Sep 18 2012

A Bit of Homeopathy Nonsense in the BMJ

OK – I’m having one of those “someone is wrong on the internet” moments. But this someone is a fellow physician (Des Spence, a general practitioner from Glasgow)  and the swirling black hole of wrongness is not just on the internet, but published in a generally respected medical journal, the BMJ. Spense is writing in defense of homeopathy, but he is not a homeopath and acknowledges that homeopathy is “bad science,” and the pills are little more than placebos.  What he does do is marshal every “shruggie” bad argument, misinformation, and logical fallacy into a “Gish gallop” of apologist nonsense.

In his introduction he acknowledges that homeopathy doesn’t work, but then states:

Today, homeopathy is medicine’s whipping boy, repeatedly and systematically beaten to the ground. Yet despite explaining that the tablets are just placebos, homeopathy always gets up to take another beating. Some homeopathy is funded by the NHS, through general practice, and in the few homeopathic hospitals. This fact enrages the growling commissars of evidenced based medicine who want homeopathy purged from the NHS.

He is trying to create the impression that homeopathy is the badly-treated underdog, and that those who defend a science-based standard of practice is medicine are little more than mad dogs (growling commissars). Yes – I would like to see homeopathy purged from every corner of legitimacy within the field of medicine – because it is abject pseudoscience defended with nonsensical arguments, and it doesn’t work. How does Spense resolve the apparent contradiction that, as he writes: “Homeopathy is bad science but good medicine.”

Here is the core of his argument:

Does it cure infection, degenerative conditions, and cancer? It most certainly does not. And if any such claims are made they must be vigorously denounced. But homeopathy is most commonly used for medically unexplained symptoms in patients dismissed as neurotic; the so called “worried well.” These patients have passed from specialist to specialist, enduring repeated invasive and needless negative investigations. Or homeopathy is used in addition to, but not instead of, conventional treatments.

So many logical fallacies. He does acknowledge that homeopathy has no actual medical effect. It is placebo, a literal sugar pill. But then he goes into what is essentially a tired old “well, modern medicine is not perfect” type of argument.  His premise is that there are patients who have non-specific symptoms that are not easy to explain (which I grant) but also that mainstream medicine is dismissive toward such patients, while simultaneously getting multiple invasive investigations.

Well – which is it? Are they dismissed, or overly investigated. These are mutually exclusive claims. Why would someone order a battery of tests on someone they dismiss as the “worried well?”

Of course, there is a range of competence and diligence in medicine, and I cannot vouch for every practitioner. I can tell you what I do and what doctors I respect do. Patients who present with non-specific symptoms are not dismissed, but taken seriously. Even if we think they are being neurotic – neurotic patients can be really sick too. Their symptoms are worked up in a reasonable way for plausible medical causes. When the tests are negative, and anything serious, progressive, or specific is ruled out, then we can reassure patients and focus on treating their symptoms and improving their quality of life. Often there are lifestyle factors that can be addressed, like poor sleep, lack of exercise, or being overweight.

It is often challenging, however, to deal with the patient’s internal narrative of their own illness. Often patients expect what I call the “Dr. House” treatment – they want a specific medical diagnosis that will lead to a cure from a specific treatment. When they don’t get that, because the workup is negative, they are likely to seek out another opinion, and another, and another. It’s challenging to change their narrative, to get them to understand that the workup has been adequate, it’s a good thing that it’s negative, that we will keep an open mind if new information comes to light, but meanwhile there are diminishing returns, and even potential harm, to endless workups. We can address their symptoms without a more specific diagnosis.

Spence would boil down this entire complex and challenging approach to these patients as simultaneously dismissive and excessive, as if he’s the only doctor in the world who can take a thoughtful and nuanced approach to such patients. He is setting up a straw man for homeopathy to knock down.

He concludes that paragraph with a “what’s the harm” type of argument. As long as patients seek real medicine in addition to homeopathic nonsense, who cares?

Next we get the torrent of pro-CAM propaganda:

The homeopathic doctors I know are caring people, disillusioned with the crudeness of conventional medicine, not your typical aggressive alpha medical type. They are not in the pay of big pharma, whose drugs potentially kill 100 000 people a year in the United Statesalone.1 They listen, spend time, and offer some explanation for the unexplainable—and their patients like them. The effect of homeopathy is the positive effect of a therapeutic relationship that is reassuring, accepting, and supportive. Society should never underestimate the healing effect of a kind word or the value of a holistic approach. These consultations genuinely improve wellbeing. Homeopathic pills are placebos, but the placebo response is great, maybe even as high as 80%.

This is the  - medicine is flawed, so that justifies pseudoscience, deception, and nonsense – argument. Modern medicine is very complex and multifarious. It is wrong to dismiss it entirely as “crude.” Some treatments are crude, we lack knowledge in some areas, while others are well developed, advanced, and even nuanced. But remember – Spense is setting up an easy straw man for homeopathy.

Then he makes a cheap shot at “Big Pharma.” This is another straw man and a false dichotomy. He is saying that doctors don’t really care about their patients. They are aggressive jocks who are compromised by conflicts of interest. While homeopaths care, spend time with their patients, and take a “holistic” approach, and have bunny rabbits and flowers in their waiting rooms.

I an my science-based colleagues have been very critical of the pharmaceutical industry for trying to put their thumb on the scale of the scientific process. We also generally agree with transparency in pharmaceutical payments to doctors, and academic researchers need to maintain their independence as much as possible. At the same time, there are legitimate partnerships between academia and industry that produce tangible benefits for the public. It’s a tricky relationship, and it’s evolving in a good way, but there are problems.

What about the homeopathic remedy industry? Spence pretends that homeopathic pharmaceutical companies are not making billions also, and that homeopaths don’t have a vested interest in their claims, profession, and products.

Further, what is Spence’s evidence that homeopaths are more caring than science-based practitioners?  Sure, they have a different practice model. They get to charge patients with disposable income cash. They get to give every patient a specific answer, because they are just making it up.

As I have argued before – CAM practices are disconnected from the constraints of science, evidence, and (I would argue) even ethics. So they evolved over time to maximize the other aspects of care that are effective marketing, telling patients what they want to hear, friendly treatments, and good bedside manner. I, on the other hand, have to tell patients the truth, give them informed consent, and consider risk vs benefit in every decision. Sometimes maximal benefit lies in an unpleasant procedure.

Spence implies that homeopathy is “holistic”  - but this is nonsense, just more propaganda. Homeopathy takes a very narrow (and wrong) approach to illness and treats symptoms with magical potions. They don’t consider actual biology or physiology. Whereas I learned to practice with the “biopsychosocial” model of medicine. Science-based medicine was “holistic” before being holistic was trendy.

Spence makes another straw man when he implies that mainstream medicine denies the power of a good therapeutic relationship. It’s challenging, but you can have good bedside  manner and maximize the therapeutic relationship within the confines of ethical science-based medicine. You don’t have to chuck science and lie to patients in order to make them feel good.

Spence finishes with an appeal to placebo medicine, and quotes the outrageous and vague figure that “the” placebo effect: “maybe even as high as 80%.” Where did he get that figure from? He gives no reference. And what does he mean - the number of people that have any placebo response, or the degree of resolution of the symptoms, and which symptoms? This is a meaningless statement – and it’s also wrong. There are many placebo effects, most of which are just illusions. For most hard outcomes, there is no measurable placebo effect. For subjective symptoms there is a variable transient placebo effect. None of this justifies giving literal placebos to patients.

Spence then gives us a false equivalency argument:

But likewise the more you understand of research evidence the more you understand it is mere modern marketing quackery. There may be some dangerous homeopathic charlatans, but there are plenty in mainstream medicine too.

Homeopathy is an easy target; we would be better to focus on the failings of conventional medicine.

Is he dismissing all scientific medical research as “marketing quackery?” His argument is the equivalent of saying, “there may be some criminals in organized crime syndicates, but plenty of ordinary citizens have shoplifted too.”

No system is perfect, so you can find fault and abuse anywhere. That doesn’t mean that a transparent democracy is equivalent to a brutal dictatorship, because there is corruption in democracy too. Homeopathy is pure pseudoscience. Telling patients made up nonsense that is not true and then giving them placebos is unethical, even if it makes them feel better. The imperfections in science-based medicine do not justify this behavior.

It gets worse:

“We need to accept that patients will still use homeopathy, and having access to it through the NHS means it is regulated and safe. “

This old argument has already been so thoroughly trashed,  I will just give Edzard Ernst’s pithy quip about it, “The most meticulous regulation of nonsense must still result in nonsense.” Regulating nonsense does not protect patients or improve quality, it just legitimizes the nonsense and causes harm.

Conclusion

I was astounded that the BMJ would publish such a pile of nonsense in their journal. Spence gets just about everything wrong. He comes off as simultaneously naive (toward homeopathy) and cynical (toward modern medicine). He gives no evidence that he has read or understood the careful and thorough arguments made for science-based medicine or against the practice of pseudoscience, so he repeatedly makes fallacious and discredited arguments as if he’s the first person to have thought of them.

He is not engaging in a productive conversation (as one would expect of a peer-reviewed journal), but spouting naive propaganda from 20 years ago. I fear how many of my colleagues share this clueless, cynical, and shruggie attitude.

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11 responses so far

11 Responses to “A Bit of Homeopathy Nonsense in the BMJ”

  1. ConspicuousCarlon 18 Sep 2012 at 8:51 am

    It’s just plain weird how a well-educated doctor can forget everything he has known and done, spout off some nonsense meme which denigrates his own work and all of science, and then turn his chair back toward his desk and continue working. And we know his words are going to be recited by some quack. It really is a mind virus.

  2. DOYLEon 18 Sep 2012 at 12:45 pm

    Homeopathy is a tentacle of the “noble” all inclusiveness model in sociality.But it is a false nobility,and moves into the realms of christian science and scientology.Moreover homeopathy and other forms of divination play into the soft spot of the competitive underdog.Just saying.

  3. SimonWon 18 Sep 2012 at 7:09 pm

    I think the question for doctors who accept homeopathy is a placebo but still promote or encourage it is “why this placebo over some other?”.

    The placebo effect exists with any other treatment.

    It is rare to have a patient in which no effective interventions are possible, at least if losing weight, exercising, or taking pain killers are included in the list of interventions.

    So why specifically choose an intervention we know has no effect over placebo to get the placebo benefit when we can pick one with a benefit as well. Also we want evidence that the placebo effect is positive for a particular intervention, otherwise we risk the nocebo effect – I’m thinking of the people who knew they were being prayed for study when they did worse. Placebos also endanger the trust relationship, unless the doctor upfront says “these are placebos”.

    So having dealt with the issue of prescribing a placebo, we need to know what placebo. Sugar pills are cheaper than those marketed as homeopathic sugar pills and if the FDA investigation pans out may be safer as well, so we have a cost benefit, but surgery has a bigger placebo effect in some studies. A cup of tea and biscuit with the practice nurse and some discussion around health issues is a potentially promising but expensive “placebo” style treatment and might elicit other information that leads to a proper diagnosis other than “worried well”. Similarly some sort of routine for weighing and measuring might enhance the placebo effect of a doctors visit even if you didn’t really need their blood pressure, weight and height recorded again. Seeing doctors has a fairly powerful effect according to some source so maybe we should shorten the NHS allotted time per patient to boost the number of people who get that benefit, or lengthen them if that boost the effect per patient more – oh dear they are contradictory – we need evidence for what to do.

    So if Des has decided a placebo effect is what a patient needs, how on earth did he get to homeopathy given the huge range of potential placebos available. We need Professor Ernst or someone with expertise in the field to research the best placebo for any given complaint. Until then sugar pills have been widely used as placebos in placebo controlled medical trials, we’d know if they did anything by now.

  4. norrisLon 19 Sep 2012 at 1:01 am

    I can forgive to some extent the under educated (although garbage like homeopathy appears to be used more by the better educated…what the?) person choosing homeopathy just through sheer ignorance. But when a university trained professional goes down this path I go totally rank! Having a university education in science SHOULD be like a vaccine against garbage like sugar flavoured water. So why does the university educated professional take this path? because it’s what his patients want? Invalid answer! Because he truly believes in it? Then he is a liar or a halfwit moron. Because he can earn a lot of money for being a purveyor on well proven ineffective placebo sugar water and sugar pills. ie: He is a scammer, nothing more or less!

  5. SteveAon 19 Sep 2012 at 7:06 am

    “I was astounded that the BMJ would publish such a pile of nonsense in their journal.”

    Hopefully their intention was to give Spence enough rope to hang himself and to generate the kind of rebuttal you’ve given here.

    Will you be writing a formal response via the BMJ?

  6. locutusbrgon 19 Sep 2012 at 9:54 am

    I would like to point out Steve that one small part of your opinion is sort of a false dichotomy.

    “Well – which is it? Are they dismissed, or overly investigated. These are mutually exclusive claims. Why would someone order a battery of tests on someone they dismiss as the “worried well?”

    You could challenge this as confirmation bias but I think realistically you see this happen quite a bit. you will often see patients with that have obvious anxiety and psychiatric issues who have been to individual specialists across multiple specialties. They have had batteries of specialty specific tests told that they are negative then told to see another specialist. In truth the patient can be extensively worked-up and the passed along. Giving them the very real impression of being dismissed. In truth I have seen very insular attitudes by providers. Given the fact that psychiatric diagnosis are very difficult for non-psychiatric practitioners, plus they are poorly received. You often see what I call the specialist “Punt”, “Well the work up was negative but you are still having this pain see your PMD.”

    This population specifically is most vulnerable to this type of crap and I think your argument in this one statement kind of falls short.

    I am not saying that a placebo is a good choice, just that his argument can be, both true.
    Steve

  7. BillyJoe7on 19 Sep 2012 at 5:44 pm

    in other words, they can first be extensively worked up and then dismissed.

  8. RickKon 19 Sep 2012 at 6:09 pm

    If you asked Dr. Spence whether Big Pharma should be allowed manufacture sugar pills that do nothing, falsely claim the pills have active ingredients, and make bold claims of health benefits without any requirement to test efficacy, he (and most pro-CAM folks) would probably say no.

  9. Mojoon 20 Sep 2012 at 6:03 am

    @RickK

    Big Pharma already does that. They call the pills “homeopathic”.

  10. TomJLon 20 Sep 2012 at 7:47 am

    I tend to flick through every issue of the BMJ and I’m pretty sure he is regular columnist. I’ve read his column a few times before and have found nothing too controversial about it. So it worries me that people could read this and agree with it based upon his position at the journal. If it was a one off article by some unknown then maybe it wouldn’t be too bad. I will be interested to see the letters page of the next issue to see if there a strong response as well as the content of his future columns.

  11. Steven Novellaon 20 Sep 2012 at 7:58 am

    locutus – That’s a fair point, but it still does not address Spence’s characterization. The problem is not dismissing patients, but not properly managing them. I don’t think it’s a false dichotomy – the kind of dismissiveness Spence is talking about is not taking patient’s concerns seriously, which is not the problem here. They are taken seriously enough to perform a workup for possible causes.

    I agree that there is often a problem with properly dealing with patients with a negative thorough workup. This is not a problem of dismissiveness, however, just clinical skill in dealing with such situations. Often the hardest thing to deal with is patient perceptions. Patient’s often feel that being told, “all the tests were negative” is dismissing their symptoms. I often have to spend a long time explaining to patients that this is not the case, the nature of clinical diagnoses, and how we symptomatically manage such situations.

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