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How concerned should we be about offending each other? And what degree of offence is acceptable? I am talking about how each of us practise, about the basis for the clinical decisions we make.
The issue came up recently when a journalist picked up on a motion in the agenda for June’s BMA annual representative meeting.
The motion was one of a common ARM genre, the mix of mischievous wording and genuine concern. It proposed that homeopathic medicine would be more appropriately regulated by the Magic Circle than the GMC.
It wasn’t debated. Any BMA division or committee can put motions forward, and there were more than 900 motions on the agenda this year. So the elected agenda committee chooses which ones will be debated, with a further opportunity for doctors at the meeting to vote on other motions they would like to be heard. Only a small minority can be considered, and even those take us four solid days.
The homeopathy motion was marked in advance as one very unlikely to be debated, but that doesn’t stop the annual game the media play in finding the most eye-catching proposals. We can’t really begrudge it. The ARM gets excellent media coverage and this is part of the risk we take for it.
Although not debated, the motion and report of it caused offence to some doctors who practise homeopathy, and I’d like to say sorry to those colleagues and fellow members who responded in this way. It echoed similar complaints five years ago when a doctor at a BMA conference compared it to witchcraft.
BMA policy is that the NHS should not fund homeopathy because it has an inadequate evidence base. You may or may not agree with that, but what I’m interested in asking you is whether it’s legitimate to go hard at each other’s practice when we disagree on its rational basis.
There are many drugs and treatments in the NHS that have never been through a randomised control trial, and we use them because they seem to work and perhaps we were taught they were good. Sometimes we don’t even know why they work, or we suspect they are a placebo. Following this argument, the first two and a half millennia of medicine wouldn’t have been out of place at the Magic Circle.
Should we be even-handed in our swipes at non-evidence based medicine? And should we only be attacking – or trying to resolve – the lack of evidence base rather than the practitioners themselves?
I’m a rationalist, possibly to a fault, and I enjoy a good argument. But I’ve seen the way that a rather larger evidence-based debate has progressed in recent years. A number of atheist writers have taken a more strident tone, and their attacks on faith communities have become quite personal and aggressive. I’m not sure who is benefiting from the debate, except a few publishers.
This is a debate about tone rather than free speech. Not that free speech has ever been an absolute right. The law has its own restrictions and the GMC used to have its own strictures about playing nicely, warning against the ‘disparagement of professional colleagues’.
It was meant as a way of maintaining the dignity of the profession and stop us sniping at, or competing with, each other. By the time it was ditched in the 1990s, there were concerns that it was too vague, and may have discouraged doctors from speaking out about colleagues’ performance issues. But we remain enjoined to ‘treat colleagues fairly and with respect’.
I’m not asking so much whether we should be able to offend, but how and in which circumstances should we should do so.
Have you been the subject of what you considered personal attacks about the way you practise medicine? Is everything and everyone fair game in the pursuit of evidence-based medicine? Are some areas of medicine unfairly singled out?
I’d like to hear your views, and please don’t worry about causing offence.
Ad hominem commentary is always best avoided.
In the case of ARM 2015 motion 338 (in which I had no hand), members of the Magic Circle might also have been offended - except that TMC does not regulate anything, and members of TMC do have a sense of proportion - and a sense of humour.
The Agenda Committee might reasonably have declined motion 338's submission on the grounds of incompetence.
BMA policy (in which I did have a hand) was specifically worded to focus on homeopathic remedies (not practitioners) and to call for NICE to assess the remedies' cost-effectiveness.
'Tu quoque' concerns about other medicines and remedies are irrelevant in giving consideration to homeopathy, and a logical fallacy in the arguement about the effectiveness of homeopathic remedies.
That spending time in a constructive therapeutic relationship with an empathic practitioner provides some patients with benefit (by their perception) is not in dispute.
Nevertheless the question has to be asked: "How can a sincere practitioner be distinguised from one who is deluded about the evidence base for homeopathy; from one who is knowledgeable, but a quack seeking to taking advantage of gullible and vulnerable patients; from a fraud who wishes to gain financial advantage from the funders of homeopathic remedies - whether the NHS, insurance companies or private individuals?"
The Royal Australian College of GPs has considered these matters and in May 2015 advised: â€˜GPs should not prescribe homeopathic remedies for their patients and pharmacists should not sell or recommend the use of homeopathic products. GPs practise evidence-based medicine and there was robust evidence homeopathy had no effect beyond a placebo as a treatment for various clinical conditions.â€™
I urge the Faculty of Homeopathy to organise proper double (if not triple) blind trials to answer "What effects of homeopathic remedies are greater than those achieved by placebo homeopathic remedies (same lactose pillules, same containers, same therapeutic regimes, but not having been exposed to homeopathic preparation)?"
Well into the ninteenth century homeopathy was regarded by many as both witchcraft and magic. If that opinion lingers, so be it.
Member of The Magic Circle.
In his comment (7 August), Richard Rawlins urges the Faculty of Homeopathy to organise proper double- or triple-blind trials to answer the question, "What effects of homeopathic remedies are greater than those achieved by placebo homeopathic remedies?" Readers should be aware that, through the British Homeopathic Associationâ€™s recent systematic review of randomised placebo-controlled trials (RCTs), we already have a preliminary answer to this question : for a broad spectrum of medical conditions, a person randomised to receive an individually prescribed homeopathic medicine is nearly twice as likely to have a positive treatment effect as a person randomised to receive placebo. That paperâ€™s key conclusions were: â€œThere was a small, statistically significant, treatment effect of individualised homeopathic treatment that was robust to sensitivity analysis based on â€˜reliable evidenceâ€™. The overall quality of the evidence was low or unclear, preventing decisive conclusions. New RCT research of high quality on individualised homeopathy is required to enhance the totality of reliable evidence and thus enable clearer interpretation and a more informed scientific debate.â€ Researchers worldwide, including Faculty of Homeopathy practitioners, are therefore focusing ever more sharply on building a reliable evidence base that quantifies the clinical effects of homeopathic medicines.
1. Mathie RT, Lloyd SM, Legg LA, Clausen J, Moss S, Davidson JRT, Ford I. Randomised placebo-controlled trials of individualised homeopathic treatment: systematic review and meta-analysis. Systematic Reviews 2014; 3: 142.
Dr Mathie's internet paper (which was not peer reviewed) is of interest, but BMA members who are concerned about the use of homeopathic remedies in the NHS should review the opinion of Professor Edzard Ernst:
Amongst his comments: "Since my team had published an RCTs of individualised homeopathy, it seems only natural that my interest focussed on why the study (even though identified by Mathie et al) had not been included in the meta-analysis. Our study had provided no evidence that adjunctive homeopathic remedies, as prescribed by experienced homeopathic practitioners, are superior to placebo in improving the quality of life of children with mild to moderate asthma in addition to conventional treatment in primary care."
And: "Some nasty sceptics might have assumed that the handful of rigorous studies with negative results were well-known to most researchers of homeopathy. In this situation, it would have been hugely tempting to write the protocol such that these studies must be excluded. I am thrilled to be told that the authors of the current new meta-analysis (who declared all sorts of vested interests at the end of the article) resisted this temptation."
Dr Mathie should know that the scientific method requires a hypothesis to be couched in terms: "there is NO difference in outcome for patients treated with remedies prepared by the homeopathic preparation (HP) method and identical remedies lacking the HP method."
Research is then carried out to disprove this null hypothesis.
Dr Mathie seems to start from the premise that HP remedies have effects on specific conditions above those of non HP remedies (placebos) - and he identifies research which prooves that hypothesis. I am sure he did guard against cherry picking results, but cannot identify how he did this.
I again call for medical members of the FoH to audit the outcomes for their patients who receive HP remedies (how many receive, but report no benefit/report benefit).
Also, to carry out research: Having completed the (lengthy) consultation, to have their patients randomised (blindly to both patient and practitioner) to a group which receives the remedy as prescribed or receives pillules identical in every way (appearance, size, colour, labelling), but not having been prepared by the HP method (true placebos).
The outcomes could easily be assessed blindly by an independent homeopath (Triple blind research). Even by internet questionaire.
If no significant difference could be demonstrated between the two groups, homeopaths could assure their patients they offered powewrful placebos, but could save considerable funds by declining to prescribe HP remedies.
Have such trials been conducted?
If not, why not?
When I joined my practice homeopathy was openly ridiculed and I was scorned and criticised. After some 5 years the most scornful of my partners had the grace to say he felt patients deserved to receive homeopathy on the NHS.
Goetzsche's recent appraisal of psychiatric medication  shows there are widely divergent views on well established treatments which seem to have become established on the basis of questionable scientific evidence. They bear significant costs to the health economy together with risks of significant harm to patients without evidence of sufficient benefit.
Homeoapthic medicines are contrary in being cheap, effective, popular and established with minimal side-effects. No homeopathic medicine has required withdrawl in 200 years of post marketing surveillance. There is reputable RCT and meta-analysis evidence of their effectiveness over placebo as referenced by Mathie in the earlier comment. Homeopathic Medicine works with the placebo effect (a derogatory term for the body's innate ability to heal) and many doctors have found Homeopathy training has enhanced their non-specific consultation effectiveness with patients, whilst simultaneously reducing their risks of burnout. Which practitioner would reject these personal benefits in the currently challenging times of severe media and political 'Doctor-bashing' ?
Rawlins' convoluted and incomprehensible question in his 4th paragraph above appears to be a declamation. The Royal Australian College of GP is to be forgiven for taking a review report with multiple methodological flaws as a sound basis for any advice.
The single medicine for a specific disease model of healthcare is considered obsolete in today's tragic chronic multimorbidity & polypharmacy world . The WHO has recently identified patients need patient centred care rather than more drugs.
This is something Homeopathy can provide.
Let's not hark back to the dark ages when the magic circle ran leech factories for doctors!
Aw gawd Ernst has been identified as biased against Homeopathic Medicine.
Professor Hahn - Research Director, SÃ¶dertÃ¤lje Hospital, stated quite clearly in his 2013 paper:
Clinical trials of homeopathic remedies show that they are most often superior to placebo.
Researchers claiming the opposite rely on extensive invalidation of studies, adoption of virtual data, or on inappropriate statistical methods.
Thank you for your apology. It was offensive and I appreciate you separating out the argument in relation to evidence from the personal derogatory language .
Interesting that i find myself checking whether i feel completely safe even to make these comments due to the personal abuse that has followed comments in other settings.
Richard Rawlins (10 August) is entitled to his own opinions but he is not entitled to make up his own facts about the British Homeopathic Associationâ€™s recent systematic review of randomised placebo-controlled trials (RCTs). Firstly, our paper was fully peer-reviewed in the normal way for an academic journal, including one that is published online. Secondly, our statistical analysis tested the null hypothesis that, for the broad spectrum of medical conditions that have been researched, the main outcome of individualised treatment using homeopathic medicines is not distinguishable from that using placebos. Our finding disproved this null hypothesis in favour of the alternative: that individualised homeopathic medicines may be distinguishable from placebos (i.e. they may have small, specific treatment effects). The results were robust to sensitivity analysis based on reliable evidence (and with or without including Edzard Ernstâ€™s asthma trial). No â€˜cherry pickingâ€™ took place, as befitting normal scientific method and collaboration with a university department of statistics.
Richard Rawlins seems to be unaware of the several clinical outcomes studies in which Faculty of Homeopathy doctors have participated and had published [e.g. 1, 2]. And he seems oblivious to the fact that the above systematic review and meta-analysis examined precisely the type of RCT that he is rightly commending; and its results were cautiously positive, as described.
1. Spence D, Thompson EA, Barron SJ. Homeopathic treatment for chronic disease: a 6-year, university-hospital outpatient observational study. J Altern Complement Med 2005; 11: 793â€“798.
2. Thompson EA, Mathie RT, Baitson ES, Barron SJ, Berkovitz SR, Brands M, Fisher P, Kirby TM, Leckridge RW, Mercer SW, Nielsen HJ, Ratsey DHK, Reilly D, Roniger H, Whitmarsh TE. Towards standard setting for patient-reported outcomes in the NHS homeopathic hospitals. Homeopathy 2008; 97: 114-121.
Dr Andrew Sikorski (a homeopath) drags red herrings into this threadâ€™s discussion of the value of homoeopathically prepared (HP) remedies. The value of other preparations and medicines is worthy of critique, but this thread is about homeopathy; HP remedies; whether it is disrespectful to have fun at colleaguesâ€™ expense; and whether they should take offence should they perceive such an intent.
Andrew refers to HPs â€˜minimal side-effectsâ€™ and advises us: â€˜No homeopathic medicine has required withdrawal in 200 years of post marketing surveillance.â€™ Could that be because no HP remedy has any effect?
Oh, and the term â€˜placeboâ€™ is not derogatory - it is how homeopathy consultations have their beneficial effect.
I am sorry if Andrew found the question in my fourth paragraph incomprehensible. I simply want to know how anyone, BMA member or patient, can distinguish between a sincere practitioner, a knowing practitioner who is a quack, and a practitioner who, being a quack, also seeks to defraud? What is the answer?
And please be advised: The Magic Circle was founded in 1908 for entertainers. It has never â€˜run leech factoriesâ€™.
Turning to Dr Mathie - I used the term â€˜peer-reviewedâ€™ in the sense that â€˜peer-reviewed (refereed or scholarly) journals publish articles which are written by experts and are reviewed by several other experts in the field before the article is published in the journal in order to insure the article's quality.â€™ Mathieâ€™s paper (not those to which his paper refers) was published in Systematic Reviews. This journal charges Â£750 to publish a â€˜Reviewâ€™ article.
The on-line journalâ€™s policy states: â€œSystematic Reviews operates using an open peer review system, where the reviewers' names are included on the peer review reports... All previous versions of the manuscript, and all author responses to the reviewers are also available to readers.â€
One (of two) peer reviewers, Dr Raghupathy Anchala (an Indian chest physician) is not an expert in homeopathy (and therefore, not a peer) but asserts: â€œThe author's research methodology provides means to answer the research question succinctly. The findings are appropriate and reasonably stated.â€ Not so. Even Mathie only claims his conclusions â€˜mayâ€™ demonstrate a demonstrable effect. And these were not â€˜research findingsâ€™ - his paper was a review of research by others.
Mathieâ€™s paperâ€™s stated hypothesis was: â€œWe tested the hypothesis that the outcome of an individualised homeopathic treatment approach using homeopathic medicines is distinguishable from that of placebosâ€ - contrary to the re-worked hypothesis he states in this blog. His conclusion was that â€œhomeopathic medicines may be distinguishable from placebosâ€ - not that they are distinguishable. Anything â€˜may beâ€™ - the purpose of science is to determine whether and to what extent.
The second peer-reviewer was Dr Wayne Jonas, an American MD and homeopath, who served as Director of the Office of Alternative Medicine at the National Institutes of Health from 1995 until 1999 and has published many papers supportive of homeopathy. Even though he is hardly un-biased, he identified 14 problematic issues with the paperâ€™s first draft, and stated: â€œI do not feel adequately qualified to assess the statistics.â€ And when commenting on Mathieâ€™s re-submission: â€œNo, the manuscript does not need to be seen by a statisticianâ€ - even though Mathieâ€™s paper is based on statistical analysis.
I cannot regard Dr Mathieâ€™s paper as being â€˜peer-reviewedâ€™ in any meaningful sense.
Mathie quotes Spence et alâ€™s paper (from the Journal of Alternative and Complementary Medicine) - but that was simply an â€˜observational studyâ€™ on 6544 patients, all of whom received HP remedies. Spence stated â€˜Comparison groups were not included by design.â€™
Lickert analysis of patient questionnaires assessed the value of the homeopathic consultation, but this was not distinguished from the value of the remedy.
The paper from Thompson, Mathie et al was designed to set â€˜standards for patient-reported outcomesâ€™. The stated â€˜aimâ€™ was not to identify the extent to which HP remedies provide any outcome greater than that for comparable patients and conditions receiving non-HP remedies. (Selection bias can be catered for by having a large enough group - as stated in Spenceâ€™s paper). Thompson, Mathie et al concluded â€œOur results are inconclusiveâ€¦we cannot recommend undertaking a further trial addressing this question in a similar settingâ€.
I remain unable to identify any paper which has patients randomised (after consultation) to receive HP remedies or identical but non-HP remedies, with both homeopath and patient blinded. Pleae advise if such exist.
The jury is not out. It has returned, and the answer is that there is no plausible evidence HP remedies obtain outcomes better than those achieved by non-HP remedies (identical containers and appearance, but pure lactose pillules). Unless and until NICE determines otherwise, BMA policy should stand: HP remedies should not be used in the NHS.
It is hardly surprising that registered medical practitioners who persist in claiming HP remedies do have effects greater than could be achieved by declared placebos lose the respect of colleagues. However, mickey taking in ARM motions is to be deprecated and should be diluted - to homeopathic levels.
Rawlins doth protest 'too much'- he previously stated magic circle members have a sense of humour, perhaps this requires re-visiting:-)( although being retired from clinical practice for some time does apparently offer the time to ruminate and 'fester'? I can't wait for these pleasures myself!
Peppering prose with personal opinion, anecdote and: 'should'; 'must'; 'ought to' would suggest a declamation is being delivered from no less than the GMC. Ho ho. Rawlins could do worse than look to GMC guidance regarding respect of colleagues as his comments seem to be singularly lacking
Around 40,000 deaths from prescription drugs are not being reported to regulators in the US. In addition, 120,000 cases of â€˜serious adverse reactionsâ€™â€”including disability, birth defects and life-threatening problems needing emergency careâ€”are also going unreported.
In all, around 10 per cent of serious adverse reactions, including death, are not being reported to Americaâ€™s drug regulator, the Food and Drug Administration (FDA), within the statutory 15-day time-frame, if at all.
The under-reporting seems to be the fault of the drug company as much as the doctor. In fact, mechanisms within drug companies appear to be in place that delay the reporting, or conceal it altogether.
Researchers from the University of Minnesota school of medicine say they have uncovered â€œstriking evidenceâ€ that drug companies delay the reporting of serious adverse reactions to the FDAâ€”and especially if the patient has died.
The number of unreported adverse reactions also includes those classified as â€˜unexpectedâ€™, in which the patient suffered a reaction that has not before been noted.
(Source: JAMA Internal Medicine, 2015; doi: 10.1001/jamainternmed.2015.3565)
Regrettably, Richard Rawlins (12 August) continues to make up his own facts about our peer-reviewed paper in the journal 'Systematic Reviews' and about the publishing approach of open-access academic journals. Anyone who works in the field of systematic reviews will be fully aware of the gravitas of this particular journal (www.systematicreviewsjournal.com/).
Consistent with its ethos, and reflecting the subject matter of our paper, the journal editors obtained peer-review input from experts in relevant disciplines: Dr Raghupathy Anchala has a track-record in RCTs and meta-analyses; he recently worked at the Cardiovascular Epidemiology Unit at the University of Cambridge. Dr Wayne Jonas is one of the worldâ€™s leading researchers in Complementary Medicine; he is also expert in systematic reviews. Clearly, our paper was meaningfully peer-reviewed.
As regards Richard Rawlinsâ€™ continuing inability to identify any paper that randomised patients of individualised homeopathy 'to receive HP remedies or identical but non-HP remedies', I can only repeat my answer (11 August): our systematic review and meta-analysis paper examined precisely this type of published RCT.
I am grateful for Dr Mathieâ€™s further assistance in helping my (and I daresay many BMA membersâ€™) understanding of these issues, but I must quote directly from the paper to which he refers: (Mathie RT, Lloyd SM, Legg LA, Clausen J, Moss S, Davidson JRT, Ford I. Randomised placebo-controlled trials of individualised homeopathic treatment: systematic review and meta-analysis. Systematic Reviews 2014; 3: 142). In â€˜Discussionâ€™ he states:
â€œTwenty-nine of the 32 trials had unclear or high risk of bias in important domains of assessment. Poor reporting or other deficiencies in the original papers prevented data extraction for meta-analysis from 10 of the 32 trials; the potential influence of the 10 on our overall meta-analysis is unknown, but because of their intrinsic low quality, their absence does not alter our principal conclusions. High and unclear risk of bias featured almost equally in our 22-trial analysis; thus, the overall quality of analysed evidence was low or unclear, necessitating caution in interpreting the findings.
As was the case for the previous â€˜globalâ€™ systematic reviews of homeopathy RCTs that have included meta-analysis, there are obvious limitations in pooling data from diverse medical conditions, outcome measures and end-points. Thus, a given pooled effects estimate here does not have a clear numerical meaning or relative clinical value: it is a summary measure that enables statistical significance and mean â€˜effect sizeâ€™ to be attributed and to be interpreted in testing an hypothesis that individually prescribed homeopathic medicines have specific effects.
Though our conclusions can be made most securely from three trials with reliable evidence, this sub-set of studies is too small to enable a decisive answer to our tested hypothesis.â€¦..
Two of the three trials with reliable evidence used medicines that were diluted beyond the Avogadro limit. Our pooled effects estimate for the three trials, therefore, is either a false positive or it reflects the relevance of new hypotheses about the biological mechanism of action of homeopathic dilutions It should also be noted that one of these same three trials displayed evidence of vested interest. It remains to be seen if our assessments of model validity support or refute the legitimacy of these three trials as currently the most important contributors to the evidence base in individualised homeopathy.â€
I am obliged to repeat my request for Dr Mathie to identify which papers (if any) in his meta-analysis answer the question I pose:
What evidence is there for HP remedies having effects greater than those achieved by non-HP remedies?â€
Or, in commercial terms, (noting manufacturers of HP remedies make large profits): â€œWhat is the value to patients, what is the point of, HP remedies?â€
The answer would appear to be - â€œnoneâ€.
I'm not getting into the homeopathy debate, but what I would like to say is this piece exemplifies the best in medicine. It's thoughtful, courteous and yet challenging. Well done Dr Porter. You sound like my best lecturer at Guy's all those years ago.
Dr Rawlins, a retired orthopaedic surgeon, or physician (uncertainty being evidenced by his preference for Dr rather than Mr) is to be congratulated. He no longer trots out the inaccurate mantra 'homeopathic medicines don't work', nor 'homeopathic medicine is just a placebo'. He is now asking the more mature question about homeopathic medicines being more effective than usual medicines. This is laudable progress indeed, and a scientist would be concerned for more research to be conducted to address this question in a mature and scientific manner. Well done!
I am reluctant to engage in philosphical ping-pong, but have to correct Andrew:
I have never suggested, anywhere, at any time, that 'homeopathic medicines don't work'. I have simply asked for any evidence that they do - to any extent greater than can be achieved by placebo HP remedies.
Placebo remedies do indeed 'work' (in the sense that patients report 'benefit'). And certainly the experience of a constructive therapeutic relationship with an empathic practitioner, homeopath or otherwise, can have beneficial effects.
And no Andrew, I am not 'asking the more mature question about homeopathic medicines being more effective than usual medicines' (whatever they might be). I am asking if HP remedies are more effective than non-HP but otherwise identical remedies (placebos). If you know the answer, please tell us (quoting your evidence for that assertion).
Dr Beaumont misrepresents my commentary on this blog as 'dispariging homeopathy'. Not so. I have been at pains to distinguish the benefit of consultations with a homeopath (often positive) from effects attributable to the homeopathically prepapared (HP) remedies (none).
More importantly, I ask Helen to further identify 'the vigorous PR campaign to discredit homeopathy'. Perhaps she refers to the 10^23 campaign of a few years ago which drew attention to the fact that HP remedies contain no plausible active principle. That campaign was simply an attempt to ensure patients were properly informed about the tenets of homeopathy and were able to give fully informed consent. I cannot believe Helen treats her patients without obtaining their fully informed consent.
The suggestion that promulgation of adverse opinions about homeopathic practitioners constitute 'a hate crime' is itself offensive and runs counter to GMC Guidance that concerns about colleagues should be raised.