“Many thanks for your email. We are aiming to get the session up on the archive for Tuesday 12th December, so please check the Nature Live archive section then. The address is www.nhm.ac.uk/nature-online/nature-live/video-archive/nature-live-video-archive.html”

i’m looking forward to it

I can recall one particular patient who appeared to have depression it turns out but initially complained in part that she felt low and thought that her dark front room was part of the problem – I advised (would have loved to prescribe) a higher Watt light bulb!

My reservations about herbalism are as you say – the side effects can be nasty and the practitioners are too mixed a bunch and they may not only lack the skills to diagnose but also the training to know when they are out of their depth (a key part of medical training known as referral to a specialist/dumping back on the GP)

So am I.

www.update-software.com/ABSTRACTS/AB004050.htm

What I meant by the “long standing folk use / track record” bit was as in something like valerian extracts for mild insomnia. Valerian has been trialled and meta-analysed: a systematic review by Edzard Ernst in 2000 found “sparse evidence” or “not enough”, though some positive results in better trials.

www.jr2.ox.ac.uk/bandolier/band81/b81-7.html

…and there are some later trials as well – for an interesting look at the argument relating to “should I recommend valerian for sleep problems” see:

ebm.bmj.com/cgi/content/full/9/3/68

…arguably in a case like this (evidence thin but some indication of benefit) the “long-standing folk use” of valerian for sleep disturbances might also factor in as a mild positive indication.

An interesting “straw man” question is: “Does EBM mean: “only well-conducted randomized double-blind placebo-controlled trials count as evidence”?”

As I understand it the answer is no, and ALL evidence (even down to anecdotal) is evidence. But the different kinds get a ranking and the DBPCRCT comes top.

On a different issue, the one complaint that the alties make that I have a little bit of sympathy with is that they can’t get large trials of (e.g.) herbal remedies going as, since there are no patented drugs to be sold with exclusive rights, there is not enough cash to be made for someone to bother (contrast drug companies). Therefore, they argue, the trial evidence on alt remedies is always going to be based on smaller studies which are underpowered.

Of course, the supplement companies do make money out of herbal remedies, so the argument is a cheat in some ways. I have no doubt that if they had to show evidence of efficacy to get the stuff on the market (instead of just flogging it as “a supplement”) they would run bigger trials.

Incidentally, herbalism is far more “mainstream” in Germany, with medical schools often offering courses in herbal medicine and many more doctors prescribing herbal remedies… may be why Mrs Dr A is a bit more sympathetic to herbs than some.

It is important to think “risk-benefit” for herbal medicines, though, e.g. WRT side effects and drug interactions. I had one friend who took St J’s Wort and then went out in the sun and got a nasty skin-rash due to its photosensitizing effect.

In Der Vaterland you have to have a degree level training and a recognised professional accreditation to be a non-medically-qualified “medical herbalist” – so they are regulated quite tightly. Comes back a bit to what one of the posters above said about Peter Fisher and his view of the “mad fringe” of barking homeopaths (see malarial prophylaxis passim ad nauseam).

i had meant to be responding to #36 and i failed to properly respond.

i try to have a consistent policy on CAMs.

it has 2 underlying principles:

1) i am a scientist and have a curiousity about how and why the world works
2) i am a frontline doctor and have a duty to provide my patients with the best evidence based medicine i can

therefore, i change my practice in 2) according to research even if i do not have a suitable answer for 1)

examples of this are my use of short courses of high dose steroids (40mg prednisolone) for acute sinusitis rather than antibiotics because that is what the latest research seems to show i should do. the other example is my referral of patients for acupuncture (among other therapies) for back pain and knee pain from OA because the research appears to support this (particularly the review by Dr Edzard Ernst)

therefore my reservations about CAMs are that they by definition lack evidence or we would use them in scientific/sane medicine

to run through how this is applied in the examples given about Frau Dr A:

herbal medicine – it works but can be messy, interacting with other medicine in unpredictable ways, is less predictable than scientific/sane medicine treatments and i am concerned that herbal medicine practitioners may not all be “safe”

acupuncture – see above, if it has evidence if not still want to know HOW though

light therapy – does not extend beyond brighter bulbs for SAD, also must plead ignorance of details

i am not sure i would recognise anything as “long-standing “folk use” track record” if nothing else, look at all of the bad examples of this from within scientific/sane medicine!

“pampering” therapies have their place and the manipulation part of massage can be as valid as some elements of physio and i would not discount the benefits of pampering in itself but… i want an evidence base for more benefit than that

i hope that no one is offended by the quantity i have posted in the last few minutes but i thought i might make an interesting case study of a front line doctor and my response to CAM

Dr A – unfortunately I did not get a chance to challenge the misguided F2 SHO but this is what happens when one trains outside London…

On a more general point, I think that we are running into a key problem here: the difference between COMPLEMENTARY medicine and ALTERNATIVE medicine (sorry about the capitals and the probable spelling mistakes).

Dr Fisher and the rational wing of the homeopaths see homeopathy as complementary to science/sanity based medicine, that it has something valid to add in addition to…

On the other hand, far too many people (possibly rightly) recognise the problems of feeling that both homeopathy and science/sanity based medicine are valid in the same philosophical world; some of these then reject science/sanity based medicine in favour of homeopathy, and so it is then an allternative. On the other hand, many of us reject the homeopathy and so we “believe” in science/sanity based medicine.

By the way, did Dr Fisher explain why RCTs don’t work for homeopathy? and please let me know if I have just stated the bleedin’ obvious above or if it really is the problem with having an argument with homeopaths (that there are 2 flavours).

My one regret is that I didn’t get to ask Peter Fisher my question on air: “What concerns me is those homeopaths who ‘rubbish’ mainstream medicine. What mechanisms does the homeopathy profession have for disciplining people who give rash advice?”

I did manage to ask him afterwards and he was pretty scathing about these people and said he has long advocated some kind of disciplinary structure. His anger and frustration were obvious. THAT would have been good to get out in the open on air. It’s an admission that there are rogue elements and they are not subject to any controls. I suppose it’s a different debate to yesterday’s topic but perhaps a more crucial one?

Oh, and Ben, I think you are too kind re Dr. Fisher’s presentation. He also spent the first five minutes saying ‘of course homeopathy works’ because lots of people believe in it and it’s been going for a long time. Puh–leeeze!!!

i mean, i guess it’s fair to say that he spent the first half of his talk telling us about something silly richard dawkins apparently once said about homeopathy in an introduction to somebody else’s book 7 years ago, and then some tv program he thought was a bit rubbish from 4 years ago, but it was a popular science event, and apart from that, and perhaps a teeny bit of arguable “cherry picking” of literature, i thought he was very pleasant and reasoned, as ever.

what was really striking to me was the difference between Fisher and the audience of homeopaths. as i said when i first posted, before the event, Peter Fisher is not representative of the wider homeopathy industry, and they showed themselves in their true colours last night.

so much about the discussion that was hugely amusing, i really can’t wait for the video to get posted.

I went to the debate as while I’m clear on my opinion on homeopathy (it’s a load of wafty nonsense that has no place being funded by Mr and Mrs T. A. Xpayer), I’m not very good at explaining to people why I think it’s rubbish, it usually ends with me growling at them and leaving the room. So I figured that if I heard a reasoned debate and considered the aurguments carefully, it might make me more effective at putting my PoV across. I did try this on my flatmate when I got home but the free wine wiped out any chance of a reasonable conversation.

I found Peter Fisher to be aggressive and confrontational, clever chap though he is. I also see from my notes (random though they are, again, blame the wine) that he used the phrase that homeopathy can “stimulate the body’s forces” which I’m sorry, from a *real* medical doctor is inexcusable.

Loved the question about homeopathic polonium 210 as well, that was inspired…

I also enjoyed the irony that the debate was being held in the “Glaxo Smith Kline Studio”. It’s all a big pharma conspiricy, I tells thee…

Great job Ben, and a thoroughly enjoyable evening!

I don’t have a totally closed mind when it comes to complementary therapies, so I went expecting – hoping – for some good rational debate, and I was prepared to be persuaded out of my sceptical position on homeopathy into one which was at least sympathetic.

However, I came away unconvinced and extremely put off by the silliness of some of the contributions of the homeopaths and their supporters.

Dr Peter Fisher is a clever man who uses science to support his position as a homeopath in the NHS. He gave a Powerpoint presentation which flashed up tables of statistics which showed, he said, that well-controlled trials and studies demonstrated that homeopathy had an efficacy which was not the result of a placebo effect. I’m not able to judge if the meta-analysis he showed proved his point because I’d want to read the actual articles myself before taking his word for it but I had the distinct feeling that he was cherrypicking his sources. He said that many of the studies which showed that homeopathy doesn’t work were based on BAD SCIENCE. But are all of them flawed?

I’d heard enough conversations in the queue beforehand to realise that many of the audience were a “rent-a-crowd” group of homeopaths who had been encouraged to attend by their websites and newsgroups and I wondered how Ben would cope because they were quite aggressive in promoting their views. I suppose they feel defensive because they find themselves often under attack and the subject of ridicule.

However, they’re a friendly lot – these homeopaths – and several tried to engage me in conversation. Maybe they thought I was one of them or maybe they wanted a convert, as they are ever eager to proselytise. I’m ethnically Chinese and the suggestion was made that I would know about alternative medicine because of my background. I was asked questions like, “Are you a sceptic or are you one of us?” One woman asked me, even before the debate began, “How are you going to vote?”

Ben arrived a bit late because of traffic problems, so I spent the 15 minutes or so studying the rest of the audience to see if I could “spot the homeopath”, or at least a supporter of homeopathy, because it seemed to me that they form a distinct sub-culture and one that is in part pretty eccentric and often downright loopy. There was one man who was so sinister that he could have walked out of the pages of an M R James ghost story.

Dr Fisher, I have to say, does not belong to this sub-culture. He’s not loopy or eccentric or sinister, does not eschew orthodox medicine and does not advise against vaccinations. Another homeopath (a woman who is one of the bigwigs in the homeopathic world) also said that homeopaths are not against orthodox medicine. She seemed pretty sane and sensible too. I wonder if they’re embarrassed by their co-believers.

I’m unable to say which is the more representative of the world of homeopathy in general but the lunatics certainly formed a lot more than just a fringe at this meeting.
Ben was amazingly patient and appeared to suffer fools maybe not gladly but at least with forbearance and courtesy. There was enough nonsense spouted to give him material for a year’s worth of Guardian Bad Science articles. One woman collared him at the end with a long, boring and completely irrelevant tale of her cat’s homeopathic treatment. I don’t know how he kept a straight face but he did decamp as soon as she had finished.

I was one who changed my vote. We were given one of those hand-held electronic voting devices and were asked at the start of the debate, “Does homeopathy work?” – answer YES, NO or NOT SURE. I voted “not sure”. At the end, when we were asked the same question, I voted “no”, because I felt that their case really had not been made, although there was anecdotal evidence in plenty and a couple of crazy rants too.

It seemed that several of the audience felt the same. An NHM member of staff read out the voting figures at the end. I’m not sure if I got them down accurately but I noted down that at the start of the debate, the audience’s answers to the question were 57% YES, 22% NO. At the end, the answers were 52% YES, 26% NO. The remainder were NOT SURE. We’ll be able to see for sure when the video goes up.

As Dr Fisher will doubtless point out, this is no proof that homeopathy is a sham and the number involved is far too small anyway. However, I think (assuming I got the figures right) that they do show that Ben made his case better than Dr Fisher.

For me the major sticking point is how this homeopathy is supposed to work. In the past I have myself resorted to acupuncture and herbal remedies as a last resort because I can see (sort of) how they might work and of course there are many phenomena for which there is no (as yet) rational explanation. However – memories in water? P-l-eeeeze!!

One homeopath told me that it wasn’t the dilution that made the difference. Oh, no. It was the energy from the shaking that did it.

Er, right.

can’t wait for the video to go up, will post a link when it does. the audience is the homeopathy industry in its true colours, often seen in the wild, rarely captured on film…

Dr Fisher’s intro (sales pitch) was carefully staged, blinding an unprepared (unlike him) audience with data, meta-analyses and numbers and such like – Ben noted at least twice that it was not the right situation to discuss these matters in detail.

What surprised me – I did put my arm up to ask him, but there was no time – is that if I remember correctly, the last set of figures with which he concluded his “survey” of “proper scientific evidence” that homeopathy works were

49% positive
3% negative
48% inconclusive

now, if I remember correctly, there was a faintly triumphant tone in his stressing the first figure and referring, rather dismissively, to the third as “the rest”. Maybe actually uttering 48 would bring out its actual closeness to 49? Don’t know. In his position, if I had planned to clinch the argument with figures I would have chosen another set altogether.

I hope that the message got through that proper scientific evidence is still lacking…except that they somehow tried to invalidate scientific methods and pre-empt the results of any value: something to do with the intrinsically very particular level at which homeopathy operates.

One more thought: perhaps trying to catch out somebody like Dr Fisher (with a foot in both camps – I just don’t get it) on the particular matter of vaccines may not be the best area in which to expose the irrationality and inherent danger of it all. Indulge me for a minute if I put to you that at some intuitive level vaccines can be seen to act in an homeopathic manner, and therefore would still make sense to his “homeopathic” left arm… Another example: I have had it put to me by one of the many holier than me, pure and resplendent, homepathically-enhanced mothers that Methylphenidate can be in a sense seen as a homeopathic kind of intervention – a stimulant to treat hyperactivity. See what I mean.

All in all, it was a joy to see(you) Ben in person. And, true to late form, the cheeky scamps made an appearance.

PPS But if you’re going to, make sure you have your Boots homeopathic arnica handy.

- Either a tree-hugger or perhaps someone who had been brainwashed by
the “cultural context / validity of patients’ individualized health beliefs” crew…?

What reason did they give for disapproving of your, erm, informed scepticism, Dr M?

I always assume that approval of homeopathy in the medical context comes from the “If we don’t have anything to give you for X, and you believe this might work, it is valid to encourage people to explore X ….” – re-empowerment, locus of control etc etc.

If the doctor concerned really BELIEVED a homeopathic medicine had any intrinsic BIOLOGICAL ACTIVITY… now that would really worry me because it effectively means they are happy to reject the whole scientific basis of medicine.

Not to labour it, but Mrs Dr Aust says that she directs the fairly numerous patients for whom there is no obvious “allopathic” remedy and who are insistent on alt therapies to (in order)

(i) the ones with some evidence base (e.g. some herbs, light therapy, acupuncture, all in certain settings)
(ii) the ones with something in them (e.g. herbs) and a long-standing “folk use” track record
(iii) varieties of “self-pampering to feel better” things (massage, relaxation, aromatherapy)

…but not to homeopathy ‘COS IT’S A CON.

just had a get together with other junior doctors, mentioned homeopathy in passing in a negative context and got evils from a fellow trainee.

there is no hope.

good luck with the debate Ben, give’em hell!