The Doctor Says: There May Be Trouble Ahead


Dr Selva Rasaiah is a regular at Merseyside Skeptics in the Pub. Here, in response to my support for real medicine, he takes an inside look at the NHS, and doesn’t like what he sees…

The other day, I read Marsh’s latest post ‘Real Medicine: I Wonder’ with interest – as (hopefully!) one of the “good doctors” he wrote of, I would like to report all is well within the NHS. Unfortunately I can’t. Virtually all the comments on his piece were positive about the use of conventional medicine, but an important point was raised regarding the care of osteoarthritic hip pain. Currently the options for “wear and tear” arthritis are very limited, the options being:

  1. do nothing
  2. take painkillers
  3. hip replacement surgery.

The only definitive treatment is option 3, which for most patients is a life changing procedure. Unfortunately it has a limited lifespan, and in general is only offered to more severely affected patients. As this condition can start in the 50’s or younger, we have the difficult task of informing people that they will have to put up with the pain for many years before surgery will be considered. The problem with evidence based medicine (EBM) is that it leaves lots of gaps, which CAM (complementary and alternative medicine) is more than happy to fill.

On a daily basis, we have to inform patients that their self limiting viral illness/gastroenteritis etc. will not respond to antibiotics. It is so easy to skip the explanation and just dish out the pills, but with the advent of MRSA and other drug resistant nasties, the finger is pointing more and more at “irresponsible GP’s” and their over-prescribing of antibiotics as the cause of this new epidemic. How tempting it would therefore be to prescribe a harmless placebo that might make people feel better, psychologically if not physically. There is however, something inherently dishonest about this approach that would prevent me and most of my colleagues from doing so.

However, a small – but noisy – bunch of GPs DO seem to have followed this route, and regularly post articles and comments in GP magazines. Here are a few quotes (s0urces available on request):

“I have studied homeopathy, scientifically, not in a non-touchy feely way, and have found it to be extremely helpful in areas of medicine where conventional alternatives have not helped. As a GP, I have found homeopathy on occasion to work exceptionally well, and if it does no harm, then why not try it?”

And:

“I couldn’t explain it then and I can’t explain it now. Those who dismiss homeopathy because it does not fit their world view do themselves a disservice, by not attempting to listen to homeopaths or read what they write, unless it is to seek out reasons to toss a few more metaphorical rocks.”

A particular vociferous voice is Andrew Sikorski, a Sussex-based GP and member of the executive council of the Faculty of Homeopaths. He regularly hounds Edzard Ernst and the blogs of Pulse magazine, quoting latin phrases in an impressively self-deluded manner. For example:

“The best EBM would be studying N=1 trials with the particular patient to see what suits their needs best and provides an optimum outcome. Rarely does my patient match the inclusion criteria of a single study, let alone amalgamated studies included in met-analyses. Yet I am heartened by the research which suggests there is an inbuilt healing system within us all and judiciously following Hippocrates’ dictat ‘primo (primum) non nocere’” – Source: Pulse 03/12/09

In other words, in his view, randomised blinded placebo controlled trials are of less value than individual anecdotal evidence. Hippocrates did indeed require that practitioners “first do no harm”, and in his day doing nothing was significantly less harmful than the black magic that was offered at the time. In fact Hippocrates dispelled a lot of the mysticism that dominated health care at the time, and I have no doubt that had he lived today, he would advocate modern evidence based medicine.

There is currently something of a battle going on at government level, fuelled by HRH’s “Foundation for Integrated Health”. Homeopathy has been part of the NHS for many years, with 5 Homeopathy hospitals nationwide, including one in Liverpool. These cost the NHS several million pounds a year to run, and are so established that it is hard to see how they will ever be closed down. The National Institute for Clinical Excellence uses the latest evidence to advocate EBM, and yet we are undermined by the government who are now proposing a “Personal health budget scheme” where patients can choose how NHS money is spent on them, including homeopathy, acupuncture and other alternative treatments. Indeed recent NICE guidelines (normally the bastion of EBM) for back pain are particularly worrying, as the working group included acupuncturists and chiropractors, but no pain management specialists. Not unsurprisingly the guidelines include these alternative therapies.

What’s the harm in CAM? Consider the death in 2000 of a 6 month old baby, whose parents refused conventional medicine in favour of alternative therapies. A leading homeopath was quoted by the BBC:

“Increasingly, with the rise in popularity of complementary medicine these situations are going to arise. Also there is considerable scepticism about some of the aspects of conventional medicine.”

I couldn’t have put it better myself.

As far as the cost is concerned, it was estimated in 2007 that the money spent on homeopathy by the NHS could have saved 600 lives by the prescribing of Herceptin to more breast cancer patients. (Source: Baum, M., et al)

The fact that Prince Charles meets the health secretary on a regular basis, and in the light of the same health secretary’s recent performance in the parliamentary select committee on homeopathy, it would suggest that CAM has more than just a foot in the door. In my view, the Merseyside Skeptics new 10.23 campaign could not have come at a better time. The more public awareness of what is being done in their name (and with their money) the better.

Dr. Selva Rasaiah
10:23

*Update: After feedback, a couple of the facts here have been happily amended to come more into line with current medical procedure*

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  1. #1 by Dr*T on January 7, 2010 - 22:08

    Thanks Dr R,

    Sadly, all manner of pseudoscientific nonsense continue to lighten the wallets of arthrites.

    Any glimmer of relief from pain will be attractive, often referred from by well-wishing friends and relatives who coax “it can’t harm to try”.

    Cherries, rosehips, chiropractic, and of course homeopathy are a few of the pseudoscientific modalities I’ve come across (and blogged for posterity).

    Anything which helps arthrites make good, evidence-based decisions with regards to pain control is an excellent thing, in my opinion.

    T

    10:23

  2. #2 by Seedy Pete on January 8, 2010 - 01:05

    As some one who suffers from ankylosing spondylitis, I understand just how desperate chronic pain can leave you! But why, when they find out that they’ve been sold a crock dont people get angry? Instead they seem to excuse the people who sold them the nonsense and pass on how good the placebo affect was to friends and relations and in so doing continuing the myth! I know NSAID drags etc arent perfect and some have even been withdrawn but surely they are better than sugar dressed in pretty clothes and empty promises!

  3. #3 by Dr Richard Rawlins FRCS on January 8, 2010 - 12:05

    NO!!

    Total hip replacements do not have a “10-15 year life span”.

    They are very much better than that.

    When asked, “if I have a hip (or knee), how ling will it last?”, most surgeons say something on the lines of “At least ten years”.

    Ten because that is a standard time span for medical decision making, prognostication, risk management – and is a number comprehensible by patients.

    But the fact is, the attrition rate, or revision rate for modern hip and knee replacements is about 1% per year. So, at ten years, roughly 10% might need revision. So for a patient, that is the risk they take.

    But even for a thirty year old whose lifespan is another 49 years, on the balance of probabilities, a replaced hip will last them a lifetime.

    Elbows, shoulders and ankles are not quite so good, but we’re getting there!

    PLEASE get statistics right if you are going to quote them.

    Thank you.

  4. #4 by Denise on January 8, 2010 - 12:59

    Just wanted to make a quick comment about hip replacement – THR is performed on younger patients. For those of us with dysplasia, it is generally inevitable, and at a young age. I’ve just had one at 45, and my surgeon has said I can hopefully have 20-30 years before I’d need a revision.

    Totally agree with the rest of your article 🙂

  5. #5 by Sel on January 8, 2010 - 16:27

    Thank you for the correction Dr Rawlins. The point though is that the majority of osteoarthritic patients are not suitable, or not bad enough for surgery and have to rely on pain management for many years. This inevitably leads to frustration with conventional medicine.

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