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Regulating fantasies

Yuri Nalyssus said:
Ihttp://www.rationalvetmed.org/papers_i-j.html#Imrie2000mrie, R.H., and Ramey, D.W., (2000) The evidence for evidence based medicine - http://www.rationalvetmed.org/papers_i-j.html#Imrie2000

and...

Ernst, E., (2004) How much of general practice is based on evidence - http://www.rationalvetmed.org/papers_e-f.html#Ernst2004

Yuri
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Thanks for that.

More here:

How much of orthodox medicine is evidence based?
http://www.dcscience.net/garrow-evidence-bmj.pdf

...and how much CAM is based on research evidence? (7.4%)
http://www.ncbi.nlm.nih.gov/pubmed/19465405

Also, there's an interesting new summary of EBM here:
http://jdc325.wordpress.com/2012/05/20/a-rough-guide-to-evidence-based-medicine/


BTW, as the topic of this thread is about regulating fantasies, here's a topical new article at Science Based Medicine:

The regulation of nonsense
http://www.sciencebasedmedicine.org/index.php/the-regulation-of-nonsense/

...the next time you find yourself in a discussion with an acupuncture proponent, heartily agree with him (or her) that of course acupuncture should be a licensed health care profession, available to everyone, as should angel therapy. When he demurs on the ground that angel therapy is totally absurd, ask him to explain exactly how acupuncture is any different.

Dr. Ernst is entirely correct. The regulation of nonsense must still result in nonsense. Rather than fooling themselves into thinking they are protecting the public with CAM practitioner licensing, state legislators should concentrate on protecting the public from CAM.
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Quite.
 
"Devon GP Michael Dixon argues the case for an integrated health service: “I don’t think that the complementary therapies I suggest to my patients are placebos, but I don’t know. ….It is possible that many complementary therapies have a very small specific effect of, say, 5 to 10 per cent, with a much larger 40 to 50 per cent effect due to the therapist/patient interaction. .….A few days ago, a new patient entered my surgery in tears and said she felt very ill. A few minutes later my computer crashed while trying to produce her prescription. While waiting for it to revive, we discussed potatoes, which turned out to be a subject of mutual interest. When she got up to leave, I apologised for talking about potatoes rather than about her. She smiled and said that she felt much better anyway. Both of us had forgotten about her prescription, which was still jammed in the computer...”
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Mojo said:
Does he discuss potatoes with all his patients? If not, why not?
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Yuri Nalyssus said:
Well quite, where's the harm. I can see potaoeopathy catching on. I feel much better after a packet of crisps and an episode of Foyle's War of an evening and no amount of double blinded sciencey stuff is going to persuade me otherwise.
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:D
 
Blue Wode said:
Michael Dixon has been at it again in a letter to The Times today. It's a behind a paywall online, but the following is lifted from the paper copy:
David Aaronovitch is right to argue for a robust scientific approach in medicine. However, he is not being logical or scientific when he says that if something is suspected to be placebo then it has no benefit and the NHS should not pay for it.

What about scientific research on remedies that many believe to be placebo? These frequently show that there is a benefit but this is confined to those who believe in the treatment given. Surely, in such cases, it would be logical to say that the treatment was beneficial albeit in a specific group of “believers”. From there, it would be good science to compare the safety costs of this supposed placebo remedy with its currently given alternative before deciding whether “believers” should be able to receive such a remedy on the NHS.

The problem here is that belief and mindset play an enormous part in healing – science needs to take account of this. Patients’ symptoms are frequently metaphors and effective treatment can often be symbolic and culturally dependent. The mind, in the right circumstances, can produce its own healing chemicals often mimicking those given in conventional medicine. Until science can explain healing in psychosocial as well as biomedical language, we must be cautious about “voting for the geeks” as Mr Aaronovitch suggests. It is far better surely that individual treatment should be tailored, within reason, to the patient and their beliefs and perspectives. Further more, might it not be wiser to direct NHS resources according to pragmatic trials of cost effectiveness and safety rather than a limited interpretation of science that excludes the effect of the mind?

Dr Michael Dixon
Chair of Council
College of Medicine.
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Edzard Ernst on why it's neither logical nor appropriate to use pure placebos that only rely on placebo effects:
http://web.archive.org/web/20100103080345/http://www.arc.org.uk/news/arthritistoday/131_1.asp
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Letters from Prof. David Colquhoun and Dr Evan Harris rebutting Michael Dixon's claims have been published in today's Times :

Alternative medicine has limited benefits for patients, and it is deceptive for doctors to suggest otherwise

Sir, Dr Michael Dixon’s letter (May 21) is fascinating. He is, of course, a well-known advocate of alternative medicine. Yet he seems now to believe that much alternative medicine is just a placebo. That’s something the geeks have been saying for years, and he appears, at last, to have accepted it.

That being the case, it follows that we have to ask whether placebos produce useful benefits, and whether it is ethical to prescribe them. Nobody denies the existence of placebo effects. But recent research has shown that they are usually both small and transient. Often they are not big enough to provide a useful degree of relief. For example, a recent paper on acupuncture in the British Journal of General Practice showed that it had a remarkably small placebo effect. And placebos have no effect at all on the course of cancer or infectious diseases.

There has been an admirable movement in medicine for doctors to be open and honest with patients. Prescribing of medicines that contain no active ingredient involves lying to patients. That is old-fashioned and unethical.

It is fair to ask why so many people seem to believe in alternative medicine, if even their placebo effects are small. The answer seems to lie in the “get better anyway” effect (known to geeks as regression to the mean). Most of the conditions for which placebos seem to work are things that wax and wane naturally. You take the “cure” when you are at your worst, and next day you are better. You would have been better anyway, but it’s hard to avoid attributing the improvement to whatever you took. That is why alternative medicine is advertised largely on the basis of anecdotal testimonials. And it is doubtless why Dr Dixon advocates “pragmatic” trials: that’s a euphemism for trials without a proper control group.

Psychosocial problems may indeed be very important for some patients. But deceiving such patients with dummy pills is not the proper way to deal with their problems.

D. Colquhoun, FRS
Professor of Pharmacology, University College London

--------------------------------------

Sir, Dr Michael Dixon argues that the NHS should fund placebo treatments such as homeopathy (though he stops short of agreeing that homeopathy is a placebo) on the basis that they can offer limited help to those who “believe” in them. It is no part of modern ethical medical practice to deceive patients into thinking — or failing to disabuse them of the belief — that an inert substance or ineffective medicine has beneficial effects. This can not be justified by the hope — or even expectation — of deriving for that patient the limited psychologically based improvement in symptoms that may follow from the deployment of the placebo.

Pedlars of homeopathy for profit in the private sector will, alas, always seek to fool people into believing the hocus pocus of “memory of water” and the effects of infinite dilution and a lot of bottle-shaking. But doctors have responsibilities not to deceive their patients, even out of a paternalistic wish to assist them to manage their symptoms; and public policy demands that the NHS spends its resources only on treatments that work without deception in a cost-effective way.

Dr Evan Harris
Oxford
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Blue Wode said:
Letters from Prof. David Colquhoun and Dr Evan Harris rebutting Michael Dixon's claims have been published in today's Times :
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"... deceiving such patients with dummy pills is not the proper way to deal with their problems"

Nicely put Prof :D

Yuri
 
Shockingly misinformed and blinkered reply in Wednesday's Times:

In the real world of frontline clinical practice things are infinitely more complex than has previously been suggested

Sir, Dr Harris and Professor Colquhoun (letters, May 26) are quite right to say that we have an ethical duty to try to “disabuse” patients of their beliefs if, as doctors, we believe that those beliefs might be harmful or lead to a patient not having a treatment that has been proven to be effective.

In most other circumstances, however, “disabusing” patients of their beliefs might seem at worst disrespectful or arrogant, and at best missing a chance to use those beliefs to amplify healing. Especially as it has been estimated that at most 25 per cent of clinical practice in primary care has an evidence base; and that the complementary therapies, that both writers ardently oppose, have yet to be finally proven or disproven. And especially as we are trying to create a patient-led service where patient views are not always trumped by clinical opinion and scientific evidence.

In the real world of frontline clinical practice things are infinitely more complex than the writers suggest. Good science must in future explain this complexity and understand and incorporate (not reject) mind/body effects in assessment of effectiveness. Until then good medicine should use current science as a guide and helping hand, not as a sledgehammer.

Dr Michael Dixon
Chair of Council

George Lewith
Vice-Chair College of Medicine
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The evidence base for primary care is around 80% whereas the evidence base for CAM, according to Edzard Ernst, is around 7%.
 
My reply to Lewith and Dixon, sent on Friday, but not yet published (I'll let you know it it does get published):

Sir,

Dr Dixon and Prof Lewith in their apparent defence of the use of placebos in medical practice (Letters, 30 May) need to be disabused of their tu quoque belief that at most 25% of clinical practice in primary care has an evidence base.

Although they don't say where they got their figure from, in alternative therapy circles, the similar and oft-quoted figure of around 10% to 20% originated from a small survey of GPs in the north of England around 1961 — more than half a century ago — with the figures first published by the US Congressional Office of Technology Assessment in 1979. However, this figure didn't even measure the proportion of treatments that were evidence based. Instead, the study looked for a way to control prescribing costs in terms of generic and proprietary medicines. It has been misappropriated ever since by proponents of alternative therapies.

In the last 50 years evidence-based medicine has gone from strength to strength. Meanwhile, the vast majority of alternative therapies remain substantially evidence-free.

A proper assessment of the proportion of primary care interventions that are supported by some form of compelling evidence, gives a figure around 80% and this has been known for many years (eg Imrie et al. and Gill et al.). Not ideal, but significantly higher than Dixon and Lewith's pathetic 25%, and much higher still than the proportion of alternative therapies with good evidence of efficacy.

A key difference between conventional medicine and alternative medicine is that practitioners of the former are always seeking to prove it is not effective and should be superseded, whereas the latter are dedicated to defending existing treatments. It is hard to identify any alternative therapy that has ever in the history of the world been disowned by its proponents for lack of effectiveness.

But if Dixon and Lewith are concerned about the lack of evidence for treatments in general practice, why do they think that adding more unproven or disproven treatments helps improve the situation?

Yours faithfully,


Alan Henness
Director
The Nightingale Collaboration
Challenging misleading healthcare claims
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Here’s an excellent piece on why the regulation of ‘alternative’ medicine doesn't work, and never will, by Prof. David Colquhoun in the Scottish Universities Medical Journal (Dundee)
http://sumj.dundee.ac.uk/data/uploads/epub-article/016-sumj.epub.pdf

In support of his comments, it’s worth noting that the UK statutory regulator of chiropractors, the General Chiropractic Council (GCC), appears to turn a blind eye to the activities of chiroquacks
http://www.thetwentyfirstfloor.com/?p=3534

…and also continues to allow mythical subluxations to be linked to “health concerns”
http://www.ebm-first.com/chiropract...sues/1825-subluxations-still-no-evidence.html
 
Asolepius said:
I am posting this with a deep sense of weariness. Yes, the Complementary and Natural Healthcare Council opens its doors today. BBC news story here. I feel like complaining to the BBC about its use of the term `crackdown', for such a toothless watchdog. We are told that in a year's time the public will demand to see only regulated practitioners. I can't really see the logic. If people are undemanding enough not to ask whether anything works, why should they care about whether the person lying to them about CAM is a qualified liar?
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The Complementary and Natural Healthcare Council is holding a seminar on regulation at CAM Expo in London on 21st October and is inviting people to come along and ask questions...
http://cnhc.org.uk/pages/newsManager.cfm?page_id=2&news_id=133

CNHC will have a stand and a seminar slot at this year's camexpo where you can come and ask questions, meet the team and hear the latest news.

CNHC will be located at Stand 2536 and CNHC Chair, Maggy Wallace, will be holding a seminar on regulation and how the CNHC's awareness-raising campaign is helping the public to understand more about the need to look for CNHC registered practitioners.

The seminar will be take place on Saturday 21 October from 13.45 - 14.30:

We look forward to seeing you there.

For further details please visit: www.camexpo.co.uk/
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Asolepius wrote:
But it all fits together - the MHRA studiously avoids talking about efficacy of CAM. And needless to say our heir to the throne is behind the whole thing.
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Interesting update on his meddling:
http://www.ebm-first.com/a-close-lo...sters-stay-secret-as-appeal-is-adjourned.html
 
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