Real Secrets of Alternative Medicine sets out a general thesis that camistry provides beneficial effects due to placebo responses mediated in the same way as hypnotic experiences and response expectancies.
Most questions can be answered by reference to the web sites of associations and practitioners who practice CAM. Just pick the specific CAM in which you are interested and use your favourite search engine. Do not believe all you read – retain your critical faculties and ask questions. Bear in mind that to establish the degree of effectiveness of any treatment or remedy, randomised double-blind controlled trials are the “gold standard” – but not essential. Nevertheless, there should be at least some plausible evidence of genuine benefit, however it has been obtained. ‘Evidence’ means an objective credible account which is offered by rational persons, and which is reproducible by other investigators. Anecdotes of the subjective experiences of enthusiastic wudoka who follow Wu, do not suffice. It goes without saying that all results should be published, not just the ones which prove the point the author wishes to make. Publication bias is research misconduct, and you must be the judge.
I have given a number of lectures and talks on these themes which have resulted in questions worthy of further explanation:
- Q: Why do camists not distinguish between the beneficial effects of the therapeutic relationship with a patient and the effects of the therapies or remedies they use?
A: They must answer for themselves, but this conflation does prevent proper assessment of each element and disguises the fact that in all cases studied, CAM therapies and remedies themselves have not been shown to have significant effects on any specific disease process. Patients benefit from the attention of a camist due to placebo responses, but camists also claim their methods can treat diseases. To believe that, an alternative mind-set is needed , which is why CAMs are ‘alternative’. As to whether the camist is deluded and does not understand the importance of the distinction between the two types of effect, or is deliberately seeking to mislead in order to promote unsubstantiated treatment methods – that has to be assessed on a case by case basis and is for you to judge. If so, you may regard the camist as being a quack. If the camist sells products or practices or otherwise gains pecuniary advantage from inherently worthless products or procedures, you will have to consider whether they are frauds.
- Q: Managing low back pain (LBP) is always contentious, Real Secrets reviews suggestions that manipulation by chiropractors, osteopaths or physiotherapists achieve similar outcomes, so on what basis can a practitioner be selected?
A: Indeed so, but chiropractic and osteopathy are not just manipulation. Chiropractors claim they are ‘primary health-care professionals’ – that they can make diagnoses and can adjust subluxations to release ‘innate intelligence’ – a ‘vital force’ mediated by nerves. Osteopaths claim manipulation releases much the same force, mediated by arteries. They may seek to disguise such beliefs, but if so, why are they practicing chiropractic or osteopathy and not physiotherapy? If you want ‘vital forces’ released then either high or low impact manipulation may help you. If you want your joints and musculoskeletal soft tissues manipulated, consider that a doctor or physiotherapist can do this without claiming to access any ‘vital force’. Such ‘forces’ have never been identified by scientific consensus, their nature remains in the dimension of metaphysical speculation, and practitioners who claim to be able to utilise them have to be challenged as being mistaken and misguided.
- Q: Why do people train as chiropractors and not osteopaths or physiotherapists?
A: Or indeed, train as nurses or doctors. Each practitioner must make their own career choices and explain their own reasons. I have not been able to identify any consistent reasons but all practitioners state they ‘want to help patients’. Some have admitted ‘it was the only course which would accept me.’ Some: ‘it was the nearest course to where I live.’ I have to assume all will understand and believe in the nature of the particular CAM they choose and can rationalise and explain their reasons for choosing a specific CAM – for otherwise they would simply be quacks or even fraudsters. You must judge their answers – just make sure you ask!
- Q: NICE guidelines say acupuncture can be ‘considered’ for the management of chronic low-back pain (LBP). Real Secrets suggests otherwise, why?
A: Most of NICE guidance on acupuncture is: ‘Do not’. Some suggests: ‘More research needed’. For LBP the review did not distinguish between having a constructive therapeutic relationship with a practitioner and the therapy of inserting needles itself. NICE has no evidence needles are needed, and therefore acupuncture is not needed. Caring is always necessary.
- Q: My relative has found CAM of benefit for managing pain. Surely it can’t all be placebo can it?
A: What else could it be? We know there are no active molecules in homeopathic pillules; no spinal subluxations which can be adjusted; no meridians along which a ‘force’ passes to balance other dimensions after needling of the skin; no vital forces in plants that cannot be refined by pharmaceutical scientists to even more basic natural compounds; no forces, energy fields or ‘aura’ that can be manipulated by the waving or the laying on of hands. Every patient has their own past individual imaginative encounters on which to base new experiences and their own expectancies and responses to suggestions. Each patient will find they respond to different CAMs variously. At different times, one particular CAM may seem ‘best’ for the individual. Placebo responses are powerful, highly individualised, and vary with the particular CAM technique employed – but any variation does not imply that is because of the CAM therapy itself, rather the variation is because of the patient’s expectation and response to the therapist. That is the nature of placebo.
Michael Phelps won his twenty-first Olympic gold medal after receiving ‘cupping’ – a variety of bleeding which orthodox medicine discarded long ago.
- Q: Why are so few CAMs funded by the NHS?
A: In general, public policy requires that if tax payers’ money is to be used for healthcare, there is plausible evidence for the benefit of any proposed treatment, remedy or procedure. In the case of CAMs, most can demonstrate benefit from a constructive therapeutic encounter with an empathic attentive practitioner – but such care can and should be provided by any appropriate healthcare professional. The unique aspect of CAMs is the particular therapy, procedure or remedy used. And there is no scientifically plausible evidence for effects of any CAM on any specific disease or illness. If there was, it would be ‘medicine’.
As Jeremy Hunt, Secretary of State for Health, said: ‘I need to follow the science and what science says, what the evidence says. I support doing what the scientific evidence says.’ And in answer to a question put to him in the House of Commons by Conservative MP David Tredinnick (who is keen to see homeopathy and Traditional Chinese Medicine ‘integrated’ with the NHS), Hunt stated: ‘Where there is good evidence for the impact of Chinese medicine then we should look at that, but where there isn’t we shouldn’t spend NHS money on it.’ These views are endorsed by the majority of doctors – but not all. (http://www.dcscience.net/BBC%20Radio%205%20Live%20DC%20Eames.mp3).
- Q: Why do some doctors and nurses support the use of CAM?
A: Some may be deluded, but generally, because doctors and nurses care. Conscientious health professionals recognise that patients want consolation, hope and love. If a patient wants to access a CAM, many healthcare professionals will try and oblige rather than attempt to explain all the issues. Hence the value of considering the Real Secrets. Some orthodox professionals may actually believe in one CAM or another, although it is unethical for them to proselytise such faith to patients.
May the wu be with you all.
- Q: What critical questions patients should patients ask camists?
A: Reference should be made to the web sites of associations and practitioners who practice in the field of the CAM in which you are interested.
Do not believe all you read – retain your critical faculties and ask:
- What is the evidence the CAM modality has any effect on any specific disease process?
- Have any controlled clinical trials been carried out?
- If not, how can I know whether the CAM works or not?
- Are all outcomes published, or just the ones supporting the CAM?
- Is there any evidence the practitioners being consulted are prepared to change their stance in the light of further and better particulars?
- How do I know whether a practitioner is an ethical and sincere camist, a quack, or a fraud?
- Do practitioners suggest patients should avoid conventional orthodox mainstream treatments?
- Does the practitioner explain all the issues and obtain fully informed consent?
- Are potentially harmful treatments or remedies promoted and sold without adequate warning of risks?
- Is false hope encouraged?
- Are critical faculties’ suppressed, magical thinking promoted, non-science encouraged?
However it has been obtained, there should be at least some evidence of effectiveness of any proposed treatment on specific diseases. Randomised double-blind controlled trials are gold standard, but are not essential. ‘Evidence’ means an objective plausible account which has been reproduced by other investigators – not simply anecdotes of the subjective experiences of wudoka (who follow wu) and opinions of camists. It goes without saying that all results should be published, not just the ones which prove the claims the camist wishes to make. Publication bias is research misconduct, and you must be the judge.
If you want and need consolation, hope and tender loving care, then seek appropriate counselling, support or physiotherapy, but avoid camist remedies and therapies which have no effect on specific conditions. It might be worth considering person-centered therapeutic counselling: http://www.bapca.org.uk/about/what-is-it.html.
- Q: Why are styles and titles used by practitioners of Conventional Orthodox Medicine and of CAM so confusing?
A: Just as the practices and products used in CAM may be couched in pseudo-scientific and misleading terms, so camists themselves may uses imaginative titles to dupe the unwary. Before the profession of medicine was regulated, the public found it difficult to differentiate a genuine practitioner acting with integrity from a quack seeking to take advantage of the gullible. Many quack practitioners styled themselves as ‘Doctor’ or ‘Professor’, but had no qualifications. Healing practices had evolved from the Middle Ages to become distinct professions by the 19th century. Apothecaries originally manufactured medicinal herbs for physicians but the Apothecaries Act of 1815 allowed them to prescribe and dispense as well. Physicians slowly improved their methods of diagnosis and the barber-surgeons improved their specialised skills. These practitioners were regulated and licensed by their own colleges, but it was not always easy to distinguish their practices from those of unqualified quacks and charlatans.
In the UK, the first Medical Reform Bill was placed before Parliament in 1840, but many disagreements delayed introduction of the General Council of Medical Education and Registration until 1858. In 1951 the name was shortened to General Medical Council. Although the title ‘registered medical practitioner’ (RMP) is protected, anybody can use the title ‘Dr’ – whether registered or not. All practitioners must be careful they are not using such a title to deceive and defraud. Today, the GMC has the task of ensuring educational standards of entry to the register and of restricting the practice of those who are deemed unfit to practice – removing them from the register if necessary. They can still practice, but must not claim to be registered (and cannot be employed as doctors in the NHS or regulated private facilities).
In the American colonies, the system of medical practice licensing was initially based on that of the British Royal Medical Colleges, diluted by the Atlantic. The advent of the United States saw change. The 10th Amendment of the United States Constitution, part of the Bill of Rights (1791), authorises each State to establish laws and regulations protecting the health, safety and general welfare of their citizens. Medicine is a regulated profession because of the potential harm to the public if an incompetent, impaired or fraudulent physician is licensed to practice. State regulation of a learned profession has had its political problems. ‘The condition of the American medical profession at the close of the Civil War was, in almost every particular, significantly different from that which obtains today. The profession was unlicensed and anyone who had the inclination to set himself up as a physician could do so, the exigencies of the market alone determining who would prove successful in the field and who not. Medical schools abounded, the great bulk of which were privately owned and operated and prospective students could gain admission to even the best of them without great difficulty.’ 1
In 1847 the American Medical Association was founded to upgrade medical education, establish medical licensing laws and replace proprietary medical schools with non-profit institutions. Non-orthodox medical sects were not welcome. In each of the United States, conventional physicians now qualify as Doctors of Medicine – identified with the initials M.D. In the United Kingdom, those initials indicate a physician who has been awarded a doctorate – a higher post-graduate qualification based on original research and publication of a thesis together with an examination on its concepts and ideas.
The basic medical qualification as awarded by a university in the UK is identified by various initials dependent upon whether the university uses English, Latin or Greek terminology! All will be double degrees as Bachelor of Medicine and Bachelor of Surgery (e.g. M.B., B.S.) Different UK medical schools have different entry criteria and curricula but all are inspected and deemed equivalent. Additionally, but controversially, the GMC is required to recognise conventional medical graduates from all European Community states.
UK surgeons who secure a postgraduate degree of the status of M.D. are usually designated M.S. or M.Ch. (Master of Surgery/Chirurgery). American doctors cannot be expected to understand these conventions, and many UK doctors attending American conferences put M.D. after their names so they may be recognised as orthodox physicians or surgeons, although strictly speaking not all will have earned that distinction as applied in the UK.
In the UK, the only title for a medical doctor with any form of legal protection is that of ‘registered medical practitioner’. Conventionally, such practitioners will style themselves as ‘doctor’ – except that just to add a spot of confusion, doctors who go on to specialise as surgeons, generally revert to styling themselves ‘Mr’, ‘Mrs’, ‘Miss’ or ‘Ms.’ This custom and practice is based on historical precedents – reflecting the time when surgeons were indeed not of the same status as physicians (the doctors) and the title Mister was adequate to describe them. It cannot be denied that this tradition is now perpetuated by an undercurrent of inverted snobbery (of the most benign and professional variety).
In many countries, dentists are also designated as ‘Dr’. In the UK it is conventional for dentists to style themselves as ‘Mr’, ‘Mrs’, or ‘Miss’ – after all, they are dental surgeons. There has been a recent trend for some dentists to use the title ‘Dr’ but as that can cause confusion with medically qualified practitioners, the General Dental Council states: ‘Dentists should not use the courtesy title ‘doctor’ (or the abbreviation ‘Dr’) unless they have a Ph.D. or are medically qualified and registered doctors. Its use as a courtesy title is potentially misleading to patients and it is important that patients do not assume that you have training or competencies which you do not possess.’ Indeed, why do dentists not use the title ‘Dentist’, and style of ‘Dn. Smith’?
Similarly, the medical profession and the Department of Health is concerned that practitioners who carry out surgical procedures but are not medically or dentally qualified should not use the title ‘surgeon’, as that too has a propensity to mislead patients. Indeed, why would practitioners use such titles unless it was their intention to deceive?
All patients need to be aware of these issues so that they can give properly informed consent to any treatment.
Section 49(1) of the Medical Act 1983 provides that: ‘Any person who wilfully and falsely pretends to be or takes or uses the name or title of physician, doctor of medicine, licentiate in medicine and surgery, bachelor of medicine, surgeon, general practitioner or apothecary, or any name, title, addition or description implying that he is registered under any provision of this Act, or that he is recognised by law as a physician or surgeon or licentiate in medicine and surgery or a practitioner in medicine or an apothecary, shall be liable on summary conviction to a fine not exceeding level 5 on the standard scale’.
Although the title ‘Dr’ is conventionally used by those who possess the relevant academic qualification as well as by those who practice as medical doctors registered by the General Medical Council, use of such a title by anybody else is regarded as pretentious and smacking of quackery. It is hard to have constructive professional relationships with parties who abuse these conventions. President Yahya Jammeh of Gambia who left school at sixteen insists on the title, ‘His Excellency Sheikh Professor Doctor President.’2
Conversely, many people who do have doctorates decline to use the title. Former Prime Minister Dr Gordon Brown Ph.D. and Queen guitarist Dr Brian May Ph.D. among them. Dolly Parton has an honorary doctorate from the University of Tennessee but she has never been known to use it.
- Q: Should CAM practitioners (camists) be licensed to practise?
A: Perhaps inevitably, some practitioners who do not wish, have failed, or cannot qualify as members of one of the regulated health professions, nevertheless wish to improve their status, repute and financial opportunities – and seek to have their status ‘regulated’ and ‘licensed’. They claim this ‘helps patients’, but US attorney Jann Bellamy has given good reasons why CAM practitioners should not be licensed:
‘Practice Acts grant CAM practitioners a broad scope of practice, including legalization of scientifically implausible and unproven (or disproven) diagnostic methods, diagnoses and treatments; CAM practitioner education is inadequate preparation for the scope of practice permitted; licensing is a stepping-stone to mandatory public and private insurance coverage; licensing confers undeserved legitimacy causing public confusion; and licensing decreases important health care consumer protections.’
Bellamy believes that regulated health care systems should be rooted in a single, science-based standard of care for all practitioners. Practitioners can practice as they wish (within the law), but those whose diagnoses, diagnostic methods and therapies have no plausible scientific basis should not be licensed or permitted to practice under any other regulatory scheme.3
Put simply, it is nonsense to regulate and license nonsense. Whatever next? Licensed witches, warlocks, palmists, tarot card readers, crystal therapists, astrologers, energy conjurors, fairy mongers?
1. Robert Hamowy. The Early Development of Medical Licensing Laws in the United States, 1875-1900. Department of History, University of Alberta. http://mises.org/journals/jls/3_1/3_1_5.pdf.
2. Damian Thompson, Daily Telegraph 12th November 2011.
3. Bellamy J. Six reasons why CAM practitioners should not be licensed. Science-Based Medicine Blog, June 27, 2013