Obvious quacks: the tip of a scary medical iceberg

February 26th, 2010 by Ben Goldacre in adverts, alternative medicine, bad science, big pharma, evidence, regulating research | 121 Comments »

Ben Goldacre, The Guardian, Saturday 27 February, 2010

After the Science and Technology committee report this week, and the jaw dropping stupidity of “we bring you both sides” in the media coverage afterwards, you are bored of homeopathy. So am I, but it gives a very simple window into the wider disasters in all of medicine.

Homeopathy, our first example, is a small sector of the pharmaceutical industry, a few sugar pill companies worth a couple of billion pounds a year in europe. Overall, trials show their pills perform no better than placebo. We therefore know that all claims to the contrary are bullshit, but bullshit being tolerated by plenty of MPs, huge swathes of the media, a fair few GPs, and most worryingly of all, the Medicines and Healthcare Regulatory Authority, who permit homeopathy pill companies to list diseases they say they can treat on the side of the bottle, with no requirement that they come up with any evidence that their treatment works.

This doesn’t only tell you a story about homeopathic sugar pills: this tells you how doctors, politicians, the media, and regulators deal with the issue of evidence in medicine.

How closely do the great and the good, for example, scrutinise the promotional material for medical drugs? The latest paper looking at this question is published this month. Researchers in Holland went through all the biggest medical journals in the world – the Journal of the American Medical Association, the Lancet, the New England Journal of Medicine, and so on – between 2003 and 2005. All adverts were included, once each, if they made a claim about the effect of a drug. For all the claims in the ads, they checked the references, found the trials they referred to, and then gave them out to an easily exploited workforce of assessors: 250 medical students who’d just finished their evidence based medicine teaching.

Each student independently assessed 2 trials, and its associated advert, using a pre-specified questionnaire and a well-established scoring system to assess the quality of trials. Scores were given for things like: whether the method of randomly assigning patients to one treatment or another was adequate, and clearly described; whether patients could know which treatment they were getting; whether drop-outs were appropriately included in the analysis, and so on. These are good measures of whether a trial is a “fair test” of a treatment.

By now you will rightly be worrying that medical students – although cheap and easy to come by – are not reliable raters, so you will be pleased to hear that each trial was scored by between 2 and 6 students, and if there was a discrepancy in scores, that trial was reviewed by a panel of 4 academics.

The results were abysmal. Only half of the claims in the adverts were actually supported by the specific trials they referenced, and of all the trials, only 55% got a score of “high quality”: overall, only 39.2% of these adverts – in the leading medical journals in the world – referenced a high-quality trial which actually supported their claim.

This is not the first time such a study has been conducted. Villanueva and colleagues, in 2003, published a paper in the Lancet assessing claims for cardiac medication adverts in six Spanish medical journals: of the 102 references they could trace, 44% did not support the promotional statement. Similar results have been found in psychiatric drug adverts, and in the field of rheumatology. To offset any suggestion that I am cherry-picking, a systematic review of this question in the open access journal PLoS ONE found 24 similar studies, and overall only 67% of the claims in adverts were supported by a systematic review, a meta-analysis or a randomised control trial.

Quacks see the shortcomings in medicine as a justification for their own even more dubious behaviour, but in reality, the horror is this: homeopathy is the obvious, easy, tip of the iceberg. It is the simplest and clearest story of how bad things are, how dumb doctors and politicians can be about evidence, and how lame regulation has become. But it is only the most obvious illustration of the dark, fearsome depths into which these problems extend. We are in very big trouble.


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121 Responses



  1. imageh said,

    February 26, 2010 at 11:36 pm

    Science has a clear methodology. Medicine is sometimes scientific, often not, (hence opinion is required – science has no room for opinion). Complementary medicine is never scientific, and rightly deserves the description Woo or Wu – whatever.. Scientists are not believers and they are professional skeptics – by definition. My main concern (as is David Colquhoun’s if I may be so bold) is the “teaching” of “science” by certain institutions – e.g. The University of Westminster – in courses which clearly are not based on science and have absolutely nbothing to do with the scientific method and everything to do with belief and lack of skepticism. There are good scientists (in other disciplines) at the U of W – who are perhaps too scared (understandably) to shout out loud about the policies of those who administer them. I propose that they need our help. I will from now on refer to this particular institution as the University of Woominster – please join me in this. If it spreads, it may just have the required effect, and perhaps allow the real scientists there to speak out about what is happening outside, and affecting their reputation, and ability to attract students – which is the thing that catches these administrators’ attention.

  2. kkbundy said,

    February 26, 2010 at 11:53 pm

    Quackery is just a continuation of the illogic of religion or superstition. We want easy answers. We want to know we can influence our world. People feel the need to be powerful, so we rely on religion, astrology, conspiracy theory, quackery and the like to pretend we are on top of the situation. In many peoples mind, the illusion of control is as good as the real thing. It’s not what you can do; it’s how you feel.

    So we believe the earth is 6000 years old. We believe in the power of prayer, and we believe in quacks telling us exactly what we want to hear. How have we ever made it this far. Oh,I remember, science.

    The Blessed Atheist Bible Study @ blessedatheist.com/

  3. CoralBloom said,

    February 27, 2010 at 1:40 am

    ‘We are in very big trouble.’
    Yes, very big trouble. I’ve used to work with a number of marketing guys; overpaid and pretty thick! Their motto seemed to be something like ‘Let truth bend or be gone to suit my needs’. Advertising standards were a non-threat.

  4. Filias Cupio said,

    February 27, 2010 at 3:32 am

    imageh said “science has no room for opinion.”

    You haven’t spent time around scientists, have you?

  5. bravante said,

    February 27, 2010 at 4:31 am

    “Science” also has its prophets. How many scientist pimping molecules do we know? I think I know one for every known amino acid….

  6. Heuristic said,

    February 27, 2010 at 4:34 am

    How do we remove/minimise this issue? Have journal editors require that the advertisers supply the evidence for their promotional material and vet the evidence before publication?

    Seems that this is an issue that requires a solution. :)

  7. juliang said,

    February 27, 2010 at 7:14 am

    So, misleading adverts are placed in medical journals. Presumably this is because the drug companies have reason to believe it will increase the prescribing of those drugs. We therefore have doctors prescribing drugs believing they are an appropriate treatment when there is no evidence to that effect. i.e. When they work, it’s the placebo effect.

    If homeopathic remedies are no longer paid for by the NHS, we will presumably have people being treated with more expensive, more dangerous conventional medicines, which work in exactly the same way as the homeopathic remedies. i.e By the placebo effect. Is that better, or worse?

  8. imageh said,

    February 27, 2010 at 7:14 am

    Filias – I didn’t say scientists have no room for opinion. As for spending time around scientists -would 43 years be significant?

  9. twaza said,

    February 27, 2010 at 10:39 am

    Another incisive analysis. But, I think the ending didn’t make the point you wanted.

    There are at least two problems with using Jeremy Clarkson-speak. People who recognize the exaggeration for effect quickly become habituated and are bored by it. And people who do not see that you are exaggerating take you seriously and start arguing about stupid points that you didn’t make.

    Here’s a stupid point, for example, that you didn’t make. Although there are big problems, the forces of evil, irrationality, and wishful thinking are countered by increasing forces for truth, rationality, and evidence-based action.

  10. gregpye said,

    February 27, 2010 at 11:12 am

    A great post the the problem of claims that are beyond obvious quackery are, I fear, much more widespread than ‘just’ medicine. One advantage in medicine is that at least there are trials that you can go and reference to find the truth. So, most doctors might not do it (and the ads are therefore very worrying) but they need to have some efficacy to at least be licensed, so the issue is more one of cost … and in the UK at least we have NICE to help work out cost/benefit reviews. The truth should out at some point.

    An exactly analogous situation occurs in most walks of life though, though with far far less ability to go and find a trial that gives the evidence. There are obviously nonsensical positions, like communicating with the dead, that some folks hold, but for the most part they can be ignored just like homeopathy. And, advertising is clearly about making the most of what you have, even if what you have is pretty pointless – anyone for silk in Shampooo? Silk is silky, so clearly it will make you hair silky, just like putting spiders webs in it does (oh, wait, it doesn’t).

    But, I’m sure I am not alone in seeing people in public and corporate life making claims and decisions on ‘evidence’ that is about as flimsy, unbalanced and downright wrong as one could imagine. And, it is where the decisions are tougher, and the thinking to understand the reality more tricky, that the danger lies. Most people can recognise that homeopathy is nonsense (if that is not true, please let me carry on in my deluded comfortable view that at least the majority can see it is rubbish or I may just go and cry in a corner). But, where the thinking effort required is larger, it is far less clear that people know what is correct and not. People are almost totally unaware of mental biases that we all carry. They know the language of statistics, but not the traps. And so, large groups can believe that global warming probably isn’t real, that large fiscal deficits are someone elses problem, that the US gets benefit from having the highest incarceration rate in the world, and that it is more important to be in power than to make meaningful change.

    What I confess I would love to see is much more systematic teaching of children about how their brain works – the amazing stuff it can do, and the infuriating ways it can let you down. I’d love to see people equipped to be informed skeptics. They should read ‘Bad Science’ – and be tought about the subject to make sure it sticksibn the same way that basic budgeting is regarded as a critical social skill. And, we should foster a society that simply made the mad claims made by advertisers, politicians and individuals in power a matter of public derision. We have passed the time when bald claims could be made by someone dressed in a white coat, and all would now see them as anachronistic. Lets get to that same stage for the modern version that has only the thinnest of veneers of trials or statistics over the top.

  11. JMS said,

    February 27, 2010 at 11:38 am

    In response to imageh’s first comment. I’m afraid that part of the problem is that colleagues in ‘old’ Universities have missed something rather important about the management structure of the post 1992 ‘new’ Universities. The ex-polys are run more like schools or FE colleges. The fact that scientist at Westminster cannot speak out is because it is really none of their business. These institutions are not ‘communities of scholars’ governed by senate or academic board. The Vice Chancellor is the chief executive. If an academic in one of these institutions has misgivings about the actions of another department, I guess they could discuss them with their line manager or possibly take the matter higher. But going outside the institution would probably be considered as gross misconduct (bringing the institution into disrepute) by management. This may not be legally the case, I’m no expert, but its not something that anyone really wants to test.

  12. CoralBloom said,

    February 27, 2010 at 3:32 pm

    gregpye

    By my unscientific reckoning of the number of nutters in UK plc insisting I take the nonsense they swear by, insisting to the point of bullying using the label as evidence, yes the label, I’d suggest you buy a bumper box of hankies.

    Sorry.

  13. DrJG said,

    February 27, 2010 at 6:24 pm

    @gregpye “…we should foster a society that simply made the mad claims made by advertisers, politicians and individuals in power a matter of public derision.”

    The trouble is that we already have a society which behaves like that – thus, when politicians and their appointees insisted that MMR was safe, large proportions of society felt perfectly able to treat that claim with derision. The problem is that it is an awful lot easier to teach a generally sceptical attitude than it is to teach the knowledge and understanding to reliably inform that scepticism. If you only achieve the first part of the task, you may in fact be making the overall situation worse rather than better.

  14. Andy Graham said,

    February 27, 2010 at 10:06 pm

    @juliang

    Visiting a homeopath remains worse for the individual patient because they have not seen a medical doctor. When a doctor prescribes a medicine there is a good chance that, if the treatment doesn’t work and the illness wasn’t serious enough to kill the patient (which is of course the reason all of this is so pernicious), the patient will return to the doctor who will prescribe other drugs which may work better. Returning to a homeopath will get you… more sugar pills.

    In a broader context, realising that the medical profession does not always apply evidence based medicine does not immediately place the profession down amongst those who reject evidence based medicine out of hand, arguing that it doesn’t work for their particular brand of quackery.

    The solution? It seems to me that when a company makes a claim for a drug which they cannot substantiate, knowing that those who see the claim will misunderstand the drug and incorrectly prescribe it to patients, that is criminal negligence for which the directors of that company should be held responsible. Financial punishments might not encourage drug ompaniea to behave, but the risk of a prison sentence would.

  15. Andy Graham said,

    February 27, 2010 at 10:10 pm

    ompaniea is… er… latin for “companies”

  16. Enders Shadow said,

    February 28, 2010 at 12:03 am

    Placebo effects can change people’s lives for the good

    Homeopathy can enable placebo effects to occur

    Therefore it is rational to allow homeopathy to continue and even pay for it as the benefits may well outweigh the disadvantages (worth a actual investigation rather than assuming it doesn’t pay for itself). OK, so perhaps there’s some ethical issues about patients needing to be told that we don’t know why it works. But it makes a positive difference in lives, and if done properly is VERY unlikely to be negative. Some phrasing ‘I’m going to refer you to a homeopath who may make you better for reasons that we don’t understand’ seems appropriate to me.

  17. Mark P said,

    February 28, 2010 at 12:13 am

    What I confess I would love to see is much more systematic teaching of children about how their brain works.

    This old canard.

    You can’t teach children to think past their biases. They are children. If they were capable of adult thinking, they would be adults.

    I teach Maths at secondary level. For most students just ensuring logical thought is a bonus.

    With the exception of a few very bright ones, kids have no interest in the issues of critical thinking. Trying to teach kids things that they don’t like is hard. As I say, I teach Maths.

    Trying to teach kids things that adults want them to learn but which are not in the end-of-year exams is a total waste of time.

    I have actually tried to examine issues of critical thought in class. A few students will rise to the challenge for a while, but even they can’t on the whole see their own biases.

    The only solution, I would suggest, is that people who spout rubbish in public not be given a free pass. So if some movie star suggests that her life was changed by some sort of woo, that the journalists actually challenge it rather than let it slide.

    Impossible, you might say. But yet we have done it with racism. Any celebrity today who mutters imprecations against some group, even in private, is roundly seized upon. That did not happen only decades ago. So it should be with magical thinking.

  18. jwm said,

    February 28, 2010 at 1:10 am

    Ender’s Shadow

    “Homeopathy can enable placebo effects to occur” “‘I’m going to refer you to a homeopath who may make you better for reasons that we don’t understand’”

    Why bother referring to a homeopathist? If doctors are going to advocate the use of a placebo, why bother involving a third wheel? I mean, we’ll be back to the good old paternalistic days when any question can be answered by ‘because I say so’. Who needs rational discussion anyway?

  19. Heuristic said,

    February 28, 2010 at 4:03 am

    One question I should have asked earlier. Did any of the journals, in which an ad was published, include journals that had previously published/been sent for publication not so flattering studies of the effects of the same drug?

  20. CoralBloom said,

    February 28, 2010 at 5:59 am

    May I suggest we set up a company. That company can be hired by the government to approve all adverts. My thinking is, if we as a society are so intent in minimising risk to the extent we now have CRB checks on millions of workers in all walks of lie, then shouldn’t we demand the same for our health and medications?

    Given the recent favour shown by our politicians towards co-ops, a co-op of scientific advertisement approvers would surely be more acceptable!

  21. Tohri said,

    February 28, 2010 at 7:06 am

    I take issue with the standpoint. This isn’t even a devil’s advocate: I’m asking why anyone cares.

    Is there even any point in trying to convince the vast unwashed masses that the sugar pill they’re taking for their mesothelioma and bad breath is worse than useless? I suppose it’s the mad scientist / comic book villian viewpoint that anyone who’s deluded/thick enough to remain uneducated in today’s world of instant information deserves to suffer the side-effects.

    Let them die. Idiots need to be weeded out, and snake oil salesmen will always make the obscene profit margins they’re entitled to. If you’re really upset about it, sugar is cheap, and regulation is sparse.

  22. Enders Shadow said,

    February 28, 2010 at 9:55 am

    jwm complains about my proposing using homeopaths to invoke the placebo effect. The answer is that it is more likely to work – in a way that nothing else is for the patient at the time. Yes it’s irrational – and as such is a cause of irritation to people who want to be wholly rational. But if it causes someone to be released from pain, then WHY NOT? Aren’t you proposing to offer sacrifices of someone else’s pain on the altar of the god of rationality?!

  23. pv said,

    February 28, 2010 at 11:38 am

    Tohri, you may be right about there not being much point to convincing people that homeopathic sugar pills have precisely the same properties as… sugar pills. People might or might not be idiots, or whatever.

    The issue though is that the likes of Boots the Chemist are nothing more than exploiters of ignorance. Even though they know very well that homeopathy is baseless, they are happy to promote and sell it because there is much money to be made from exploiting ignorance. Simply by selling it they are promoting its efficacy. In their comments to the Parliamentary committee they more or less acknowledged their position.

    If it were a bank or financial institution offering fraudulent insurance or savings schemes they couldn’t get away with the excuse that there is a public demand. Bernie Madoff should have tried the Boots’ excuse.

    Both Boots and Madoff have something in common. It’s what they don’t tell their clients that exposes their dishonesty. This is true of all quacks, all AltReality Medicine, and to a certain degree the pharmaceutical industry in general.

  24. stev said,

    February 28, 2010 at 12:37 pm

    Enders, if that’s the principle then why not just have the doctor offer them a nice green sugar pill themselves? Why involve the homeopath at all? If all that’s required is to invoke the placebo effect through an unexplained declaration of efficacy seated in authority alone then why not have the doctor do thus? Oh wait, I know why..

  25. natsils24 said,

    February 28, 2010 at 1:09 pm

    @Tohri

    I have to take issue with your comments “Is there even any point in trying to convince the vast unwashed masses that the sugar pill they’re taking for their mesothelioma and bad breath is worse than useless?”.

    Do you think many of the people who take homeopathy understand it? Or understand the placebo effect? No, I don’t think they do. Is it fair for people with a scientific background who do understand such things to mock them? No in my opinion. Is it about educating people? Yes. If someone asks me my opinion on homeopathy I explain to them what a placebo is and why there is no evidence for homeopathy.

    Doctors have a role to educate their patients as well as treating them, a perfect example is I always explain to patients why antibiotics won’t work for a viral infection. If after explaining to someone why homeopathy doesn’t work they still want to use it than that is their choice. But calling people ‘idiots’ is not only insulting but it is massively detrimental to trying to enagage the general public in science and increase their understanding as a result.

  26. DrJG said,

    February 28, 2010 at 3:23 pm

    @Enders Shadow

    I’ve made clear over the last few of Ben’s articles my admittedly uncertain thoughts on making use of the placebo effect. But consider this: You entrust your child to a friend who believes in homeopathy. Your child develops appendicitis. What would you rather your friend does: Take them to a GP, who is a reasonably likely to suspect appendicitis and refer your child to a surgeon for appendicectomy, or to take the child to a homeopathist and take the placebo prescribed until after your child has peritonitis from a ruptured appendix – or, if they are lucky, develops an appendix abscess which needs more radical surgery than the original complaint?

    I will freely concede two things: Firstly that GPs sometimes miss appendicitis, and secondly that sometimes people have surgery which turns out to have been unnecessary, when their appendix turns out to be normal. But science works hard at reducing those numbers, and, if you are being completely honest, which of the various scenarios I have suggested do you think are the more likely ones given the two courses of action open to your friend, and which ones would you least like to happen?

    @natsils24

    I have no problem with honest ignorance as long as it is open to discussion – not least because I am well aware that there are so many things that I am ignorant of. But when someone persists in insisting that their ignorance trumps the knowledge of those who have far more reason to know what they are talking about, then I think they are probably fair game. When, as I have suggested above, there are scenarios where that insistence on the validity of their ignorant opinion could have very serious consequences, that attitude is strengthened; What, for example, is your attitude to the drunk who in their alcoholic haze insists that they are perfectly capable of driving safely?

    Having said that, Tohri’s chosen example of Mesothelioma is probably a bad one, as the sugar pill will have just as much (or as little) effect as any other pill and obesity and tooth decay are, in that scenario, the least of your concerns. I am being somewhat cynical and I am not up on the latest developments in oncology, but I am fairly confident that mesothelioma is still one of the most refractory malignancies to suffer.

    Tohri asks “why does anybody care”. I care partly because we have all done stupid things, those who claim that they haven’t are the ones deceiving themselves more than they deceive anyone else. “There but for the Grace of God go I…” For example, I knew how stupid smoking was even as a kid, didn’t stop me trying it for all sorts of complicated and subconscious reasons. I was lucky and it made me feel lousy, so I didn’t continue, but I would hope that Tohri would not deny conventional cancer treatment to those “stupid” enough to have carried on the smoking?

  27. jwm said,

    February 28, 2010 at 3:53 pm

    Thanks Stev, thought I’d made it clear in my original post but ender seems to have missed the point.

    Ender’s Shadow (or Bean in other words) –

    ‘jwm complains about my proposing using homeopaths to invoke the placebo effect. The answer is that it is more likely to work’

    are you actually suggesting that homeopathists somehow have a greater mastering of the placebo effect than anyone else? Or are you trying to insinuate that theres more than just the placebo effect going on? I dont know which is more ridiculous.

    ‘Yes it’s irrational – and as such is a cause of irritation to people who want to be wholly rational. But if it causes someone to be released from pain, then WHY NOT?’

    The problem with this approach is that all medications have both a pharmaceutical effect, and a placebo effect contributing to the overall observed effect of the pill. Therefore for a patient who has not been helped by conventional therapy, are unhelped not only by the pharmaceutical aspect of the pill they are taking, but the placebo aspect of the pill they are taking. So what you are suggesting is to start them on another placebo when a placebo effect has already failed to improve situations. Surely a waste of time and money, and a sadistic false raising of patients hopes who are already laid low by their condition.

  28. iamjohn said,

    February 28, 2010 at 5:17 pm

    @jwm
    Actually I think homeopath may well be able to elicit a greater placebo response in many cases. If I were to go to a homeopath I would be very unlikely to experience a placebo effect because I know they are just sugar pills. But there are a large number of people who do believe in it and as a result they may well get better.
    Of course I’m not arguing that it should be covered by the NHS (I don’t think it should), only that it may be effective, if very expensive, for many people.

  29. ghizlane said,

    February 28, 2010 at 6:17 pm

    «You can’t teach children to think past their biases. They are children. If they were capable of adult thinking, they would be adults».

    Children are the “fathers and mothers» of adults: we all were children and our ways of thinking as adults were forged then and evolved bit by bit. I am a teacher too and I am afraid I have to disagree with that: we can not teach children critical thinking the way we teach it to adults; but we can implement and develop seeds of critical thinking in children.

    For example, we can make them participate in choosing and criticizing the evaluations criterion: each time they get tested, instead of giving them only their grads, we can make them talk about where they failed and succeeded and according to what criteria they did so. We can also make them see how by changing the criteria, their notes would have been otherwise.

    It might be an indirect way of teaching them critical thinking, but the “principle” is already there even if they don’t get to see it or realize it yet. I think one of the most important things to teach them at that stage, is not to take things as being eternal truths and to train them to question everything, even the teachers’ evaluation criteria. I might have widened the principles of the “pedagogical and didactic contract” withing classrooms, but I have tried it and it works pretty well.

  30. truthygum said,

    February 28, 2010 at 10:16 pm

    Enders Shadow:‘I’m going to refer you to a homeopath who may make you better for reasons that we don’t understand’…Crikey!
    It would be a big porky to tell people that homeopathy sometimes works but we don’t know why. We do. If the power of the placebo is ever to be honestly brought into play people need to know the truth about it: to be educated and understand it,and possibly even learn to self-administer with something harmless and of their own choice. Preferably not lies and homeopathy.

  31. Enders Shadow said,

    February 28, 2010 at 10:31 pm

    Thanks jwm – that’s a interesting point about expecting a new placebo effect when that associated with the previous drug regime didn’t work. However I think it is presumptuous to be dismissive of the complexities of human psychology as to why the placebo effect kicks in and to assume that it will be invoked by conventional medicine to the same extent as with homeopathy is equally unscientific. To dismiss such a claim as ‘ridiculous’ is to shout loudly because your argument is weak. Have you got the scientific data to establish this? If not… An especially difficult study to make rigorous as there would be no way to make it double blind. Maybe it does invoke the placebo effect better in some cases. You don’t know; it is VERY foolish to make any predictions about the human mind works.

    To clarify DrJG – I would only want to move onto homeopathy when mainstream approaches have proved ineffective, and when there is a clear diagnosis with a clear treatment pattern well established, as with appendicitis, then proposing homeopathy is clearly wrong. However there are many chronic diseases where conventional medicine is largely ineffective; admitting that in some cases the placebo effect apparently invoked by homeopathy does make a useful difference is embarrassing, but happens to be the case.

  32. jwm said,

    February 28, 2010 at 11:43 pm

    Ender’s shadow:

    “However I think it is presumptuous to be dismissive of the complexities of human psychology as to why the placebo effect kicks in and to assume that it will be invoked by conventional medicine to the same extent as with homeopathy is equally unscientific.”

    A very good point that also works wonderfully if phrased:

    “However I think it is presumptuous to be dismissive of the complexities of human psychology as to why the placebo effect kicks in and to assume that it will be invoked by homeopathic medicine to the same extent as with conventional medicine is equally unscientific.”

    There is evidence in neither direction but your entire arguement is based upon the unproven thesis that homeopathists provide a better placebo effect. Therefore for your arguement to hold up regarding continuing homeopathy as a placebo, then first it must be proven to be a better placebo. Although this kinda sidesteps the ethical issues.

    Also:-
    ‘However there are many chronic diseases where conventional medicine is largely ineffective’

    Care to name some? I can think of maybe 1 or 2 extremely difficult to manage chronic conditions, but even they have treatment strategies with reasonable NNTs.

  33. Enders Shadow said,

    March 1, 2010 at 12:25 am

    jwm – let’s agree there’s no evidence either way. In the absence of such, it is appropriate to be open to either outcome!

    Eczema, ME and IBS / Crohn’s disease all spring to mind as diseases which we are very bad at healing and where claims for non-conventional approaches are made.

  34. Tohri said,

    March 1, 2010 at 6:27 am

    To those it may concern:
    My statements 24 hours ago were made under the influences of several complicated organochemicals, most notably fructose, and ethyl alchohol.

    Sober and unrepentant 24 hours later, I will now clarify:

    No, it’s not fair that people will lie and mislead other people into forking over huge amounts of cash in return for hope, however empty it may be. They’re still going to do it. The lottery, and most all forms of christianity are based on this law of nature. There’s a sucker born every minitue, and plenty of barnums to go around.

    That, plus the known fact that you can’t fix willful ignorance makes it clear to me that if you let yourself get tricked in today’s world, you probably deserved it.

    And as for the cancer care for the poor tumor ridden smoker: The warning was on the pack, don’t expect health insurance. (I work at a convienience store to pay for a college education. Changes your point of view somewhat.)

    Schadenfreude, maybe. I like to think of it more in terms of darwinism.

  35. skyesteve said,

    March 1, 2010 at 8:17 am

    @enders shadow – Eczema? Have to disagree – modern medicine is largely effective at controlling this in the patients I see. Crohn’s disease? Again, have to disagree – modern medicine has actually offered hope to patients with this potentially devastating disease (and many now lead good lives because of it). ME? Not a term I recognise but if you mean “chronic fatigue syndorme” show me the evidence that this represents a genuine specific disease entity. People do suffer from fatigue of course. Some have genuine underlying biochemical deficiencies that repsond to therapy but that’s about it as far as I can see. In any case many people with CFS can and do respond to psychological interventions such as cognitive behvioural therapy and almost all the ones I have dealt with get better eventually.
    Remeber those with chronic disease who attend hospital specialists on a regular basis represent the tip of a vast iceberg of chronic disease which is very effectively managed in primary care by Gps and, more often nowadays, by practice nurses.
    Modern medicine has hugely improved the management and well-being in those with a vast range of chronic disease. It may not “cure” all of them in the simplistic sense of the word but to view good quality healthcare simply in terms of “cure” IS very simplistic. Indeed, the standard definition of health form the World Health Organisation makes no mention of “cure” – it talks about a state of “physical, mental and social well-being”.
    As Guy said on another thread, there is no doctor I know who thinks modern medicine is the be all and end all or that it has all the answers. And, as Ben points out in ths thread, there are still those making claims that cannot be susbtantiated even within the realms of modern medicine.
    But the bottom line is that modern western healthcare is better than anything else out there and its track record over the last 50 to 100 years is second to none.
    What’s ironic now is that the thing that is possibly making the biggest impact in terms of killing people prematurely in the UK is self-inflicted stuff – fags, booze, crap diet, nae exercise, etc. – and there aint much modern medicine can do about that.

  36. skyesteve said,

    March 1, 2010 at 8:32 am

    P.S. – life expectancy in those with Crohn’s disease is generally the same as the general population at 77 for men and 79 for women and is only reduced in those diagnosed under 20 years of age

    www.medscape.com/viewarticle/550715_3

    Cheers

  37. DrJG said,

    March 1, 2010 at 5:24 pm

    @jwm – I’m afraid that all sorts of unpredictable factors appear to influence the placebo response, including such things as colour and shape of the pill. I have no doubt that some people will get a better symptomatic response to a pure placebo than to a pharmacological agent plus its own placebo effect, not least because the circumstances and surroundings in which it is prescribed are quite possibly very different.

    @truthygum – the dilemma is that most of the placebo effect seems to rely precisely on the patient not knowing that is a placebo. Bringing the placebo effect into play and honesty are mutually exclusive, it appears. I wish it were otherwise, it would certainly resolve a lot of moral dilemmas for me!

    @ Enders Shadow – I’m not sure if Skyesteve has already done a reply to you which has disapeared into cyberspace, but you’ve a bit of a mixed bag of conditions there, and I’m a bit dubious about your apparent liking of IBS and Crohn’s disease, which are two extremely different conditions. Of course, before the 1939 Cancer Act of 1939, when cancer had a far worse prognosis than now, you could have included that in your list – until the law banned people from preying on the most desperate.
    Whether or not I agree with your list, it is hardly surprising that those after a fast buck are going to target common and/or chronic or relapsing conditions, some of which may not respond very consistently to conventional therapy. Not good business practice to push an alternative therapy for an uncommon condition that responds well to simple conventional medicine, is it? And, of course, there are plenty of instances of parents choosing Traditional Chinese remedies for fear of using those terrible steroid creams on their child’s eczema, when in fact many of the supposed herbal remedy have been found to contain far more potent steroids than the bit of hydrocortisone that the GP was recommending.

  38. irishaxeman said,

    March 1, 2010 at 5:32 pm

    ME is only bad at healing because the fools advising the government said it was a psychiatric condition (and some still insist it to be). If time had been spent, as in North America, actively chasing the viral and genetic origins many people in this country would not be desperately trying any woo-woo to alleviate their condition. I feel very strongly about this as my wife – previously a runner, cyclist, power lifter – has suffered from ME for 4 years and for three of them treated as a head case. As if she is so-unmotivated to sleep for 20 hours a day instead of legging it up a Welsh 3000er.
    Woo-woo survives because ordinary concerns aren’t addressed, especially where there’s no profit to be made.

  39. paddyfool said,

    March 1, 2010 at 8:06 pm

    @Irishaxeman,

    I also feel that Woo is largely a god-of-the-gaps fallacy. Hopefully we can continue to make the gaps narrower to the point that this becomes ever more evident, and where few people get stuck in the gaps anymore.

    However, I’m curious. In what precise way, and on what basis, are you saying that the response has been better in North America – more research, or more effort pinning down individual causes in individual patients?

  40. DrJG said,

    March 1, 2010 at 10:46 pm

    @Tohri – out of interest, where do you draw the line on personal culpability? If, in your organochemical-induced state, you had stepped in front of a bus or pitched yourself headfirst downstairs, would you expect to be turned away from ITU or presented with a bill afterwards? Or perhaps, like I did when I was a student, you simply fell flat on your face, cut yourself up and broke a few teeth? We could get even lower levels of culpability – perhaps you stayed up too late at night reading Badscience, woke late, went over on your ankle hurrying to be at work on time and suffered a nasty trimalleolar fracture? What if you suffered a sporting injury – it was your choice to do the sport – or perhaps you do not do enough exercise, and end up with weight-related arthritis needing a hip replacement?

    It is not difficult to draw up a spectrum of personal blame, from deliberate self-inflicted injury at one end, to marginal carelessness at the other, but all in some way related to your own choices. Where do you draw the line, apart from the self-interested approach of “comfortably on the right side of where I happen to stand”?

  41. emen said,

    March 1, 2010 at 11:14 pm

    DrJG

    I have been reading your comments this week and last week with a lot of interest.

    In general, I am also against homeopathy and glad the truth is out, but totally see your point about the placebo dilemma. (As a patient.)

    Given that somebody tries some kind of placebo AFTER they have seen a medical doctor and not INSTEAD (as in your appendicitis example), I can see a genuine place for using placebos in everyday medicine.

    It is true that it is unethical to lie to patients, but it must also be unethical NOT to prescribe something that you know might work (a placebo).

    Placebos are powerful and homeopathy uses the placebo effect – therefore it is wrong to say it “doesn’t work”. Evidence suggests that it doesn’t work more than placebo, but for some patients that might be as much as they need.
    And as you explained the other day, it’s wrong to suppose that “real medicines will have the placebo effect AS WELL as the effect, so end of story”. Some patients won’t get better from antibiotics or paracetamol, but will get better from some kind of placebo – I don’t know why, but yes: part of the explanation must be the “5 minutes with a rushed GP versus one hour with a homeopath”.

    I don’t think homeopathy is the answer to the placebo dilemma though. The person who prescribes a placebo has to know that it is only placebo (which is not the case with homeopaths), even if it reduces the effect a bit. Also if somebody responds well to a homeopathy placebo, they might START with that next time (see your appendicitis example).

    I definitely think that the popularity of woo is to a large extend caused by the lack of time, lack of attention or simply the laziness of medical doctors. It’s breathtaking how often GPs (in my experience) prescribe antibiotics for example, without having properly investigated the problem, “just in case”. Give me 25 minutes with my GP and give him proper diagnostic tools (ultrasound, ECG etc)- then his care and his antibiotics will have a much more powerful effect. And a lot fewer people would be seeing quacks.

    It’s the wrong approach to simply ridicule patients using homeopathy, when convincing care is not offered in the first place.

  42. jwm said,

    March 2, 2010 at 12:13 am

    emen

    ‘Give me 25 minutes with my GP and give him proper diagnostic tools (ultrasound, ECG etc)- then his care and his antibiotics will have a much more powerful effect.’

    Ah, the ever present patient belief that tests = good care even though 90% of a patients diagnosis comes from a good history. Its why outpatient ECG and ultrasound lists are the most boring thing on the planet as you’ll only ever see about one or two cases of genuine pathology per afternoon/morning session as the rest are all being done as patient pacificants. Which is partly fair enough, if a patient needed a therapeutic scan (yes, even CT scanners carry that good old placebo effect we’re all currently chasing) I’d choose US too given its lack of harmful radiation.

    Although I do agree that GPs should be given funding to be able to give more time per patient, as well as using antibiotics less if he is using them as indiscriminantly as you are suggesting.

  43. stev said,

    March 2, 2010 at 12:44 am

    @Enders, while there are inherent difficulties measuring how the placebo effect is invoked by conventional medicine versus homeopathic sugar pills (isolating the medicine’s placebo effect from its pharmaceutical effect, for one), there are many studies measuring the placebo effect of homeopathic remedies against regular, non-homeopathic sugar pills. The results as have been widely publicised show that both sets of sugar pills perform the same. If homeopathy had any greater power to invoke the placebo effect, then it would do so to a greater extent than plain old sugar. It doesn’t. As such it becomes a shaky question simply of whether the doctor feels ethically sound prescribing sugar pills to a patient with a condition, or not.
    Homeopathy doesn’t come in to it as a consideration.

  44. Enders Shadow said,

    March 2, 2010 at 1:34 am

    At the risk of repeating myself:

    1) Being subject to homeopathic care is associate for some people with an improvement in otherwise problematic medical conditions.

    2) We seem to have established that this is not caused by the medicines prescribed by homeopathy.

    3) In a rational world this would not happen – but it does. In the interim we label the effect ‘the placebo’.

    4) Until we can fully explain why the placebo effect works, we can either deprive some people of its benefit, or we can admit that hurting people are being helped by it.

    Given the above, IMHO it is healthier to be pragmatic and allow people to gain relief from their symptoms than pursue a ‘fundamentalist’ line and deny them the possibility. Yes, it makes for a less than pure ethical line, but in the real world ethics are never absolute… I still think that it is not unreasonable to expect a doctor to come out, when asked, with some phrasing like: ‘Homeopathy seems to enable healing to occur in some people who otherwise remain ill. We don’t understand why…’ Yes it’s mumbo jumbo – but it’s helping people. Isn’t that what doctors are there for?

  45. Filias Cupio said,

    March 2, 2010 at 3:25 am

    (continuing from messages 1, 4, 8)
    I’ve only had 20 years with scientists, so you have me beat there – but you must have some alternate definition of “opinion” or “has room for” compared to me for that statement to bear any resemblance to reality.

    Scientist A writes a paper saying “while most scientists in our field believe Z, in fact it is unsupported by evidence and/or utterly wrong.” Scientists B, C and D write a response strongly defending proposition Z. Neither side convinces the other, but other scientist readers are convinced one way or the other.

    Is this scenario not science, or does it not not include at least one opinion? I’ve seen this many times, with Z as diverse as “elliptical galaxies are formed by mergers of spiral galaxies” to “the Chicxulub meteor impact caused the extinction of the dinosaurs”.

  46. Filias Cupio said,

    March 2, 2010 at 3:28 am

    P.S. that is “(continuing from messages one, four, eight)” – I was caught out by an over-enthusiastic smiley translator and no ‘preview’ option.

  47. Sriram said,

    March 2, 2010 at 6:24 am

    Many people initially go in for regular allopathy treatment for any ailment. It is when this treatment fails or creates side effects, that they switch over to homeopathy. If the homeopathy medicine gives relief only due to the placebo effect, then the earlier treatment using regular medicines should also have given relief due to the placebo effect. This is not so. Surely the placebo effect is not applicable only for homeopathy!!

    Secondly, for any ailment, specific medicines like say Bryonia or Nux Vomica are given in homeopathy, which only will cure the patient. Any other medicine ( say Lycopodium or Sulphur) will only complicate matters and maybe increase the problem. So placebo cannot be the explanation.

    Finally, homeopathy has been known to work on infants and animals where the placebo effect is irrelevant. The often given explanation of ‘placebo by proxy’ is meaningless!

  48. Enders Shadow said,

    March 2, 2010 at 7:47 am

    Indeed Filias Cupio, it never ceases to amaze me how often we hear the phrase ‘scientists believe’ in respectable scientific discourse – but then find ‘rationalists’ objecting when scientists use the same language when talking about their belief in God…. ;)

  49. DrJG said,

    March 2, 2010 at 7:57 am

    @Sriram – in haste before heading for work:

    Para. 1: To prove your contention, you would (at least) have to prescribe your “remedies” in identical circumstances by the same practitioner under the same time constraints. Otherwise, you have not demonstrated that it is the sugar pill alone which has made the difference.

    Para. 2: Can you point to any credible evidence that the homeopathic preparation given really does make the slightest difference to the perceived outcome?

    Para. 3: When the infants or animals in question tell me directly what improvement they have experienced, I might take that argument seriously. Until then….

  50. Guy said,

    March 2, 2010 at 8:21 am

    Sriram,
    you may believe this mumbo jumbo
    “Secondly, for any ailment, specific medicines like say Bryonia or Nux Vomica are given in homeopathy, which only will cure the patient. Any other medicine ( say Lycopodium or Sulphur) will only complicate matters and maybe increase the problem. So placebo cannot be the explanation.”
    But that is why we have RCT’s to show that none of these medicines have any specific action at all. Please don’t go over the same old ground. Homeopathy is placebo. That’s fine and interesting to discuss. Ignoring the research and continuing the mumbo jumbo isn’t interesting.

  51. Sriram said,

    March 2, 2010 at 9:32 am

    Hi Guy,

    But taking the wrong homeopathy medicine will not cure the problem, it could aggravate it. That’s not placebo!!

    Also, you haven’t told me how placebo works on infants and animals. And why regular allopathy medicines that are taken before switching over to homeopathy, do not exhibit the placebo effect.

    Research is a continuous process. Many medicines are approved after much research and then banned after further research. No research is ever final.

    Cheers.

  52. dabscience said,

    March 2, 2010 at 9:45 am

    While we were distracted by the homeopathy story we missed much more exciting news about a promising but often neglected cancer treatment that has been with us for at least 2000 years- brought to you again by the BBC:
    news.bbc.co.uk/1/hi/world/asia-pacific/8452403.stm

  53. skyesteve said,

    March 2, 2010 at 10:10 am

    Hi Sriram – placebo effects are “real” – the argument is is homoeopathy more than just placebo effect and so far the answer is a resounding no. The “success” in children and animals is NOT based on RCTs but rather on observational anecdote. Give the baby some chamomilla teething powder and it stops crying but unless you do an RCT how do you know that’s not because you’ve just put something sweet and tasty in the baby’s mouth? Or give a colicky baby colocynthis and 30 minutes later the colic settles but given the nature of infant colic that would have happened anyway so how do you know the colocynthis had a specific effect?
    It’s already recognised that at least part of the benefit of a drug are placebo – give an antibiotic and people will feel better even if there are no bacteria present; “red” ibuprofen works better than “blue” ibuprofen (why? because red is the “colour” of pain in people’s minds); “blue” antidepressants work better than “red” ones (why? because “blue” is the colour of depression); etc.
    But the difference is that with an active drug the real physiological effects (and side effects) are more powerful than placebo and, therefore, they mask or overwhelm whatever placebo effect there might be.
    In addition, you are not giving an active drug because of its placeebo effect – you are making a presumptive (or confirmed) patho-physiological diagnosis and then using an active chemical with demonstrable physiological/pharmacological effects in an attempt to address that patho-physiology.
    For example, how antibiotics kill bacteria or how ACE inhibitors reduce blood pressure or how insulin reduces blood sugar levels is quite clear (unless of course you just want to dismiss 100 years of established scientific research and understanding). That’s the kind of evidence that homoeopathy needs if it wants to be taken even remotely seriously. It’s not enough to say I gave it to my dog and now he’s chasing rabbits again.

  54. Guy said,

    March 2, 2010 at 11:12 am

    Sriram,
    you state “But taking the wrong homeopathy medicine will not cure the problem, it could aggravate it”.
    That is your belief. There is no evidence that taking the “wrong” or the “right” homeopathy medicine will make any difference. To assert there is, you need to produce some randomised placebo controlled trial evidence. That is what the MP’s spent their time looking at and rightly concluded that homeopathy doens’t work in children, pets or adults. As Ben has outlined many times, there is now sufficient research in homeopathy to be final- it is purely a placebo.
    If you really want to learn about the placebo effect, then read Snake Oil Medicine, which is excellent.

  55. pv said,

    March 2, 2010 at 11:33 am

    There is no physical difference between any homeopathic remedy at 30C dilution. As has already been stated by some “leading” homeopath in the House of Lords some time ago, the only way to tell the difference is by reading the label on the bottle. If you swapped the labels no-one would be any the wiser and there would be no effect outside any possible placebo effect – which in my view has been highly overstated.
    There is no right and wrong medicine in homeopathy because it’s basically free of anything medicinal.

  56. Sriram said,

    March 2, 2010 at 2:46 pm

    Hi skyesteve, Guy and PV,

    I understand the point you’re making. I am not undermining clinical trials nor the need for such trials. My point is that we do not yet understand how homeopathy works. Fine. So what? We might understand it in the future. We cannot take a dismissive stand on such an important issue when millions of people are finding it useful.

    I know from personal experience that the pills work and work very well in some cases. There are millions of people like me from educated communities who also use homeopathy regularly.

    I have tried them on my own children and they work very well for a variety of ailments. We obviously need to use homeopathy medicines judiciously for the right type of problems.

    I have been intrigued by the simplicity of homeopathy and have therefore, over many years, studied it (informally) and have tried out various medicines on myself. I know the medicines work and would certainly recommend them to others also. That is all I am talking about.

    I have no idea how they work but I know they work. Placebo simply cannot be the answer.

    Cheers.

    Sriram

  57. Guy said,

    March 2, 2010 at 3:19 pm

    Sriram
    this is a rather pointless discussion.
    you state “I know from personal experience that the pills work”.
    This then becomes a discussion about how we know what we think we know. There are hundreds of years of scientific study and philosophy behind this. Yes we know how to test if something works. Otherwise we’d still be bleeding patients and using thalidomide.

    Homeopathic medicines are no different to water, ie have no effect. Yet you find they work. That is a good definition of the placebo effect.

    Surely you can understand that you trying them out on you or your kids is pure anecdote and nothing to do with evidence?

  58. Sriram said,

    March 2, 2010 at 3:26 pm

    Hi Guy,

    It is an anecdote for you but a personal experience for me! Obviously I will see it somewhat differently from the way you see it!

    I know it is a pointless discussion because I can’t ‘prove’ my point…..but I thought it is necessary to state my view all the same.

    Cheers.

    Sriram

  59. Guy said,

    March 2, 2010 at 3:27 pm

    Sriram
    I’ve included a link to Robert Carroll’s site on Critical Thinking so that you can get some background on how we know what we know.
    www.skepdic.com/refuge/ctlessons.html
    hope this helps your understanding.
    Guy

  60. jgrellier said,

    March 2, 2010 at 4:16 pm

    @Sriram

    “It is an anecdote for you but a personal experience for me! Obviously I will see it somewhat differently from the way you see it!”

    Anecdote: an account of a personal experience i.e. exactly the kind of thing that you have been posting, and precisely the kind of inappropriate and irrelevant nonsense that prevents interesting discussion of any of the real issues at stake here.

    As for your general desire to remain completely ignorant of science, consider this: if engineers had been relying on a couple of centuries of weakly inductive “personal experience” to inform them on the principles of electricity, do you really imagine that you’d be sitting in front of a functioning computer now? Why are you people so happy to put your faith in the science (and the philosophy that is behind it) to build the tools you see all around you, but refuse to accept that the same rigorous methods can be applied to your quackery?

  61. skyesteve said,

    March 2, 2010 at 4:33 pm

    @jgrellier – you hit the nail right on the head. All the people who refuse to accept that homoeopathy is no more than placebo yet are quite happy to accept all other scientific research and evidence that allows them to watch TV, listen to the radio, play music on their MP3 player, fly off on holiday, switch on their central heating, live in a building that won’t fall down, drive a car, hop on a train, keep their food cool in a fridge (or heat it in a microwave), taste the flavour of their favourite crisps or curry sauce, enjoy a cold beer on a warm day, etc., etc. are, IMHO, just living in cloud cuckoo land.
    The fact that some folk who are supposed to be educated in science or medicine believe in homoeopathy just astonishes me but, in the end of the day, it’s very difficult to reason against willful ignorance.

  62. Sriram said,

    March 2, 2010 at 4:43 pm

    Hi jgrellier,

    This is not about the veracity of science at all. It is about knowing something to be true that science is unable to investigate at present. That’s all. There are many such phenomena.

    At any rate, I am not interested in entering into a general discussion on Objectivity vs Subjectivity on this thread.

    Cheers.

    Sriram

  63. skyesteve said,

    March 2, 2010 at 4:59 pm

    Hi Sriram – science has investigated it thoroughly and found it wanting – that’s the whole point of this and other recent threads.
    If it helps you and you want to pay for it that’s fine – you pays your money and takes your choice, as they say.
    But why should a health service which is based on the idea of an evidence-based medicine approach ignore the evidence and pay for it anyway?
    That’s the real issue at the heart of recent deliberations and discussions.
    I believe it’s not good enough for the homoeopathic lobby to say “we don’t care that we can’t prove it – just gives us the money”!

  64. DrJG said,

    March 2, 2010 at 5:14 pm

    @emen – “if somebody responds well to a homeopathy placebo, they might START with that next time..” Aha, thank you – I think you’ve put your finger on something I’ve been groping for.

    But I am going to defend my colleagues (I’m Sure you didn’t mean Me!) from your accusations of laziness, at least in antibiotic prescribing, and I will also defend us from jwm’s comments about over-investigating.

    The problem with antibiotics is not that they don’t work, but that they are unlikely to work. Statistically, for, say respiratory infections, the antibiotic group recovers a few hours faster than the placebo group. As it is unlikely to have a small effect on most patients, the more likely explanation is that the antibiotic has a major effect on a small number of people – but which? It has been suggested that the antibiotic helps in the small proportion of cases who would otherwise have gone on to develop pneumonia. One figure I read somewhere – sorry, no idea where, was a rough estimate that, for every 150 “withheld” prescriptions for an antibiotic, there would be one serious illness – but obviously this will depend enormously on what criteria are used to decide when an antibiotic might otherwise have been prescribed.
    Then, the problem for the doctor is that, in the rare case, if the patient wants to complain, the 149 times the antibiotic was withheld with no consequences doesn’t count for a thing. “Failure to prescribe”, with “failure to refer” are still amongst the commonest reasons for complaints against GPs. I know this from personal experience. The last time I had a serious complaint – quite a while ago, but around the time of the “antibiotics – don’t wear them out” campaign – was a toddler with the most straightforeward coryza possible – not a hint of any lower respiratory involvement. After seeing this child for the thrid time in a week, and declining a direct request for antibiotics, parents carted her of to A+E where, according to the complaint letter, they were told that she needed “strong” antibiotics (this always puzzles me – I was never taught when it was appropriate to prescribe “weak” antibiotics”.) OK, partly I was stitched up by a junior A+E doc, though I doubt that they ever said a fraction of the damning things claimed for them. But where it really went wrong was the attitude of the management at the PCT, and even, I’m sorry to say, my defence organisation. The PCT clearly wanted me to apologize for my “error”, so they could close the complaint. No interest whatsoever in whether or not I had acted appropriately. When the defence lot advised me to apologize too, I realised that I was on a losing hand and folded.
    Therefore the family “learned” that the doctor who gave appropriate advice had to apologize and the doctor who failed to do so was “right”, I learned not to stick my neck out, and the PCT couldn’t give a stuff.

    Regarding investigation, my next anecdote – sorry, illustration, is about testicular lumps. When I was fairly new in GP land, I saw a young man with a scrotal lump. This felt benign but, at that time, I was still unsure enough to refer al such lumps for an ultrasound. However, the referral was returned as the department had recently decided only to accept such referrals from a specialist clinic. Fortunately for all concerned, as I had already promised the patient a referral of some sort, I did refer them to the Urology clinic. The consultant also reported confidently that this was benign, which is how I can be sure that it was not my clinical skills at fault. However, the patient was referred for an ultrasound, which in fact showed that the lump was malignant. The policy on GP referrals for scrotal ultrasounds was rapidly reversed after that.
    My point is that it is not the nice neat textbook cases which cause the difficulties, it is the unusual ones. It is the patient with all the hallmarks of non-cardiac chest pain who has actually had an MI. It is the vague abdominal pain with no tenderness that does turn out to be appendicitis.
    In fact, more experience in my career has actually made me less confident in many ways, as I have seen more and more of the exceptions to the rule. Add to that all those who are perfectly willing to hang you out to dry if you get it wrong, and certainly will not say a word to defend you that you did actually follow guidelines, and you might start to understand why we are sometimes a bit circumspect in our practice. A friend of mine quit his psychology career as he was fed up with the blamestorming – generally led my non-clinicians – on the occasions when a patient committed suicide.
    So if society wants doctors and other clinicians to stick to what is regarded as best practice, then society needs to be a whole lot more supportive of them when that leads to negative consequences. Remember, complaints are stressful and grossly time-consuming whether they are upheld or not, and few of us have much faith in the system, at least at local level, to have any real interest in making good decisions.
    Now, who wants a script for some Augmentin?

  65. Guy said,

    March 2, 2010 at 5:14 pm

    Sriram,
    you hit it on the head when you said it was my anecdote and your experience. What you would realise if you investigated this a little further, is that everything that I observe is also anecdote. I am no better at knowing whether the little white sugar pills helped me or not, than you are. This isn’t criticising you. It is criticising the way people reason and think. I can’t possibly know if anything I take or give someone helps them. That’s why we have critical reasoning, science and the gold standard RCT, which could have been designed purely to test homeopathy it is so well suited.

  66. emen said,

    March 2, 2010 at 5:28 pm

    Sriram,

    I understand perfectly where you are coming from.

    If you compare taking homeopathy with taking nothing, homeopathy will often work. Everybody understands that here, I think.
    I have seen a lot of people benefit from homeopathy to such extend that I’m almost sorry I know it is only placebo and it won’t work for me!

    It is because the placebo effect IS powerful, even when your illness is real – you are NOT just imagining the effect. (And the placebo works for pets and babies.)

    The problem is that when we compare homeopathy with the placebo effect, we dont’ really find any difference.

    Now, if homeopathy plays such an important part in your life as you describe it, your brain will refuse to take this information in – I kind of understand.
    But don’t fight on behalf of homeopathy on this blog…

  67. Sriram said,

    March 2, 2010 at 5:39 pm

    Hi everyone,

    I am not lobbying for homeopathy on the NHS or whatever. I don’t even live in the UK.

    But when I have found something useful I find it hard not to support its cause.

    I also cannot accept that my personal experiences become invalid just because a few scientists tell me that it is invalid. Science has its place while our personal experiences have their place and value.

    And knowing science, it could make a volta face a few years down the line, and some scientist could very well discover the reason why homeopathy works. I can’t wait for that….I know that it works for me.

    Cheers.

    Sriram

  68. Guy said,

    March 2, 2010 at 6:18 pm

    You are welcome to your view. Just not sure why you are posting on a website called bad SCIENCE. Science is about how we measure and know things. Ignorance and anecdote aren’t part of science.

  69. emen said,

    March 2, 2010 at 6:44 pm

    jwm #42

    “Ah, the ever present patient belief that tests = good care even though 90% of a patients diagnosis comes from a good history. Its why outpatient ECG and ultrasound lists are the most boring thing on the planet as you’ll only ever see about one or two cases of genuine pathology per afternoon/morning session as the rest are all being done as patient pacificants.”

    How dare you SAY that??

    I imagine next time, after 2 months of waiting in sick-in-the- stomach chilling scare, if your sonographer finds that you haven’t got a tumour and it’s nothing to worry about AFTER ALL, you will curse the machine and the doctor for such a boring waste of your time.

    No, I tell you what it’s like: you have a piercing pain at the side of your stomach. You see your doctor, he examines you and he says:
    1. it could be “nothing”
    2. it could be a bladder infection
    3. it could be bladder stones

    Mm…don’t know without a scan… Let’s go for #2 and give the patient antibiotics. No wonder the placebo effect of those tablets will not be very strong.

    A friend of mine had a baby and didn’t stop bleeding for weeks. She saw the GP twice, each time the GP prescribed antibiotics without asking her any questions. Finally she went to A&E, they did an US, found something horrible was going on and that she needed surgery. The hospital doctor asked her why she hadn’t come earlier….well, somebody had kept reassuring her with the placebo antibiotics, hadn’t they?

    Dodgy knee? Take ibuprofen, GP has no time to even have a proper look. Getting worse? Take diclofenac. Even worse? Take slow release diclofenac. The cyst has burst? Ah, but there was really no way of knowing, was there…?

    I could go on forever with such stories, trust me.
    And there are countries in Europe where the GP will scan your dodgy knee the first time you turn up.

    It is one thing to know that state healthcare in the UK is rubbish. Last time we talked about it on this blog, doctors agreed GPs need more access to tests and scans if they need to keep patients away from expensive secondary care.

    But it is quite another thing for you to come here and have the cheek to say it is only in patients’ imagination.

  70. ghizlane said,

    March 2, 2010 at 8:27 pm

    Hi Sriram,

    The choice of homeopathy as a treatment is a personal and private choice and can not have the same STATUS as medicine as long as it has not satisfied the scientific medical criteria, standards and procedures.

    It might work for those who BELIEVE in its efficacy and effectiveness, but this doesn’t give them the right to say it will work for everyone and so recommend it for people.

    Yes, I am talking about status and believe because, deep beneath this seemingly simple and obvious question, there is a whole society choice: what kind of illness treatments do we want as societies and what are the logical implications of each choice? do we want to recommend treatments which are built upon personal beliefs of the patients or the ones that are proved objectively to be working regardless of the patient linguistic, cultural, religious… backgrounds?

    The question is that simple and that complicated; I have a tragic example (sorry, but sometimes it helps get the bigger picture): If I had children and one of them gets sick, what do I want for my children? And if the disease doesn’t get cured, what do I say to my child then? «Honey, doctors didn’t find a cure yet but they are trying hard.. maybe in a few years…» or «it didn’t work because you didn’t BELIEVE enough, it is all YOUR fault».

    You might not agree yet, but the logic behind each kind of treatment is the same here in this example. If we choose as a society to be treated with non-medically and scientifically recognized ways, then we are back to the religious and religious like healing ways and the «if you believe you will be cured» discourse. In that case, why do we bother have medical trained doctors at all: let us go back to all kinds of religious and religious like figures whom would tell us that it is «our faith that cures us».

    This is why science and scientific standards must be respected in giving any new treatment a medical status: science might take time to find cures for some diseases, but it had proved us its worth and it is the only objective way we can, as a society, be sure to progress and evolve in making new breakthroughs and finding new treatments to all kinds of diseases.

    Now having said this, if, as it is observed, the mind has an amazing power over the body and believing in the efficacy of a treatment can make it work better, even if it has no active chemical components (the placebo effect); then why not believing in the worth of our doctors instead of using this to divert from conventional medicine? This would add to the objective efficacy and effectiveness of the medical treatments.

    At the end, I can maybe add this: could a now homeopathy treatment become one day a scientifically proved working one: I don’t know, maybe! but, until then, if we were as a society to start allowing all kinds of subjective claims to be held as objective and having the same status of the medical practice… then we would be in big trouble!

  71. jwm said,

    March 2, 2010 at 9:44 pm

    emen

    I apologise for the calousness of my statement.

    Your not medically trained so I’ll forgive the numerous fallacies in your clinical examples, however, to address some issues you raised:

    “And there are countries in Europe where the GP will scan your dodgy knee the first time you turn up.”

    This is extremely worrying as US is THE most operator dependant scan there is, and if youve not been doing a large number in a specialised training environnment for several years then your going to produce a very large number of false positives and false negatives. So that ‘large dangerous mass’ in your kidney which your GP saw
    and you then waited for 2 weeks to see the specialist, then another 3 weeks for a properly trained scanner with the diagnosis of ‘confirmed cancer’ running through your head will turn out to be a benign lump of no significance.

    “GPs need more access to tests and scans if they need to keep patients away from expensive secondary care”

    Secondary care is expensive because lots of tests are involved. Primary care is cheap because few tests are involved. If you increase the number of tests occuring in primary care, what you get is expensive primary care. Its a balancing act, with extreme difficulty determining what will actually save money.

    “It is one thing to know that state healthcare in the UK is rubbish”

    I couldnt disagree more. The NHS is a phenomenal organisation which will provide you the same exceptional level of care whatever your background, staffed by doctors who are interested in your illness rather than the contents of your wallet.

  72. Filias Cupio said,

    March 2, 2010 at 10:34 pm

    @Enders Shadow:

    All I’m claiming is that scientists often have scientific opinions, which may conflict with those of other scientists. We can expect these disagreements to eventually be resolved by more science. Indeed, they are a vital part of science – they highlight where uncertainty lies and therefore where more research is required.

    You seem to take from this an equivalence between scientific belief and religious belief. This is certainly not what I intended. (My personal “religious” beliefs are in pretty close alignment with those of Richard Dawkins.)

  73. toumai said,

    March 3, 2010 at 6:14 am

    @ Siram

    Homeopathy works on babies and animals because the people recording their results KNOW what treatment has been given. That gives a bias (however unintentional) to any data. It is not a scientific test.

    In scientific trials there have been NO replicated positive results showing homeopathy performing better than chance (can I check that with the more current scientists here, please?). In a scientific DOUBLE BLIND trial, the person giving the remedy does NOT know if it drug (in this case “drug” = homeopathic remedy) or placebo and the person recording the data also does NOT know.

  74. Sriram said,

    March 3, 2010 at 12:18 pm

    Hi toumai,

    But how can the blisters, rashes, diarrhoea, fever indigestion etc. of a baby disappear because his father knows that a treatment is being given? That would be miraculous! Why doesn’t the same ‘miraculous’ cure happen when regular allopathy treatment is being given? Why does that lead to side effects?

    If placebo is so effective, maybe we should do away with all medicines and only work with sugar pills. Won’t the Pharma companies be mad?!!

    Anyway I realize most people have made up their minds that Homeopathy cannot possibly work and therefore they need to come up with convoluted arguments as to how it may work. I also know I cannot possibly convince anyone over a blog. So let me end my discussion here.

    Thanks & Cheers.

    Sriram

  75. emen said,

    March 3, 2010 at 1:25 pm

    jwm #71

    Ha-ha-ha

    I’m ever so grateful that you FORGIVE me for the numerous fallacies in my clinical examples. All the more so, because all the things I said were simply original quotations by doctors.

    You say “that ‘large dangerous mass’ in your kidney which your GP saw and you then waited for 2 weeks to see the specialist, then another 3 weeks for a properly trained scanner”

    – except it is only under NHS UK that you wait 2 weeks and then 3 weeks, a lot less in other European countries

    (it is also the speciality of the NHS that once they DO have the result whether your tumour is benign or malignant, you have to wait 2 weeks for them to tell you – because they have to give you an appointment at clinic and “you don’t want to hear it on the phone”, they decide)

    you say: “Secondary care is expensive because lots of tests are involved. Primary care is cheap because few tests are involved. If you increase the number of tests occuring in primary care, what you get is expensive primary care. Its a balancing act, with extreme difficulty determining what will actually save money.”

    Notice how you say “save money”, not save lives.

    But as Mike Richards, the national cancer director for the Department of Health puts it: “Undoubtedly, our cancer survival rates have been poorer than many other countries. The question is, why? The more we look into that, the more apparent it is that late diagnosis is the problem and, therefore, failure to get the patient to the curative treatment. The curative treatments for cancer are very often not that expensive. The best treatment for cancer in many cases is surgery, and well-done surgery is not that expensive, whether it is for breast cancer, lung cancer or colorectal cancer. We are simply not picking up patients early enough. This comes back to the previous discussion about primary care, of which I am a very strong supporter; I am from a family of general practitioners. We have tied the hands of our general practitioners to a certain extent because we have asked them to be overzealous gatekeepers, but we have not given them access to diagnostic tests. This is why I so strongly welcome the recent announcements that we will improve access to diagnostics for GPs. For cancer patients, for example, this will mean that people who have a low risk of having cancer based on their symptoms – but not no risk – will be investigated, and investigated quickly. The vast majority will then be reassured, but the small number who are found to have cancer will go into the system at a curable stage. That is a very important point. We need to put more emphasis on diagnosis and take more money out of the hospital system in terms of people being in beds when they do not need to be.”

    you say: “The NHS is a phenomenal organisation which will provide you the same exceptional level of care whatever your background, staffed by doctors who are interested in your illness rather than the contents of your wallet.”

    Let me ask you for a definition of “exceptional” here. Exceptionally what?
    Bad?
    Compared with private healthcare or healthcare in other countries? Which countries?

    As I have pointed out the NHS will not be interested in the contents of your wallet, it will be interested in the content of ITS OWN wallet, and not your illness.
    Go and study how German healthcare is funded, and you will see what it is like to provide EXCEPTIONALLY GOOD service without knowing the content of your wallet.
    Until you have done that, save your brainwashed propaganda for yourself.

  76. emen said,

    March 3, 2010 at 1:39 pm

    Oh, and this acute worry about GPs doing scans and then coming up with a lot of false positive and false negative results.

    Obviously you would have to TRAIN these doctors first. I would have thought it would occur to some.

    For example: if you are a woman and you want a contraceptive coil fitted, the coil’s manufacturer tells the doctor to do an US after it’s fitted to check if it’s OK. In the UK, they don’t follow the manufacturers’ instructions (as opposed to everywhere in the EU, including Eastern Europe), because the doctors are not sufficiently trained to do their job.
    (Before you jump again, this too was explained to me by an NHS consultant gynaecologist.)

  77. pv said,

    March 3, 2010 at 2:29 pm

    Sriram, firstly there is no such thing as allopathy. There is medicine and there is stuff that isn’t medicine. Homeopathy isn’t medicine, it’s medical fraud.

    About the things that babies get – rashes, diarrhoea, fever, indigestion, etc. – most of the time they are self-limiting so it is no miracle that they get better by doing nothing.
    However, if I’m not wrong, you don’t quite grasp the difference between feeling better and actually being better. People,including babies, often feel better by being comforted. The expectation of feeling better often leads to just that – ask any intelligent parent. With self-limiting conditions, such as babies often get, recovery not unsurprisingly tends to follow… giving the ever so slightly dimwitted the impression that it wos the ‘omeopathy wot dun it.
    When the same gullible adults are advised that plain water and sugar pills contain magical medical properties, the outcome for self-limiting conditions is not surprisingly no different as for babies.

  78. DrJG said,

    March 3, 2010 at 3:20 pm

    @emen – Re training GPs – I’ve been waiting for a while for the (usually financially motivated) claim that “given suitable training and equipment, GPs could carry out the Coronary Artery Bypass Grafts” for those of their patients languishing on the waiting lists.
    Which may well be true, but would also mean that we were no longer GPs but were Cardiothoracic Surgoens, who tend to be less skilled at managing such things as depression.

    On a slightly less cynical note, where is the time going to come for all of this on-site investigations (nevermind the training itself, and required ongoing training. We have already established that lack of time for a GP compared to a woo-merchant is likely to be a significant factor in patient satisfaction rates. I am already perfectly capable, without the need for further training, of taking blood tests from my patients. In fact, I would love to have the sort of workload where I had that much time to spend, at need, with my patients. The reality, of course, is that if I do not delegate such tasks to others, I have even less time to spend with the next patient.
    Of course, in many countries doctors charge per task, so there might be financial incentives to perform scans which have extremely low pickup rates. That does not make them good use of a doctor’s time, however.
    I’ll come back to you on the IUCD rubbish later.

  79. commedesenfants said,

    March 3, 2010 at 3:38 pm

    Dr Goldacare,

    have you heard of this… (atrocious) thing called neuro-linguistic programming (NLP)?

  80. commedesenfants said,

    March 3, 2010 at 3:39 pm

    I apologise for the typo error in the above post.

    Dr Goldacre*

  81. emen said,

    March 3, 2010 at 3:49 pm

    DR JG #56

    Ooh, sorry!, I completely missed reading your comment until now.

    Thank you – what you say all makes sense and is useful, and I totally sympathise with you about this “complaint culture”. It must be stressful and weary and often unfair.

    1. To make my point a bit clearer: my issue with SOME of the GPs I know (not you or skyesteve or anybody here) is not about antibiotics or no antibiotics.
    More about the lack of more self-help advice, more listening, a few more tricks about massaging my tense shoulders to prevent headaches, gargling with salted water for a sore throat etc (if it’s printed on a leaflet if there is no time to explain, that’s fine). A little bit more explanation on what causes what and why. I realize that every patient is different, with different expectations, different anxiety levels about say a mild sinus infection or toddler vomiting. I’d rather have a GP who is not nicey-nicey, but willing to explain and name things, and give a few more of those little extra ideas. Patients can fill in the unexplained gaps with the most shocking ideas coming from their untrained imagination, believe me.

    This is where the placebo comes into it: my little daughter has recently been sick. I wasn’t too worried about it but even a day later she kept on saying it hurts, she feels nauseous, she was pale and worried and unhappy.
    So we took her to see the GP, who listened to her, examined her and said to her “You are not going to be sick again now”. That sentence completely changed our little one, she stopped feeling nauseous, perked up and started to eat. She repeated this several times that day, “Dr D says I’m not going to be sick again, now I don’t feel sick!” This is the kind of placebo effect I am after, and also “drink a lot of water, eat bland foods because that will help a lot”. No sugar pills prescribed, not medicine prescribed, but it was a lot of help.
    But some GPs will just say, oh, that’s normal, you don’t have to do anything with her, this will go away by itself (it will, but we need a little more attention somehow to be happy).

    Now, I realize that it is usually a question of time (money, funding): if the GP had 30 minutes, we could have all this and would recover quicker and would be a lot happier.
    That would be the ideal alternative to homeopathy the way I see it.

    One illustration I have just heard: baby’s viral bronchitis, no antibiotics needed. NHS GP examined the baby and explained quite a lot about it (so he is a good one!), so the family is happy to wait. Same case in Germany, baby, viral bronchitis, no antibiotics needed. But while they are waiting, the baby is given a salt pipe to help clear the infection quicker and exact instructions to watch out for signs of asthma (how would the cough change) for the parents etc. Sounds like there is no basic difference in the care this time – but still, the parents do feel better that there is something they can do while they wait. It DOES make a big difference.

    2. The other issue was about having access to tests and scans – obviously it depends what the problem is. But it is often my impression that a scan or a blood test or urine test or a throat swab in SOME cases would be helpful (virus or bacterium? and which one?), is the gall bladder infected or is it just trapped wind? is there an underliing dustmite allergy in this patient’s constant coughs and colds or just unlucky?
    Or if not the GP himself: in Germany you can go to see a gynaecologist without seeing the GP first (you might need a letter from him), and the wait to see the specialist is about a week, and she will have US and tell you exactly there and then what seems to be the problem and what to do next.
    Here on the NHS I wait for the GP to refer me (2-6 weeks?? by the time I convince him), then wait for a month to see the specialist and wait another month to have the scan done. Then the sonographer can’t tell me what’s wrong, she will write to my specialist and they have a multidisciplinary team meeeting in the hospital within two weeks, and then they write to me with another appointment some time in the future, where the specialist can finally tell me what the German one would have said the first week.
    One week or 3 months do make a big difference, especially if you don’t know what is wrong. And even it’s not cancer or some other sinister news, things tend to deteriorate when untreated.

    No Augmentin for me please… :-))
    but you do sound like you don’t live your life thinking ah, what a fantastic world class service, and life on NHS is paradise on earth, and most patients are idiots.

  82. emen said,

    March 3, 2010 at 3:52 pm

    I meant

    Dr JG #64 (not 56)

    sorry

  83. truthygum said,

    March 3, 2010 at 4:32 pm

    Thank you pv. We can be very grateful for a dose of time (that which we take so much for granted) for curing most things. It works remarkably well with trivial ailments. How often its powers must be lost to all forms of labelled concoctions.
    So what’s the harm with homeopathy if it sometimes helps things along with its placebo effect and further, that some of those who prescribe it are even prepared to admit that its singular positive attribute is the placebo effect?
    Try denial, deception, and a sideswipe at the fabulous reality of the natural healing process, to name a few. Oh and cultivating ignorance about the true power and potential of the placebo, which is yet to be fully harnessed. Just give it time.

  84. Sriram said,

    March 3, 2010 at 5:44 pm

    Hi pv,

    So what you’re saying is that time will heal everything. No need for pediatricians at all. Hmmm!

    Not sure the NHS will agree though!

    Cheers & goodbye

    Sriram

  85. pv said,

    March 3, 2010 at 5:49 pm

    truthygum, homeopathy is fraud – that’s what’s wrong with it. A means of deceiving and extracting money from the gullible and vulnerable. It is simply lying… taking money under false pretences… like selling fake insurance policies.
    There is no more reason for believing homeopathy does any more than its actual ingredients allows (water/lactose) than the core of the planet Earth being made of mozzarella, or the existence of phlogiston. The evidence for each is not only zero, it is to the contrary.

    The “power and potential of placebo” my arse. Homeopathy is more than 200 years old. How much time would you like? Its record against non-self-limiting conditions is precisely zero, while its record against everything else can be explained by any number of confounding factors.
    And how many times would you like it repeated that the placebo effect is there for all medicine? It’s even there for a hug and a few kind words.

    “Homeopathy didn’t work for me” would make a good slogan, because I’d hazard a guess that for most people who try it it doesn’t even have any placebo effect. Then they grow up, see it for what it really is and move on.

  86. pv said,

    March 3, 2010 at 5:52 pm

    Siriam, no I am not saying time will heal everything. Yours is the sort of dimwitted, and dare I say dishonest, selective quoting and reinterpretation so beloved of woos and quacks. Learn to read!

  87. emen said,

    March 3, 2010 at 6:29 pm

    Sriram,

    where do you live by the way?
    That alone can make a big difference to how much effect homeopathy will have.

    We are not saying homeopathy doesn’t work because it is incompatible with what we know about the world. You don’t need to understand HOW something is supposed to work to determine whether it works or not.
    So when you compare homeopathy with placebos in double blind trials, homeopathy doesn’t seem to work better than placebo. Patients WILL get better in BOTH groups, of course, some will heal spectacularly!
    That’s why we say it is “only” placebo.

    It works and it has no side-effects, so you can use it for small ailments, or if mainstream medicine has nothing to offer, you can definitely try it. I have seen people completely recover from asthma, hay-fever, eczema, flu, coughs, sleep-problems, chronic sinusitis, mood problems etc with homeopathy. So I don’t doubt what you are experiencing is true.
    If you are careful not to forget to use real doctors when it’s necessary (or rather: try to get a diagnosis from a medical doctor first!), that’s fine.
    Although it is easy for me to say that here, I am not a doctor and I have no responsibility, I’m just chatting.
    But you also need to understand that on this blog we don’t tend to leave “proven to be ineffective” quack therapies uncriticised.

  88. DrJG said,

    March 3, 2010 at 9:10 pm

    @emen – as promised, I now turn to your comments on IUCDs which, I am afraid, are a load of foetid dingos kidneys, certainly when it comes to the UK. There is no expectation of routine ultrasound examination after fitting of IUCDs. The information leaflets produced by the manufacturer of the Mirena Intrauterine System make no reference to routine ultrasound. The guidance produced by the Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists makes reference to Ultrasound examination in the following situations: If uterine perforation is suspected at the time of insertion; if the thread cannot be felt, in case the device has been expelled; and, for the Mirena, if menorrhagia continues after insertion.
    I do not know what the procedure is in other European countries, but once again I reference the temptation to perform unnecessary investigations when a fee can be charged. Maybe relevant that the only place I could find that appeared to be suggesting routine ultrasound after IUCD fitting was a private clinic somewhere in the Midlands, though frustratingly the link has disappeared on re-doing the search. This is, as I note above, contrary to the advice of the relevant authority on the subject.
    A possible explanation for your confusion might be the routine requirement, during the fitting of an IUCD, to “sound” the uterus. This is a different thing altogether. But if you want to get into a “my source is more important that your source” willy-waving contest, I shall ask John Guillebaud when I see him at a family planning update in a couple of weeks time. I think that most medics would think that “Dr Contraception” would trump pretty much any Gynaecologist.

  89. jwm said,

    March 3, 2010 at 9:41 pm

    emen

    “Obviously you would have to TRAIN these doctors first. I would have thought it would occur to some.”

    Stunning idea which hadnt occured to me. But now that you’ve brought me into the light lets examine this idea a little further. For a sonographer to scan a patient without supervision they must work supervised for a year, so thats 35 hours a week for 45 weeks, bringing us to 1,575 hours. On top of that, even at this point a sonographer requires a radiologists (or gynaecologist for fetal US) to be around to review concerning/difficult cases. This is only to gain competancy in general ultrasound rather than vascular ultrasound and cardiac ultrasound, both of which require a further 6 months each. So for a GP to be fully competant he would require over 3, 000 hours of training. Although you could argue this down potentially to 1,500 to 2,000 hours as GPs are medically trained which sonographers are not, or if you excluded vascular and cardiac scans, this could be further wittled down to a mere 750 hours. And this is before we start to consider deskilling if a procedure is not practiced enough.

    Wonder how many GPs have 750 hours of time to spare?

  90. MedsVsTherapy said,

    March 3, 2010 at 11:57 pm

    Can residents rate the quality of empirical studies? Not really:
    Windish DM, Huot SJ, Green ML. Medicine residents’ understanding of the biostatistics and results in the medical literature. JAMA. 2007 Sep 5;298(9):1010-22.

    However, these raters were probably given an acronym, so they probably did just fine in consistent judging.

  91. jwm said,

    March 4, 2010 at 12:36 am

    Emen:

    “Same case in Germany, baby, viral bronchitis, no antibiotics needed. But while they are waiting, the baby is given a salt pipe to help clear the infection quicker”

    Please say we were back on the issue of placebo, as that is pretty much the only mechanism by which that will work.

    “but you do sound like you don’t live your life thinking ah, what a fantastic world class service, and life on NHS is paradise on earth”

    This is something we both are guilty of for our respective countries if judged by our comments so far. Although I try not to be, I am of course biased. Both by working for the NHS, and having had several family members receiving exemplary care which drove me to enter the medical pathway in the first place. But that is mere anecdote, and of no interest to a reasoned discussion, so will go no further.

    As for Germany, there are many ways we can learn from them, just as I’m sure there are things they could learn from us. We could increase our spending on healthcare to that of germany (9.4% vs 10.8% of GDP respectively, and this is ignoring the difference in the countries GDP as well), and with that money increase our number of doctors (currently 2.2/1000 vs 3.4/1000). Germany in return could find out how to maximise inpatient management efficiency to reduce it’s inpatient length of stay (5.7 vs 9 days), although given the way hospitals in Germany are fiscally renumerated for inpatient care, I suspect this is something they will not want to learn anytime soon.

    “Notice how you say “save money”, not save lives.”

    Its true, that is exactly what I said, in response to a comment by yourself about avoiding expensive secondary care, a comment also about money. But that is what national healthcare is all about, how best to allocate limited funds for the maximal good. It involves both saving money as well as saving lives, as saved money can be diverted or re-invested.

  92. Sriram said,

    March 4, 2010 at 8:00 am

    Hi emen,

    You wrote:

    “I have seen people completely recover from asthma, hay-fever, eczema, flu, coughs, sleep-problems, chronic sinusitis, mood problems etc with homeopathy. So I don’t doubt what you are experiencing is true.”

    So…that’s it then! I am sure they wouldn’t have got well by just ‘leaving them alone’ as some people seem to suggest nor by just taking some house-hold sugar cubes.

    Cheers.

    Sriram

  93. pv said,

    March 4, 2010 at 9:04 am

    Sriram, yet more misrepresentation of other people’s comments. Lying for quackery and fraud, I think we can call it… unless you are just exceptionally dim (which is quite likely given your comments thus far).

    Do you really have no idea what a “self-limiting” condition is? Do you really not know what a non-self-limiting condition is?
    Apparently you don’t. Nor do you seem to grasp the difference between feeling better and actually being better. Extraordinary!

    Btw, there is no hyphen in “household”, for obvious reasons if you had the capacity to think about it for a microsecond.

  94. Guy said,

    March 4, 2010 at 10:07 am

    Sriram,
    If you look at post 59. I gave you a link that will teach you how to think properly about these things.
    yes, this can be learnt like any other skill.
    Can I suggest that you spend an hour reading these before you post on here again and embarass yourself further.

  95. truthygum said,

    March 4, 2010 at 12:40 pm

    Of course homeopathy is totally fraudulent.
    The false claims completely devalue the power of the placebo. Research into the placebo effect is an entirely separate issue and for that we don’t need the label of homeopathy, its history or the nonsense.

  96. elvisionary said,

    March 4, 2010 at 6:17 pm

    To me, the ethical dilemma is how the medical professions can fully exploit the placebo effect without falling into the trap of making false claims.

    It is demonstrably beneficial to the patient to believe in the remedy. So there is a cost to being open about its lack of active ingredients. But what is ethically wrong with saying to a patient, “You might want to take this – it doesn’t really have anything in it, but we often find that people who take it start feeling better.” This might (a) be truthful, (b) deliver superior results to prescribing nothing, due to the placebo effect, and (c) be significantly cheaper than the alternative, which is to prescribe a proper drug that isn’t actually necessary.

    To my mind this is only acceptable if (a) the remedy doesn’t cost the patient anything, and indeed is very cheap for the health service to source (because it’s got nothing in it – and doesn’t even need to be bashed against walls and diluted multiple times); and (b) it is administered by a doctor who has at his/her disposal the proper remedies where they are required.

    In other words, it’s wrong to say that homeopathic remedies are “no better” than sugar pills. They are far worse, as they divert patients from an informed choice between remedies that are either more effective or cheaper.

  97. Guy said,

    March 4, 2010 at 6:58 pm

    Elvis,
    25 years ago all prescriptions used to have a little box on them. When the doctor ticked this box, then the medicine was dispensed by the pharmacist with no name on it, just directions. In 1985 the government of the day banned prescribing of a lot of dubious value medicines including cough mixtures which were often given as placebos.

    So placebos like cough mixtures could be given without knowing there was nothing in them. Now too often antibiotics are given for their placebo effect instead.

    The old way was rather paternalistic but sometimes useful.

  98. DrJG said,

    March 4, 2010 at 8:00 pm

    @ jwm – I would be cautious about praising shorter average hospital stays unless you have got pretty good evidence that the shorter stays actually benefit patients – or at least don’t disadvantage them. It would be interesting to know what readmission rates are like in Germany – though, of course, there are all sorts of social confounding factors for both these figures.
    My mother was discharged just a few days after her hip replacement. The price of this was the “hospital at home” service, basically an intensive parallel to the district nurses, which can’t be cheap itself. Purely anecdotally, it took her a long time to get going again, certainly much longer than average, and it is hard not to wonder if a few more days as an in-patient might have given her the chance of a much more rapid recovery.

    A similar issue is the pressure on out-patient medics to discharge patients. My Ophthalmologist friend is driven to distraction by management fussing about mean number of follow-up appointments and wanting the clinics not just to meet the average for neighbouring hospitals, but to meet the lowest of them. This means two things – firstly, when patients get worse and have to be re-referred, they are at the back of the queue, and secondly the GP side of the financial fence has to pay another new referral charge to the hospital side of the financial fence, plus, of course, all the repeat paperwork involved. Thus, budgets based on historical referral data are inadequate, and PCTs have to slash things like District Nursing services as they are under a three-line whip to balance the books. Then, for example, the exceptional cases committee pores over every referral to it and seizes on any irrelevant loophole to turn people down.

    Shorter is not necessarily better – what we really want to find is “optimum”, but that is the hardest to

    Still, it keeps the bean-counters in employment, doesn’t it?

  99. jwm said,

    March 4, 2010 at 9:49 pm

    Dr JG

    “I would be cautious about praising shorter average hospital stays unless you have got pretty good evidence that the shorter stays actually benefit patients”

    Avery good point, re-admission data would indeed be interesting. Interestingly the states have a similar average length of stay to our own, and this is from a country which spends almost double us on healthcare, and due to high risk of litigation I would also imagine they practice extremely defensive medicine, so inappropriate early discharge should be low. But I admit this is conjecture.

    I share your frustration with the beaurocracy of ridiculous referal tennis all in the aim of maximising a PCTs profit. Only one of the many disadvantages of the introduction of PCTs. But, as you say, in a world ruled by pen pushers why would they change the system and put themselves out of a job?

  100. DrJG said,

    March 4, 2010 at 11:06 pm

    @ jwm – I wonder if they admit more people with more minor issues in the US, as part of what we at least perceive as more defensive practice. I they do have a case-mix skewed to the less serious, this would tend to reduce the average stay. But I, like you, am speculating.

  101. Enders Shadow said,

    March 4, 2010 at 11:50 pm

    I’m not sure whether laughter or anger is the best response to the fundamentalism of toothygum here:

    “Of course homeopathy is totally fraudulent.
    The false claims completely devalue the power of the placebo. Research into the placebo effect is an entirely separate issue and for that we don’t need the label of homeopathy, its history or the nonsense.”

    Fundamentalism I’m defining as being willing to assume that the evidence you don’t have will conform to the theory that you are espousing. In this case we see the claim that ‘we don’t need the label homeopathy’ in order to study the placebo effect, assuming apparently that any placebo inducing process is equally effective. THIS IS BAD SCIENCE. The scientific statement is that homopathy is an effective catalyst of the placebo effect for reasons we don’t understand. Until we do, accept the fact that homeopathy is effective in curing some people… Yes it’s uncomfortable for your worldview, but science doesn’t progress if people aren’t willing to look hard at what the BELIEVE.

  102. Martin said,

    March 5, 2010 at 5:44 am

    Enders Shadow – I’m not sure if this exactly what you meant, but we don’t need the label ‘homeopathy’ to study the placebo effect – it can be studied perfectly well without homeopathy.
    When tested under rigourous conditions (randomised, double-blinded, controlled trials) homeopathy works as well as placebo.
    The only benefit of homeopathy is that it provides a ‘catalyst’ for the placebo to operate. But that doesn’t mean that the NHS should divert resources away from more effective treatments.
    Nor should homeopaths be allowed to get away with lying about the effectiveness of conventional medicine in order to line their own pockets.

  103. DrJG said,

    March 5, 2010 at 8:03 am

    I know that we have drifted slightly off topic here, but given the discussions on the state of the NHS, I thought that this from “M.D.” in this fortnight’s Private Eye is worthy of wider readership:

    “The take-home message at Bristol [child cardiac surgery unit] came from Steve Bolsin, the anaesthetist who first raised concerns and paid for them with his NHS career: ‘If you want to avoid another Bristol, never lose sight of the patient.’ This is strikingly similar to the conclusion of Robert Francis QC in the Mid Staffs report: ‘If there is one lesson to be learnt, I suggest is is that people must always come before numbers. It is the individual experiences that lie behind statistics and benchmarks and action plans that really matter, and that is what must never be forgotten when policies are being made and implemented.’…..That “new” labour could contrive a culture where £105 billion goes into the NHS at it’s still no safer than bungee jumping, with widespread staff shortages, overcrowded emergency departments, disillusionment and patient harm, suggests that much of our increased funding hasn’t gone where it is needed. Oh, and we’re desperately short of inspirational managers who’ll stick two fingers up at Whitehall and focus on helping their staff to serve their patients.”

  104. Enders Shadow said,

    March 5, 2010 at 8:52 am

    I guess my aim here is to encourage us to be pragmatic: to recognise that for some people homeopathy makes a massive positive difference to their otherwise blighted lives for reasons that we don’t understand, and the studying of ‘Why’ is a MAJOR project whose results we must resist the temptation to believe we know the answer to.

    Given that for some people it does work where other treatments have not been effective, it IS rational to divert a very small amount of NHS cash to it. However I would agree that “homeopaths [should not] be allowed to get away with lying about the effectiveness of conventional medicine”, though given how often other groups within the mainstream medical profession do it, there’s no shortage of target for that campaign, and every time that a doctor prescribes an antibiotic to get rid of a whinging patient, they are guilty of the same behaviour :)

  105. skyesteve said,

    March 5, 2010 at 9:41 am

    @enders shadow (103) – your conclusion only stands up if you believe the NHS should pay for any quakery that makes a “massive positive difference” to some people – as I’ve listed before, massage, aromatherapy, hot stones, shamanism,etc.
    People can spend their money on what they want and if it helps them then that’s good too. But the NHS shold not resources things which cannot be backed up with an evidential base and I would apply that to a lot of things currently funded by the NHS, not just homoeopathy.

    @jwm and DrJG – one anecdote from the US – I worked there for a very short spell and was curious to know why even the most minor of head injuries presenting to the ER got a CT scan. So I asked assuming it was to do with fear of litigation – but it wasn’t. It turned out that the senior ER doctors had shares in the CT scanner and received a “dividend” each time it was used! The joys of a private, for-profit healthcare system

  106. Sriram said,

    March 5, 2010 at 9:42 am

    “to recognise that for some people homeopathy makes a massive positive difference to their otherwise blighted lives for reasons that we don’t understand, and the studying of ‘Why’ is a MAJOR project whose results we must resist the temptation to believe we know the answer to.”

    Enders Shadow….I agree with that! A little bit of balance in such matters wouldn’t come amiss.

    Cheers.

    Sriram

  107. elvisionary said,

    March 5, 2010 at 10:21 am

    Enders, although I think you’re wrong, you do highlight something very interesting: the placebo effect does bring real benefits to patients, but it will be most effective if the patient believes that it is more than just a placebo. This presents an ethical dilemma: is the prescription of sugar pills labelled as something else a kind of white lie where the potential ends (an improvement in the patient) justify the means (deception of the patient about what they’re really taking)?

    Rather than getting into an ethical debate about whether ends can ever justify means (philosophers have wrestled with this for centuries), I would answer this question in a different way by picking up your comment about doctors prescribing unnecessary antibiotics. Would it be better for all GPs to have sugar pills in their toolkit? When prescribing them, they could simply say “We’re not entirely sure why this works for this kind of condition, but the evidence is that some patients get better after taking them”. That statement would be truthful. It would enable doctors to harness at least some of the power of the placebo effect. And if these pills could be manufactured and supplied very cheaply (no need to dilute and bash against the wall multiple times, no need for dubious marketing or branding, no need for expensive trials), then the patient would not be being exploited for financial gain.

    So it would be a cheaper and more honest alternative to homeopathy, and a cheaper and more honest alternative to the unnecessary prescription of proper drugs. But to me the critical point is that it would be a medical professional making the prescription on the basis of what was in the best interests of the patient. So if the patient really would benefit from proper drugs, they would get them. And this is where homeopathy is so indefensible: the fact that homeopaths are selling/prescribing it leads to highly undesirable results. Patients who should get proper drugs don’t get them, and instead pay for sugar pills. Patients who might benefit from sugar pills end up getting expensive proper drugs when they don’t need them, which can ultimately undermine the effectiveness of those drugs.

    This is why I don’t think it is true to say that homeopathy is “no better than placebo” – it is far, far worse.

  108. Guy said,

    March 5, 2010 at 10:31 am

    Enders, you state “for reasons that we don’t understand,”. Yes we do understand them. There has been hundred of millions of dollars spent by congress on investigating complementary medicine, so a lot is known about the placebo effect. The evidence is there, plain to see for anyone who can read and critique a scientific paper. You talk as though there is absence of evidence, which could mean there was an effect. It is absence of effect beyond the placebo that is demonstrated everytime a properly conducted trial is reported.

    This brings us back to the beginning to the MP’s report showing that it is placebo pure and simple. So no it doesn’t work. It is just placebo. We know that for a fact. No futher investigation is needed or warranted.

  109. Guy said,

    March 5, 2010 at 10:39 am

    Defenders of homeopathy might like to read Simon Singh’s work and comment
    www.1023.org.uk/whats-the-harm-in-homeopathy.php

  110. elvisionary said,

    March 5, 2010 at 2:14 pm

    …or maybe it’s technically more accurate to say that homeopathy is a misleading, exploitative and damaging application of the placebo effect.

  111. emen said,

    March 5, 2010 at 2:19 pm

    jwm,

    I’m not German and I don’t live in Germany.

    Yes, a bigger percentage of GDP spent on healthcare is one reason. The other one is that the German system is a mixed-funded system: everybody in employment contributes to their healthcare costs: about 7% percent of their income is chopped off, and about the same amount of money is paid by the employer. (It is, of course, more complicated than that, because the Germans make anybody above a certain income or working in certain occupations take out private health insurance etc.)

    Of course the German system is not perfect, they too struggle with the increasing costs of healthcare, and also, the element of “let’s just do this extra test and claim the fee for it from the state” is definitely there.

    The reason why I mention it is because if you look at the history of healthcare in Britain, pre-NHS the system was more or less trying to be what the German is now. Then, of course, the war broke out, war-time healthcare, poverty, rationing, all sorts of reasons, and the NHS was created. The NHS has always been a very controversial system, partly because financially it never worked, that was very clear after the first one or two years. Since then it has always been about how to make it work without changing the basic idea of it being completely taxation funded and free for all at the point of delivery.

    I’m happy that you and your family have had exceptionally good experiences on the NHS. My anecdotes are, unfortunately, not so shiny. I spent a year struggling on the NHS, and it completely destroyed me, both physically and emotionally (but not DIRECTLY financially). It was different hospitals, different doctors, different problems , and I can’t pick out one place or one person, and comfort myself that apart from them, everything must be, surely, fine. To me it seems to be a sick, almost dead system, unbearably slow, unresponsive and superficial. I wish I could have paid some money towards it (or top it up) and got quicker, better care and be back at work quickly to earn that money back.

    I think here in Britain we pay a very big price for not wanting to pay for healthcare. Either by contributing directly like the Germans, or contributing by taking out private insurance, or or at least have the choice to top up the NHS costs when we think we need to. I’m not saying we should copy the German system, something that works over there might not work here at all for a variety of reasons. But the longer we wait and the longer we leave it, the more difficult it is going to be to change it.
    There is not enough money in the NHS and what there is, seems to be very badly managed. At the same time, patients are not in the customer position, more like beggars at the mercy of whoever seems to be there to care for them.

    In my experience, that is.

  112. emen said,

    March 5, 2010 at 2:41 pm

    Dr JG

    was that M*** in Solihull by any chance? The one that recommends routine US after coil-fitting?

    OK, let’s not train GPs to check everything by scans and tests then (it wasn’t my idea, mind you, but some cancer expert worrying about the low cancer survival rates in the UK).
    So they can treat depression instead (they are very good at that, aren’t they).
    Let’s have more sonographers then! :-)
    I don’t mind, as long as the waiting is days rather than months, when it comes to suspected cancer.

    Regarding the tendency to early discharge from hospitals after operations. In my experience part of the problem is that when they discharge you, you find yourself in the hands of your GP immediately – that is, once you are out of hospital, the communication between you and the people who know what they have done to you and what is normal, what isn’t is completely halted. I think it is unrealistic to expect GPs to be fully prepared to answer every question that you should be asking the surgeon really. So you find yourself in a vacuum of care (like so often), when you aren’t allowed to speak to the person who could help, and the doctor who is willing to see you can’t help.

    Ho-hum.

  113. skyesteve said,

    March 5, 2010 at 2:48 pm

    @emen – GPs are not perfect and, like any other sector, there are good ones and bad ones. But I believe that the vast majority are good. I can only speak for myself, but I do the best I can every day for every patient. I don’t regard anyone as a “heart sink” or “time waster” – I see it as part of my job to inform all my patients of the best and most appropriate way to use the health service. I am happy to answer any questions and sufficiebtly humble to say when I don’t have the answers. But one of the features of a good GP is to know where or how to find the answers. I often sit with my patients during a consultaion and do an internet search for difficult questions then I print off material if that is helpful for them. You might say they could do that myself but I guess my years of training and experience allow me to sort out the wheat form the chaff that they mighht struggle to do.
    I will agree, however, that communication between secondary care and primary care is not as good as it should be.

  114. skyesteve said,

    March 5, 2010 at 3:10 pm

    @emen (again – sorry!) – I have genuine sympathy for anyone who feels that the NHS has let them down but I still think, in Scotland at least, such people represent a minority of users. As I say often, I can’t comment on the NHS in England, Wales or Northern Ireland as I don’t live or work there and NHS Scotland is to all intents and purposes a separate organisation.
    Primary care in Scotland has patient satisfaction rates in the high 90s percent and those figures are consistent year on year. The model of primary care we have in scotland remains the envy of most of the world. The cost of looking after one average patient in primary care for a whole year is half what it costs for the same average patient to spend on night in hospital.
    The NHS was not established out of nowhere in 1948. It was modelled to a greater or lesser extent on the Highlands and Islands Medical Scheme which started just before the First World War. For the first time this produced a uniformity of primary care provision across the impoverished Highlands and Islands of Scotland. It gave every community, no matter how remote, access to doctors and nurses. It built houses for the doctors and nurses and provided them with transport (including, in one instance I know of, a horse!).
    I am very proud to work in NHS Scotland and I think it does a wonderful job. Between 2002 and 2005 I was heavily involved as a user of the service and it was fantastic.
    Of course, if something bad happens to you then the rate of that is 100% but anecdote (and even mutliple ancedotes) doesn’t stack up to a large body of evidence (any more than the tens of thousands who claim homoeopathy worked for them or their dog).
    But even now if I have someone with something I think my be a pelvic maligancy I can get a scan done locally the next working day just by picking up the phone and having a chat with the sonographer.
    In any case throughout Scotland there is a national programme that all suspected cancer will be seen in secondary care withing a maximum of 2 weeks (of course, as a GP, you have to suspect cancer in the first place for that to kick in) and in general we have a target of 18 weeks from referral to treatment – 18WRTT – and that’s the start of TREATMENT not just you basic initial out-patient assessment.
    The fundamental principle behind any civilised healthcare system is that access must be based on need not ability to pay. The only way to truly achieve that, IMHO, is through taxation and a service free at the point of access. As soon as you introduce an element of co-payment that will favour those who can afford to pay.
    But I agree we live in times where everyone thinks they are entitled to something for nothing. they want free healthcare, free education, free social care, free roads, etc. but at the same time they want to have sufficient disposable cash (i.e. low taxes) for the faster car, the bigger house, the nicer holiday, etc. and that for me is the situation which is not sustainable.

  115. pv said,

    March 5, 2010 at 4:45 pm

    Enders Shadow said,

    March 5, 2010 at 8:52 am
    Given that for some people it does work where other treatments have not been effective…

    The point is that it isn’t “given” at all. Ascribing the effect of real medicine to homeopathic magic water/pills isn’t what I would call “working where other treatments have not been effective”.
    Nor is ascribing to a homeopathic effect a normal self-limiting of such types of condition something that can honestly be described as “working where other treatments have not been effective”.

    Claims of efficacy don’t constitute evidence of efficacy.

  116. jwm said,

    March 5, 2010 at 7:37 pm

    emen,

    some very interesting points, and it sounds like youve lived a very interesting (but perhaps unlucky?) life having managed to experience several healthcare systems.

    re: “everybody in employment contributes to their healthcare costs: about 7% percent of their income is chopped off, and about the same amount of money is paid by the employer”

    Im not an accountant but this sounds like tax by another name, with the only difference being that people are aware that a fixed percentage of their pay is being ringfenced for healthcare. The contribution by the employer is tax-deductable, and therefore essentially just tax as far as they’re concerned. Although it may be that increased awareness of healthcare costs has a benficial effect on population usage of the health system with the knowledge that 7% can go up.

    “I don’t mind, as long as the waiting is days rather than months, when it comes to suspected cancer.”

    This is thankfully something which is changing, with most hospitals running a 2 week wait system for possible cancer cases, and an 18 week system from referal to final treatment, although over 2/3s of cases currently reach this stage within only 12 weeks, and there is moves to reduce this to 9 weeks in cancer.

  117. Martin said,

    March 8, 2010 at 1:14 am

    Enders Shadow and Sriram:

    “to recognise that for some people homeopathy makes a massive positive difference to their otherwise blighted lives”

    No, homeopathy doesn’t do anything. Sitting down with someone who has a sympathetic ear for an hour (rather than the rushed 5 minutes you get with a GP) talking about your problems and the homeopath emphasising and going “Oh, yes” and “I know” makes a massive positive difference to people.

    Taking a sugar pill which you think will make you better makes a massive positive difference to people.

    Even paying large sums of money to a charlatan can make a massive positive difference to people.

    All of these things make people think they’re being proactive about their (self-limiting) condition.

  118. What said,

    March 11, 2010 at 7:54 pm

    I wonder whether a change to the advertising policies at these journals might be beneficial. ‘You can’t mention any clinical trial that doesn’t score at least X on this standardized scale’ wouldn’t be hard to enforce. (In fact, it would be rather easier than the current discretionary rules, in which an editor can reject any ad as ‘offensive’.) I’m not sure that the unintended consequences (ads that mention no studies at all?) would be worth it.

  119. ips said,

    March 21, 2010 at 11:53 am

    repply to Skye Steve…..

    ‘But I agree we live in times where everyone thinks they are entitled to something for nothing. they want free healthcare, free education, free social care, free roads, etc. but at the same time they want to have sufficient disposable cash (i.e. low taxes) for the faster car, the bigger house, the nicer holiday, etc. and that for me is the situation which is not sustainable’.

    Steve, I have followed some of the debate and tend to agree with most of your conclusions especially the above!
    However, I tend to think that the waters are much muddier than many here seem to suggest (in terms of practically dealing with pain and suffering in the clinic). I work as a NHS Physiotherapist primarily in GP clinics , formerly in teaching hospitals with specialist consultants in both orthopaedics and pain management.
    Many people like to think that things are scientifically rational and that care is optimised to treat ‘rational people’ with ‘rational’diseases’…..After nearly twenty years dealing with medically unexplained pain syndromes, chronic pain and the ‘no mans land’ between orthopaedics and psychology I can assure most people that a lot of people out there remain a mystery. Sometimes this is due to fragmentation of care , often it is due to a dualistic philosophy perpetuated by outmoded thinking and failure to think of the person in a holistic context.
    There does seem to be a lot of Homeopathic bashing and it is an easy target.
    Personally, Homeopathy does not interest me that much neither do most ‘modalities’ that get discussed (acupuncture,manipulation etc etc). What I do believe is that there is nothing mere about the placebo or nocebo phenmenon (which clinics are often very good at inducing. For example a lady with a lifelong hx of trauma,’ptsd’ anxiety etc was sent for ‘breathing exercises’ ….the clinic had told her she may need a lung transplant ….this leads to further catastrophisation .
    Many people I see are informed that there discs/hips etc ‘are out’ , that they have spines of an old person etc –iatrogenic disability in our inactive society often caused by misinformation is a big part of my caseload. This nocebo situation needs to be understood by many in the medical profession and Benedetti has done some interesting Fmri studies in this area see’When words are painful: Unraveling the mechanisms of the nocebo effect’….Many people seem to need or have been conditioned into expecting help for self limiting problems or problems of living. There is abundant scientific evidence that many common problems can be assisted through ‘self help’ i.e movement restoration , ‘meditation’ or low cost stress reduction techniques. Indeed, I have tried to set these up myself at no cost to patients or the doctors locally…..These measure have not been acceptable and none of the doctors have expressed any interest in coming along or referring patients…..Self management is not a popular option especially if it is ‘free’ —–placebos work much better if you pay for them and they are delivered by a credible hierarchy figure (perhaps I have to wear the bow tie and inject saline for best effects?
    I too think that the NHS is the best way to deliver care and also agree that in Scotland (particularly away from the central belt) that the service is largely excellent. However, I sense on a Monday morning now matter how much money you throw at it or doctors that you employ many people will continue to moan or demand more……
    I enjoyed Nic Humphrey’s take on understanding the placebo response here (talking with Richard Dawkins).The debate is interesting re self – cure.
    www.youtube.com/watch?v=e1AQPue7FEM

  120. ips said,

    March 21, 2010 at 11:53 am

    in respone to to Skye Steve…..

    ‘But I agree we live in times where everyone thinks they are entitled to something for nothing. they want free healthcare, free education, free social care, free roads, etc. but at the same time they want to have sufficient disposable cash (i.e. low taxes) for the faster car, the bigger house, the nicer holiday, etc. and that for me is the situation which is not sustainable’.

    Steve, I have followed some of the debate and tend to agree with most of your conclusions especially the above!
    However, I tend to think that the waters are much muddier than many here seem to suggest (in terms of practically dealing with pain and suffering in the clinic). I work as a NHS Physiotherapist primarily in GP clinics , formerly in teaching hospitals with specialist consultants in both orthopaedics and pain management.
    Many people like to think that things are scientifically rational and that care is optimised to treat ‘rational people’ with ‘rational’diseases’…..After nearly twenty years dealing with medically unexplained pain syndromes, chronic pain and the ‘no mans land’ between orthopaedics and psychology I can assure most people that a lot of people out there remain a mystery. Sometimes this is due to fragmentation of care , often it is due to a dualistic philosophy perpetuated by outmoded thinking and failure to think of the person in a holistic context.
    There does seem to be a lot of Homeopathic bashing and it is an easy target.
    Personally, Homeopathy does not interest me that much neither do most ‘modalities’ that get discussed (acupuncture,manipulation etc etc). What I do believe is that there is nothing mere about the placebo or nocebo phenmenon (which clinics are often very good at inducing. For example a lady with a lifelong hx of trauma,’ptsd’ anxiety etc was sent for ‘breathing exercises’ ….the clinic had told her she may need a lung transplant ….this leads to further catastrophisation .
    Many people I see are informed that there discs/hips etc ‘are out’ , that they have spines of an old person etc –iatrogenic disability in our inactive society often caused by misinformation is a big part of my caseload. This nocebo situation needs to be understood by many in the medical profession and Benedetti has done some interesting Fmri studies in this area see’When words are painful: Unraveling the mechanisms of the nocebo effect’….Many people seem to need or have been conditioned into expecting help for self limiting problems or problems of living. There is abundant scientific evidence that many common problems can be assisted through ‘self help’ i.e movement restoration , ‘meditation’ or low cost stress reduction techniques. Indeed, I have tried to set these up myself at no cost to patients or the doctors locally…..These measure have not been acceptable and none of the doctors have expressed any interest in coming along or referring patients…..Self management is not a popular option especially if it is ‘free’ —–placebos work much better if you pay for them and they are delivered by a credible hierarchy figure (perhaps I have to wear the bow tie and inject saline for best effects?
    I too think that the NHS is the best way to deliver care and also agree that in Scotland (particularly away from the central belt) that the service is largely excellent. However, I sense on a Monday morning now matter how much money you throw at it or doctors that you employ many people will continue to moan or demand more……
    I enjoyed Nic Humphrey’s take on understanding the placebo response here (talking with Richard Dawkins).The debate is interesting re self – cure.
    www.youtube.com/watch?v=e1AQPue7FEM

  121. joey89924 said,

    November 16, 2012 at 2:23 am

    I care partly because we have all done stupid things, those who claim that they haven’t are the ones deceiving themselves more than they deceive anyone else.
    www.hqew.net

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