. That doesn't mean that all products of Big Pharma are ineffective. As always when faced with someone who suggests some sort of parity between the alternative industry and real medicine, I ask if they decline general anaesthetics for surgery or local anaesthetics at the dentist.
It isn't at all clear what Ron Law means when he talks about the "battle of the paradigms". One paradigm is science. What's the other? Making stuff up?
Competing interests: No competing interests
There are many observations that any observant physician will pick up, which are not explained in the blinkered realms of Newtonian physics, and Einstein is the next step, but not the whole. Whilst the whole will never be achievable, stopping within the bounds of conventional science will be encouraged if wider medical thinking is restricted in this way.
Competing interests: No competing interests
Re: Assaulting alternative medicine: worthwhile or witch hunt?
The Friends of Science in Medicine are concerned that teaching pseudoscience puts patients at risk suggesting that real science and medicine does not. This smacks of arrogance and delusions of self grandeur. Let us not forget that in 2006, that an estimated 7% of admissions to hospitals in the UK were due to the adverse effects of medications prescribed by doctors. We should be more humble and accept that there are other therapists that can heal or complement the work of the physician in the healing process.
If all these complementary and alternative are pseudoscience then are we conventional doctors practising science? Medicine is an art – it is the art of healing and involves both physical and emotional healing and takes into account knowledge of all aspects of environmental factors, which are often intertwined. This is what is meant by holistic or integrative medicine.
The skills that doctors have lost are the ability to listen and empathise with our patients due to outpatient clinics and GP surgeries being under severe time constraints resulting in a supermarket situation: get them in and out as quickly as possible with the minimum of communication addressing the patients concerns.
Why do patients go to complementary therapists in the first place? For exactly the reasons given above. They want to be listened to and their concerns understood. They don’t want a physician who hardly looks up from his computer and is only interested in extracting the prescription from the printer so he can get rid off this patient and move on to the next one in the queue. Remember the quotation of William Osler ‘care more for the individual patient than the special features of the disease’
As has already been pointed out much of our conventional medicine is not evidence based. As a practising oncologist, the treatment of malignant melanoma with the chemotherapy agent has never been shown to be superior to no treatment in pr longing survival. So before we attack other therapists for not being evidence based , we need to be sure that we are.
The purpose of universities is to pass on knowledge from one generation to the next and to encourage thinking that leads to further questions and the quest for answers to these questions. This research is how we gain knowledge. If there are courses in complementary therapies, these will stimulate thinking into further research which in turn will lead to evidence which therapies have true potential and those which don’t. You can’t move forward in understanding if you refuse to look into a subject because of your predetermined bias that it is all pseudoscience.
Competing interests: No competing interests