Revolt of the British Doctors
May. 23rd, 2006 08:25 am![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
danalwynI noticed today that the revolt of some NHS doctors against Alternative and Complementary medicines made the front page at BBC. I wondered if that debate would ever actually come to light, given the fighting that traditionally goes on backstage.
I've never particularly been fond of the Alternative Medicine establishment, so I have my own two cents to interject, even though I'm not even British. Besides, nobody has flamed me recently, and maybe I'll get one or two out of this.
I've never particularly been fond of the Alternative Medicine establishment, so I have my own two cents to interject, even though I'm not even British. Besides, nobody has flamed me recently, and maybe I'll get one or two out of this.
I am naturally reluctant to trust anything that refuses to test itself thoroughly.
There it is, my reason for ranting on this subject in the first place. After all, in Physics, anyone who comes up with a wild theory and then refuses to test it is pretty much always either a quack or a string theorist, and those two are not mutually exclusive. Medicine is an area that tests itself more frequently (although not as rigorously in terms of statistical accuracy) as physics, simply because dealing with human beings is a lot more complex than dealing with sub-atomic particles. And a lot of the medical establishment is suspicious of the way in which Alternative Medicine claims to have benefits that are not properly testable.
The controversy revolves around the placebo effect. It is well recognized that Alternative Medicine (AM) has some sort of effect. The question has been whether or not it is within the placebo range or not. This is why double-blind clinical tests are so important, but it is difficult to perform a double-blind test on AM partially because of its nature, and partially because there are several practitioners who claim that the therapies do not work in a clinical setting. This has effectively allowed a great deal of stonewalling on the subject, and a great deal of bad science to slip through.
For instance, the Bristol Homeopathic Hospital reported that out of 6,500 patients, 70% reported positive effects after their treatment. On one hand, this means that something happened. On the other, it does not constitute a scientific survey. There is no mention of a control group, either a placebo control (people given fake medication), or a natural control (people with similar conditions not given anything at all). There is also an enhanced placebo effect possible, since people who believe a medicine may work are more likely to experience a placebo effect, and presumably people who volunteered for treatment at the Bristol Homeopathic Hospital believed that their treatment was likely to work (unless the NHS is forcing people around).
Homeopathy, of course, is one of Science's most frustrating opponents at the moment, both because of a stubborn insistence that they cannot be tested properly, and by a claim that they operate beyond the bounds of normal science in a way that they cannot explain. The problem runs something like this; in homeopathy, a substance similar to the one that causes ailment is diluted in solution with water until it reaches an appropriate state. The problem is that the original founder of homeopathy, Hahnemann, maintained that the ideal dilution factor is approximately 1 in 1060. This is difficult to obtain, as there are only approximately 1051 atoms in the Earth. According to the wikipedia calculations, even an extremely potent 15C solution, diluted to 1 in 1030 has an average of one molecule of diluted substance per 25 metric tons of water. Homeopathy claims that, since most of what they give you is water without chemical trace of the active ingredient, that the solution retains a "memory" of what it was in contact with. Additionally, the process of dilution is somehow "special" (although it is my understanding that they do not claim to understand how), and thus the solution does not maintain a memory of any other substance it may have come in contact with over its long history (since water goes so many places, you might expect it to contain "memories" of almost every possible substance so far). Recently, the dilution factor has also been reduced to boost effectiveness, although still below the detectable level in several cases. There is no established canon on what effective dilution is; practitioners admit that theories and approaches vary.
There is, of course, an easy way to do a double-blind clinical test of homeopathy, but so far nobody has stepped up to the plate on the AM side. Given that they have made a rather extraordinary claim, you would expect that they would be eager to prove it, but the latest wide-scale survey I can find is that of the Lancet, which claims that the effects are no better than the placebo level. The James Randi one million dollar prize is also available to anyone who can prove homeopathy in a double-blind clinical test, and even though Randi's views on the subject might disuade practitioners (regardless of the accuracy of the test), you would think that somebody would have made their quick million by now.
On the other side, you have something like Acupuncture, which is very difficult to run as a double-blinded test. The easiest way that they have found so far is to simply have a medical intern stick needles in a patient's back (or other location) in improper and randomized points and see if this produces an effect. So far, I've only seen one test (with an extremely small sample size) run in this manner, reported here, which claims that there is no appreciable difference between traditional accupuncture and placebo. Clearly a more wide-scale test is in order, but that is an effort that so far appears not to have been undertaken (I may be mistaken about this).
Regardless, at the moment, I don't think the NHS should be supporting AM as an accepted treatment until they can get some confirmation of how it works. It is entirely possible that AM may involve new principles of biology that so far remain unknown to the rest of us. The problem is not that the medical community does not understand, but that the practitoners themselves do not understand it. With ignorance at this high a level, it is difficult to understand how to police the practice. Apparently, practitioners of therapies like homeopathy can recognize each other, but because they cannot codify their reasoning or their selection process, they have no way of testing whether another homeopath is a doctor or a fraud. To put it another way; what is to stop me from setting up my own shop and declaring myself a dispenser of homeopathic medicines, and partially qualified for NHS money. Preumably, if I am a fraud, the other homeopathic doctors can suss me out, but it would be nearly impossible in practice. Normally, it would be demanded that I show that my procedure produced clinical benefits, but this is not part of the current program, and other homeopaths seem reluctant to setup a series of clinical trials to test their own medicines. Without that level of testing they could, of course, disprove me if my program worked in ways counter to homeopathic theory, but since they themselves do not claim to fully understand the theory, I can just claim that everything I do was discovered accidentally and must take advantage of a portion of the theory that is not understood. In other words, freed of the constraints of either producing non-placebo results or scientifically explaining my product, I can keep my scam going almost forever.
This is my chief complaint at the moment. Simply because there are few concrete constrains on many forms of AM, a procedure should not qualify for NHS money until it has been both documented and proven clinically to produce beyond-placebo results. Without that, the number of quacks in the system will multiply until scams grow entirely out of control. In the meantime, there are enough problems with regular health care that the money could be put to use elsewhere.
I'm not British of course, but sooner or later this will become an issue in the US as well. When it does, I can just hope that there is a testing procedure in place.
There it is, my reason for ranting on this subject in the first place. After all, in Physics, anyone who comes up with a wild theory and then refuses to test it is pretty much always either a quack or a string theorist, and those two are not mutually exclusive. Medicine is an area that tests itself more frequently (although not as rigorously in terms of statistical accuracy) as physics, simply because dealing with human beings is a lot more complex than dealing with sub-atomic particles. And a lot of the medical establishment is suspicious of the way in which Alternative Medicine claims to have benefits that are not properly testable.
The controversy revolves around the placebo effect. It is well recognized that Alternative Medicine (AM) has some sort of effect. The question has been whether or not it is within the placebo range or not. This is why double-blind clinical tests are so important, but it is difficult to perform a double-blind test on AM partially because of its nature, and partially because there are several practitioners who claim that the therapies do not work in a clinical setting. This has effectively allowed a great deal of stonewalling on the subject, and a great deal of bad science to slip through.
For instance, the Bristol Homeopathic Hospital reported that out of 6,500 patients, 70% reported positive effects after their treatment. On one hand, this means that something happened. On the other, it does not constitute a scientific survey. There is no mention of a control group, either a placebo control (people given fake medication), or a natural control (people with similar conditions not given anything at all). There is also an enhanced placebo effect possible, since people who believe a medicine may work are more likely to experience a placebo effect, and presumably people who volunteered for treatment at the Bristol Homeopathic Hospital believed that their treatment was likely to work (unless the NHS is forcing people around).
Homeopathy, of course, is one of Science's most frustrating opponents at the moment, both because of a stubborn insistence that they cannot be tested properly, and by a claim that they operate beyond the bounds of normal science in a way that they cannot explain. The problem runs something like this; in homeopathy, a substance similar to the one that causes ailment is diluted in solution with water until it reaches an appropriate state. The problem is that the original founder of homeopathy, Hahnemann, maintained that the ideal dilution factor is approximately 1 in 1060. This is difficult to obtain, as there are only approximately 1051 atoms in the Earth. According to the wikipedia calculations, even an extremely potent 15C solution, diluted to 1 in 1030 has an average of one molecule of diluted substance per 25 metric tons of water. Homeopathy claims that, since most of what they give you is water without chemical trace of the active ingredient, that the solution retains a "memory" of what it was in contact with. Additionally, the process of dilution is somehow "special" (although it is my understanding that they do not claim to understand how), and thus the solution does not maintain a memory of any other substance it may have come in contact with over its long history (since water goes so many places, you might expect it to contain "memories" of almost every possible substance so far). Recently, the dilution factor has also been reduced to boost effectiveness, although still below the detectable level in several cases. There is no established canon on what effective dilution is; practitioners admit that theories and approaches vary.
There is, of course, an easy way to do a double-blind clinical test of homeopathy, but so far nobody has stepped up to the plate on the AM side. Given that they have made a rather extraordinary claim, you would expect that they would be eager to prove it, but the latest wide-scale survey I can find is that of the Lancet, which claims that the effects are no better than the placebo level. The James Randi one million dollar prize is also available to anyone who can prove homeopathy in a double-blind clinical test, and even though Randi's views on the subject might disuade practitioners (regardless of the accuracy of the test), you would think that somebody would have made their quick million by now.
On the other side, you have something like Acupuncture, which is very difficult to run as a double-blinded test. The easiest way that they have found so far is to simply have a medical intern stick needles in a patient's back (or other location) in improper and randomized points and see if this produces an effect. So far, I've only seen one test (with an extremely small sample size) run in this manner, reported here, which claims that there is no appreciable difference between traditional accupuncture and placebo. Clearly a more wide-scale test is in order, but that is an effort that so far appears not to have been undertaken (I may be mistaken about this).
Regardless, at the moment, I don't think the NHS should be supporting AM as an accepted treatment until they can get some confirmation of how it works. It is entirely possible that AM may involve new principles of biology that so far remain unknown to the rest of us. The problem is not that the medical community does not understand, but that the practitoners themselves do not understand it. With ignorance at this high a level, it is difficult to understand how to police the practice. Apparently, practitioners of therapies like homeopathy can recognize each other, but because they cannot codify their reasoning or their selection process, they have no way of testing whether another homeopath is a doctor or a fraud. To put it another way; what is to stop me from setting up my own shop and declaring myself a dispenser of homeopathic medicines, and partially qualified for NHS money. Preumably, if I am a fraud, the other homeopathic doctors can suss me out, but it would be nearly impossible in practice. Normally, it would be demanded that I show that my procedure produced clinical benefits, but this is not part of the current program, and other homeopaths seem reluctant to setup a series of clinical trials to test their own medicines. Without that level of testing they could, of course, disprove me if my program worked in ways counter to homeopathic theory, but since they themselves do not claim to fully understand the theory, I can just claim that everything I do was discovered accidentally and must take advantage of a portion of the theory that is not understood. In other words, freed of the constraints of either producing non-placebo results or scientifically explaining my product, I can keep my scam going almost forever.
This is my chief complaint at the moment. Simply because there are few concrete constrains on many forms of AM, a procedure should not qualify for NHS money until it has been both documented and proven clinically to produce beyond-placebo results. Without that, the number of quacks in the system will multiply until scams grow entirely out of control. In the meantime, there are enough problems with regular health care that the money could be put to use elsewhere.
I'm not British of course, but sooner or later this will become an issue in the US as well. When it does, I can just hope that there is a testing procedure in place.