Download Lectures on Biostatistics (1971). Corrected and searchable version of Google books edition
Download review of Lectures on Biostatistics (THES, 1973).
It seems very reasonable to suggest that taxpayers have an interest in knowing what is taught in universities. The recent Pittilo report suggested that degrees should be mandatory in Acupuncture, Herbal Medicine and Traditional Chinese Medicine. So it seems natural to ask to see what is actually taught in these degrees, so one can judge whether it protects the public or endangers them.
Since universities in the UK receive a great deal of public money, it’s easy. Just request the material under the Freedom of Information Act.
Well, uh, it isn’t as simple as that.
Every single application that I have made has been refused. After three years of trying, the Information Commissioner eventually supported my appeal to see teaching materials from the Homeopathy "BSc" at the University of Central Lancashire. He ruled that every single objection (apart from one trivial one) offered by the universities was invalid. In particular, it was ruled that univerities were not "commercial" organisations for the purposes of the Act.
So problem solved? Not a bit of it. I still haven’t seen any of the materials from the original request because the University of Central Lancashire appealed against the decision and the case of University of Central Lancashire v Information Commissioner is due to be heard on November 3rd, 4th and 5th in Manchester. I’m joined (as lawyers say) as a witness. Watch this space.
UCLan is not the exception. It is the rule. I have sought under the Freedom of Information Act, teaching materials from UClan (homeopathy), University of Salford (homeopathy, reflexology and nutritional therapy), University of Westminster (homeopathy, reflexology and nutritional therapy), University of West of England, University of Plymouth and University of East London, University of Wales (chiropractic and nutritional therapy), Robert Gordon University Aberdeen (homeopathy), Napier University Edinburgh (herbalism).
In every single case, the request for teaching materials has been refused. And that includes the last three, which were submitted after the decision of the Information Commissioner. They will send things like course validation documents, but these are utterly uninformative box-ticking documents. They say nothing whatsoever about what is actually taught.
The fact that I have been able to discover quite a lot about what’s being taught owes nothing whatsoever to the Freedom of Information Act. It is due entirely to the many honest individuals who have sent me teaching materials, often anonymously. We should be grateful to them. Their principles are rather more impressive than those of their principals.
Since this started about three years ago, two of the universities, UCLan and Salford, have shut down entry to all of their CAM courses. And Westminster has shut two of them, with more rumoured to be closing soon. They are to be congratulated for that, but is far from being the end of the matter. The Department of Health, and some of the Royal Colleges, have yet to catch up with the universities, The Pittolo report, which recommends making degrees compulsory, is being considered by the Department of Health. The consultation ends on November 2nd: if you haven’t yet responded, please do so now (see how here, and here).
A common excuse: the university does not possess teaching materials (yes, really)
Several of the universities claim that they cannot send teaching materials, because they have no access to them. This happens when the university has accredited a course that is run by another, privately run, institution. The place that does the actual teaching, being private, is exempt from the Freedom of Information Act.
The ludicrous corollary of this excuse is that the university has accredited the course without checking on what is taught, and in some cases without even having seen a timetable.
The University of Wales
In fact the University of Wales doesn’t run courses at all. Like the (near moribund) University of London, it acts as a degree-awarding authority for a lot of Welsh Universities. It also validates a lot of courses in non-university institutions, 34 or so of them in the UK, and others scattered round the world.
Many of them are theological colleges. It does seem a bit odd that St Petersburg Christian University, Russia, and International Baptist Theological Seminary, Prague, should be accredited by the University of Wales.
They also validate the International Academy of Osteopathy, Ghent (Belgium), Osteopathie Schule Deutschland, the Istituto Superiore Di Osteopatia, Milan, the Instituto Superior De Medicinas Tradicionales, Barcelona, the Skandinaviska Osteopathögskolan (SKOS) Gothenburg, Sweden and the College D’Etudes Osteopathiques, Canada.
The 34 UK institutions include the Scottish School of Herbal Medicine, the Northern College of Acupuncture and the Mctimoney College of Chiropractic.
The case of the Nutritional Therapy course has been described already in Another worthless validation: the University of Wales and nutritional therapy. It emerged that the course was run by a grade 1 new-age fantasist. It is worth recapitulating the follow up.
What does the University of Wales say? So far, nothing. Last week I sent brief and polite emails to Professor Palastanga and to
Professor Clement to try to discover whether it is true that the validation process had indeed missed the fact that the course organiser’s writings had been described as “preposterous, made-up, pseudoscientific nonsense” in the Guardian.
So far I have had no reply from the vice-chancellor, but on 26 October I did get an answer from Prof Palastanga.
As regards the two people you asked questions about – J.Young – I personally am not familiar with her book and nobody on the validation panel raised any concerns about it. As for P.Holford similarly there were no concerns expressed about him or his work. In both cases we would have considered their CV’s as presented in the documentation as part of the teaching team. In my experience of conducting degree validations at over 16 UK Universities this is the normal practice of a validation panel.
I have to say this reply confirms my worst fears. Validation committees such as this one simply don’t do their duty. They don’t show the curiosity that is needed to discover the facts about the things that they are meant to be judging. How could they not have looked at the book by the very person that they are validating? After all that has been written about Patrick Holford, it is simply mind-boggling that the committee seems to have been quite unaware of any of it.It is yet another example of the harm done to science by an unthinking, box-ticking approach.
Incidentally, Professor Nigel Palastanga has now been made Pro Vice-Chancellor (Quality) at the University of Wales and publishes bulletins on quality control. Well well.
The McTimoney College of Chiropractic was the subject of my next Freedom of Information request to the University of Wales. The reasons for that are, I guess, obvious. They sent me hundreds of pages of validation documents, Student Handbooks (approx 50 pages), BSc (Hons) Chiropractic Course Document. And so on. Reams of it. The documents mostly are in the range of 40 to 100 pages. Tons of paper, but none of it tells you anyhing whatsover of interest about what’s being taught. They are a testament to the ability of universities to produce endless vacuous prose with
very litlle content.
They did give me enough information to ask for a sample of the teaching materials on particular topics. But I gor blank refusal, on the grounds that they didn’t possess them. Only McTimoney had them. Their (unusually helpful) Freedom of Information officer replied thus.
“The University is entirely clear about the content of the course but the day to day timetabling of teaching sessions is a matter for the institution rather than the University and we do not require or possess timetable information. The Act does not oblige us to request the information but there is no reason you should not approach McTimoney directly on this.”
So the university doesn’t know the timetable. It doesn’t know what is taught in lectures, but it is " entirely clear about the content of the course".
This response can be described only as truly pathetic.
Either this is a laughably crude form of obstruction of my request, or perhaps, even more frighteningly, the university really believes that its endless box-ticking documents actually provide some useful control of quality. Perhaps the latter interpretation is more charitable. After all, the QAA, CHRE, UUK and every HR department share similar delusions about what constitutes quality.
Perhaps it is just yet another consequence of having science run largely by people who have never done it and don’t understand it.
Validation is a business. The University of Wales validates no fewer than 11,675 courses altogether. Many of these are perfectly ordinary courses in universities in Wales, but they validate 594 courses at non-Welsh accredited institutions, an activity that earned them £5,440,765 in the financial year 2007/8. There’s nothing wrong with that if they did the job properly. In the two cases I’ve looked at, they haven’t done the job properly. They have ticked boxes but they have not looked at what’s being taught or who is teaching it.
The University of Kingston
The University of Kingston offers a “BSc (Hons)” in acupuncture. In view of the fact that the Pittilo group has recommended degrees in acupuncture, there is enormous public interest in what is taught in such degrees, so I asked.
They sent the usual boring validation documents and a couple of sample exam papers . The questions were very clinical, and quite beyond the training of acupuncturists. The validation was done by a panel of three, Dr Larry Roberts (Chair, Director of Academic Development, Kingston University), Mr Roger Hill (Accreditation Officer, British Acupuncture Accreditation Board) and Ms Celia Tudor-Evans (Acupuncturist, College of Traditional Acupuncture, Leamington Spa). So nobody with any scientific expertise, and not a word of criticism.
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Further to your recent request for information I am writing to advise that the University does not hold the following requested information: (1) Lecture handouts/notes and powerpoint presentations for the following sessions, mentioned in Template 3rd year weekend and weekday course v26Aug2009_LRE1.pdf (a) Skills 17: Representational systems + Colour & Sound ex. Tongue feedback 11 (b) Mental Disease + Epilepsy Pulse feedback 21 (c) 18 Auricular Acupuncture (d) Intro. to Guasha + practice Cupping, moxa practice Tongue feedback 14 (2) I cannot see where the students are taught about research methods and statistics. I would like to see Lecture handouts/notes and PowerPoint presentations for teaching in this area, but the ‘timetables’ that you sent don’t make clear when or if it is taught. The BSc Acupuncture is delivered by a partner college, the College of Integrated Chinese Medicine (CICM), with Kingston University providing validation only. As such, the University does not hold copies of the teaching materials used on this course. In order to obtain copies of the teaching materials required you may wish to contact the College of Integrated Chinese Medicine directly. This completes the University’s response to your information request. |
So again we see that Kingston has validated the course but has not seen a timetable, far less what is taught. My reply was thus
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Yes I am exceedingly unhappy about it. The university attaches its name to the course so it must obviously be able to get the material simply by asking for it (I’m surprised that the university should endorse a course without knowing what is taught on it, but that’s another matter). I request formally that you obtain this material. If necessary please read this as a formal appeal. |
I await with interest. In every single case so far, the internal review has merely confirmed the initial refusal. It means a bit of a delay before the case goes to the Information Commisssioner’s Office.
Napier University Edinburgh
Napier University runs a "BSc (Hons) Herbal medicine". (brochure here). Since herbal medicine is a subject of the Pittilo recommendations, there is enormous public interest in what they teach. So I asked, under the Freedom of Information (Scotland) Act (2002). They sent quite quickly validation and accreditation documents, some examination papers, timetables and lecture lists.
The validation was the usual vacuous box-ticking stuff though it did reveal that the course “made extensive use of techniques such as tongue and pulse diagnosis”, which are well known phoney diagnosis methods, about as much use as a pendulum (as used at Westminster University).
As at Kingston University, the exam papers they chose to send were mostly "pretend doctor" stuff. One of them was
Discuss the herbal practitioner’s role in the management of IHD [ischaemic heart disease)
How one would like to see what the students said, and, even more one would like to see the model answer. Amateurs who try to treat potentially serious conditions are a danger to the public.
So then we got to the interesting bit, the request for actual teaching materials.
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I have looked at the material that you sent and I’d now like to make the following supplementary request (A) Lecture notes/handouts and powerpoint slides for the following small smaple of lectures HRB09102 Materia Medica 4 Materia Medica 3 HRB08103 Clinical Medicine and Diagnosis 4 (HRB09104) HRB09100 Materia Medica & Herbal Practice BSc Herbal Medicine : Materia Medica HRB07102 Lastly, I can see nowhere in the timetable, lectures that deal with Research methods, clinical trial design and statistics. |
No prizes for guessing the result Total refusal to send any of them. To make matters worse, the main grounds for refusal were the very "commercial interests" which, after careful legal examination, the Information Commissioner (for England and Wales) had decided were invalid. They say too that "The public interest in withholding the information is greater than the public interest in its release".. It is hard to see how the public interest is served by concealing from the people who pay for the degrees what is taught on degrees that Pittilo wants to make compulsory. [Download the whole response]
The matter is now under internal appeal (read the appeal) and eventually we shall find out whether the Scottish Information Commissioner backs the judgement.
Robert Gordon University Aberdeen
This case has particular interest because the Vice-Chancellor of Robert Gordon University is Professor Michael Pittilo, chair of the highly contentious steering group that recommended degress in CAM. Robert Gordon University (RGU) does not teach herbal medicine or acupuncture. But they do run An Introduction to Homeopathy. All the degrees in homeopathy have closed. It is perhaps the daftest and most discredited of all the popular forms of Magic Medicine. But Professor Pittilo thinks it is an appropriate subject to teach in his university.
So again I asked for information under the Freedom of Information (Scotland) Act 2002. They sent me quite quckly a list of the powerpoint presentations used on the courses [download it]. I asked for a small sample of the powerpoints. And again the university did not possess them!
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I should like to see only the following three powerpoint presentations in the first instance, please.
Please can you let me know also who produced the powerpoints. (1) Evidence for homeopathy I note that you will have to request them but since they are being offered as part of a course offered by RGU, so RGU is responsible for their quality, I presume that this should cause no problem. |
The request was refused on much the same grounds as used by Napier University. As usual, the internal review just confirmed the initial proposal (but dropped the obviously ludicrous public interest defence). The internal review said
“it is mainly the quality of our courses (including course material) and teaching which has given us the position of "the best modern university in Scotland"
I am bound to ask, if the university is so proud of its course material, why is it expending so much time and money to prevent anyone from seeing a small sample of it?
My appeal has been sent to the Scottish Information Commissioner [download the appeal].
What are vice-chancellors thinking about?
I find it very difficult to imagine what is going through the heads of vice-chancellors who run courses in mumbo-jumbo. Most of them don’t believe a word of it (though Michael Pittilo might be an exception) yet they foist it on their students. How do they sleep at night?
Recently the excellent Joe Collier wrote a nice BMJ blog which applauded the lack of respect for authority in today’s students, Joe Collier says good riddance to old-fashioned respect. I couldn’t resist leaving a comment.
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I couldn’t agree more. There is nothing quite so unnerving as being addressed as “Sir”. It is an advantage of age that you realise what second-rate people come to occupy very grand positions. Still odder since, if occasionally they are removed for incompetence, they usually move to an even grander position. I guess that when I was an undergraduate, I found vice-chancellors somewhat imposing. That is, by and large, not a view that survives closer acquaintance. |
Should teaching materials be open to the public?
There is only one university in the world that has, as a matter of policy, made all of its teaching material open to the public, that is the Massachusetts Institute of Technology (MIT). I can recommend strongly course 18.06, a wonderful set of lectures on Linear Algebra by Gilbert Strang. (It is also a wonderful demonstration of why blackboards may be better than Powerpoint for subjects like this). Now they are on YouTube too.
A lot of other places have made small moves in the same direction, as discussed recently in Times Higher Education, Get it Out in the Open.
Now the OU is working with other British universities to help them develop and share open course materials. In June, at the celebrations for the 40th anniversary of the OU, Gordon Brown announced funding to establish the Support Centre for Open Resources in Education at the OU, as part of a £7.8 million grant designed to enhance the university’s national role.
The funding follows a separate grant of £5.7 million from the Higher Education Funding Council for England for universities across the sector to make thousands of hours of free learning materials available.
Much material is available on the web, when individual teachers choose to place it there, but at the same time there is a move in the other direction. In particular, the widespread adoption of Moodle has resulted in a big decrease in openness. Usually you have to be registered on a course to see the material. Even other people in the university can’t see it. I think that is a deplorable development (so, presumably, does HEFCE).
Conclusion
I was told by the Univerity of Kingston that
“The course is one which the University has validated and continues to be subject to the University’s quality assurance procedures, such as internal subject reviews, annual monitoring and external examining”
The only conclusion to be drawn from this is that “quality arrurance procedures” work about as well in universities as they did in the case of baby Peter. No doubt they were introduced with worthy aims. But in practice they occupy vast amounts of time for armies of bureaucrats, and because the brain does not need to be engaged they end up endorsing utter nonsenes. The system is broken.
Resistance is futile. You can see a lot of the stuff here
It is hard to keep secrets in the internet age. Thanks to many wonderful people who have sent me material. you can see plenty of what is taught, despite the desperate attempts of vice-chancellors to conceal it. Try these links.
What is actually taught
Chinese medicine -acupuncture gobbledygook revealed
https://www.dcscience.net/?p=1950
Consultation opens on the Pittilo report: help top stop the Department of Health making a fool of itself
https://www.dcscience.net/?p=2007
Why degrees in Chinese medicine are a danger to patients
https://www.dcscience.net/?p=2043
More make-believe from the University of Westminster. This time its Naturopathy
https://www.dcscience.net/?p=1812
The last BSc (Hons) Homeopathy closes! But look at what they still teach at Westminster University.
https://www.dcscience.net/?p=1329
The opposite of science
https://www.dcscience.net/?p=1191
Bad medicine. Barts sinks further into the endarkenment.
https://www.dcscience.net/?p=1143
A letter to the Times, and progress at Westminster
https://www.dcscience.net/?p=984
Nutritional Fairy Tales from Thames Valley University
https://www.dcscience.net/?p=260
Westminster University BSc: amethysts emit high yin energy
https://www.dcscience.net/?p=227
References for Pittilo report consultation
A very bad report: gamma minus for the vice-chancellor
https://www.dcscience.net/?p=235
The Times (blame subeditor for the horrid title)
http://www.timesonline.co.uk/tol/comment/columnists/guest_contributors/article4628938.ece
Some follow up on the Times piece
https://www.dcscience.net/?p=251
The Health Professions Council breaks its own rules: the result is nonsense
https://www.dcscience.net/?p=1284
One month to stop the Department of Health endorsing quackery. The Pittilo questionnaire,
https://www.dcscience.net/?p=2310
An excellent submission to the consultation on statutory regulation of alternative medicine (Pittilo report)
https://www.dcscience.net/?p=2329
Follow-up
39 Responses to Not much Freedom of Information at University of Wales, University of Kingston, Robert Gordon University or Napier University
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Bloody brilliant, David.
I think myself that this is the real reason why the Pittilo “recommendations” are so flawed. If you can’t trust academic institutions to have real standards in these areas (and all the evidence is that you can’t) then how can you possibly have meaningful “practitioner standards”?
If the people practising and teaching something are not scientists, then it cannot be taught as a science.
Brilliant, but v depressing.
I discovered this in the 2006 NICE guidelines on dementia today:
This recommendation on aromatherapy was made on the basis of two trials, one with 7 patients (1) in each arm, and one with 36 patients in each arm (2). The abstract for second study says it was double blinded, but does not explain if they used nose-pegs. The guideline itself does not assess the risks of bias in the studies.
A recent, subsequently published systematic review (3) found 11 RCTs of aromatherapy for dementia and concluded “: Data supporting the efficacy of aromatherapy are scarce; available studies reported positive and negative consequences for both people with dementia and their carers. The side-effect profile of commonly used oils is virtually unexplored.”
These recommendations seem to be based more on hope than on evidence.
References
(1) Ballard, C.G., O’Brien, J.T., Reichelt, K., et al. (2002b) Aromatherapy as a safe and effective treatment for the management of agitation in severe dementia: the results of a double-blind, placebo-controlled trial with Melissa. Journal of Clinical Psychiatry, 63, 553–558.
(2) Smallwood, J., Brown, R., Coulter, F., et al. (2001) Aromatherapy and behaviour disturbances in dementia: a randomized controlled trial. International Journal of Geriatric Psychiatry, 16, 1010–1013.
(3) http://preview.ncbi.nlm.nih.gov/pubmed/17918182?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=6
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Come on David you know as well as I do that Chancellors of Vice are happy to run such courses because they bring in cash. Just like they are happy to run courses with no British students since every one of the students on those courses will be paying through the nose.
The modern university cares only about making money. RAE’s are adhered to only because they determine where the money goes which means those who churn are promoted while those who do careful methodical science are discarded for being insufficiently ‘productive’.
It is only that some universities profit from it that high academic standards and probity are still adhered to in the top places. As well of course a concern not to fall behind the Yales and Harvards and MiTs. Otherwise we would have seen a race to the bottom as universities try to steal the students from community colleges and other tertiary institutions.
I just hope that at least some places will have true academic standards and not just a veneer of them.
Utterly depressing. One is left with the impression that these institutions are happy to accept money from students (or funding bodies) for these supposedly scientific courses while at the same time not being prepared to enter into a full, frank, public debate about the quality of the evidence underpinning them. This is unfair to both the students and any future patients of theirs, who would very likely see a university science qualification as “official” evidence of efficacy and quality for the particular therapy concerned.
G’day David,
The “public interest” rejection is particularly ridiculous for an institution originally charitably set up to teach people – are they afraid release of the material will improve the standards of teaching of the subject across the U.K.?
Have you tried asking The McTimoney College of Chiropractic and the College of Integrated Chinese Medicine for selected materials ? It is possible they would co-operate.
This is very important campaigning, well done. You still have work to do with Napier University as it continues to debase the reputation of one of Scotland’s finest mathematician. The also run a degree in Aromatherapy. I met one of their graduates who complained the NHS in Scotland wasn’t offering jobs to aromatherapists. Well done the NHS I say.
Interesting debate. I’m currently in my final year of a herbal medicine degree and I’ve found it both academically and professionally stimulating. Much more than the pharmacy degree and post grad in clinical pharmacy I did. I find the rose-tinted view that the EBM brigade have of conventional medicine somewhat disheartening. Why the hell are we still being prescribed drugs like diclofenac (which was recently been shown to be cardio-toxic as the COX-2 inhibitors) or doxazosin for hypertension with a numbers need to kill of 52? I’ve spent the past 20 years looking at drug-drug interactions and adverse reactions and I can safely say that my medicine cabinet is a conventional free zone.
Depressing stuff, but excellent work. I have to say I don’t think I could handle the burocracy to do what you’ve done.
Is it worth trying to pull a stunt like the old “register your dead cat for a nutrionism degree” as performed by Ben Goldacre (and someone else too, if I remember correctly). If the only requirement to be accredited by the University of Wales is that you give them money (and, I guess, have a knack for paperwork) couldn’t someone see how they fare registering their garage as a Bsc-awarding entity? Obviously, if you have that amount of money floating around there’s probably better causes (courses?) to invest in. Hmmm. Do you know how they charge for accredition? If it’s on a by-the-student basis it shouldn’t be too pricy (especially if your only student is your dead cat).
The rationale here being that the University of Wales do this because they get away with it. They get money and their reputation doesn’t suffer because no-body knows. I doubt that appealing to the governing board’s better nature will improve the situation, but some form of media stunt might…
What an astonishing account of dissembling.
For what it’s worth have submitted a response to Pittilo report consultation (via the web-form). Twopence worth at least, I guess.
@Dangerous Conventional
Blimey! 20 years to finish a degree? I’ve heard of “eternal students” but that really takes the cake…
And if your medicine cabinet is a “conventional free zone” then I sure hope I don’t ever come round your house for dinner, have a bout of diarrhoea, and find that you haven’t got any immodium. You’ll be cleaning up the mess for weeks.
On a slightly less flippant note, would you be so kind as to point to some of the evidence you have regarding your claims about diclofenac and doxazosin? And explain how on Earth you think that those claims in any way is actually *representative* of evidence-based medicine?
@Dangerous Conventional
Err.. ‘cos it works well for ailments, like bad osteoarthritic pain, which need treating to give people a reasonable quality of life?
All therapies which work represent a trade-off of various risks, because things which have real biological effects have useful effects ones and unwanted ones.
That’s why you need trained people to prescribe them, and also to explain the trade-offs to the patients.
For a view from GP-land on diclofenac, see here
PS Oops – link got mysteriously deleted. Here it is:
http://thejobbingdoctor.blogspot.com/2009/10/making-choice.html
@Dangerous Conventional
“I’ve spent the past 20 years looking at drug-drug interactions and adverse reactions and I can safely say that my medicine cabinet is a conventional free zone.”
It is also a zone devoid of any properly assessed balance of risk versus benefit. Your cabinet contents are probably only relatively “safe” because they do almost nothing at all and have little scope to cause significant harm, so your risk/benefit ratio is calculated as small/trivial. Both numerator and denominator are probably tiny, but the ratio could still be astonishingly large.
You may have done a whole degree in herbal medicine and I have only done a 1-day course, but I have looked at the standard texts and while it may be that you have spent 1,000 days studying those same texts this merely means you have been exposed to 1,000 times as much superficial and poorly documented herbal lore, not that you are in possession of 1,000 times the depth of high quality evidence.
No one needs to learn Hahnemann’s Organon and know the Materia Medica inside out to know that homeopathy is a crock. The same is true of herbal medicine when it is not allied to a formal drug-discovery discipline.
@Claire // Oct 21, 2009 at 11:31 am
“Utterly depressing. One is left with the impression that these institutions are happy to accept money from students (or funding bodies) for these supposedly scientific courses while at the same time not being prepared to enter into a full, frank, public debate about the quality of the evidence underpinning them”
This cannot be emphasised strongly enough. The mere fact that these institutions resort to obfuscation and legal hair-splitting to conceal the content of these courses does rather suggest that their are not proud of their content. If they were not cynical bums-on-seats exercises, their content would be demonstrated for the good of the institutions, to impress potential students and silence critics.
Concerning diclofenac and adverse reactions;
Increasing number of patients with long term conditions are being prescribed more and more drugs (polypharmacy) but there are few robust studies looking at the adverse effects associated with such prescribing.
One major study, undertaken by Liverpool University, looked at 18,820 hospital admissions through accident and emergency departments or acute medical and surgical assessment units. In patients over 16 years of age, researchers found that 1225 admissions were related to adverse drug reactions (ADRs) giving a prevalence rate of 6.5% with a fatality rate of 0.15%. Median hospital stay was 8 days. This equates to an annual cost of admissions to the NHS of £500 million per annum. 72% of ADRs were classified as avoidable (1). The most commonly implicated drugs were Nonsteroidal anti-inflammatory drugs/NSAIDs (this includes aspirin, diclofenac, ibuprofen etc.) 29.6%, diuretics (water tablets) 27.3%, warfarin 11.5%, ACE inhibitors (used for heart failure and blood pressure) 7.7% and antidepressants 7.1%.
NSAID associated emergency admissions in the UK are about 12,000 per annum with 2,500 deaths. In the over 75s, taking a NSAID for one year is associated with a 1 in 647 risk of dying from a gastro-intestinal bleed. The general population have a risk of dying from a road traffic accident of 1 in 17000 (2). NSAID are associated with an increased risk of the patient developing renal and/or heart failure.
The MEDAL study showed that the widely prescribed NSAID diclofenac (Voltarol) is associated with 4 extra cardiovascular events (mainly heart attacks) for every 1000 patients treated for a year (3) which is consistent with the increase seen with COX-2 inhibitors such as etoricoxib and rofecoxib (Vioxx). A further study backs this up with the authors stating that “the prolonged use of diclofenac increases the risk of heart attacks in patients with no prior strong risk factors by around twofold.”
One clinical paper involving the analysis four studies found that taking an antidepressant (SSRI) such as fluoxetine (Prozac) or paroxetine (Seroxat) caused a doubling in gastro-intestinal bleeds but a six fold increase in those also taking an NSAID (4).
There are many, many examples where we could be doing more harm than good where I could go on. Isn’t it time to ban NSAIDs first before we start attacking natural medicine.
In my herbal medicine course I’ve done units on research methods, pathophysiology, differential diagnosis, diagnostic skills, phytochemistry, pharmacy and formulation. I’ve shown the course material to pharmacist colleagues and they’ve been impressed by the standards and more importantly, the relevance. I hope the learned professor can say the same about his pharmacology course. I could be a pain and make a FOI request, but then again I have a good idea what’s in it.
(1)Pirmohamed M et al, Adverse drug reactions as a cause of admissions to hospital: prospective analysis of 18 820 patients. BMJ 2004;329, 15-18
(2) Blower AL, et al Aliment Pharmacol Ther 1997 11:283-291
(3) Cannon C. et al. Cardiovascular Outcomes With Etoricoxib and Diclofenac in Patients With Osteoarthritis and RA in the Multinational Etoricoxib and Diclofenac Arthritis Long-term (MEDAL) Programme. Lancet 2006;368:1771-8
(4) Loke, K. Meta-analysis: gastrointestinal bleeding due to interaction between selective serotonin uptake inhibitors and non-steroidal anti-inflammatory drugs.Alimentary Pharmacology & Therapeutics Volume 27, Issue 1, Date: January 2008, Pages: 31-40
@Dangerous Conventional
I don’t hold any particular candle for diclofenac – though I have used it myself after surgery.
I do wonder whether you are taking a fair look at the evidence though. For instance a recent Cochrane review on “Diclofenac for acute pain in children” says in part: “The main conclusions of this review are that diclofenac is effective for relief of acute pain arising from operations in children, with a low risk of serious adverse reactions.”
Is this review badly wrong? And if so, what specifically have they missed?
Another review from this year, “Single dose oral diclofenac for acute postoperative pain in adults” again concluded in part:
“This review shows that single dose oral diclofenac provides effective pain relief for adults experiencing moderate or severe pain following a surgical procedure. For every five participants with moderate to severe postoperative pain treated with a single dose of diclofenac, two would experience at least 50% pain relief who would not have done so with placebo. […]. The incidence of adverse effects did not differ significantly from placebo in these single dose studies.”
This, again, doesn’t seem to fit with your views. Could it be that you are onlly interested in a partial picture?
Sorry, Dangerous Conventional, you seem to have missed the point. The reason you can write a post like that is because the data exist. There are no equivalent data for herbals. The aggregate cost of harm done by NSAIDs is going to be a big number because they are hugely widely used. The current aggregate cost of herbals and similar pseudomedicines cannot be huge because their current market is small. However, there is no quantifying of their risk/benefit. Advocates of CAM, such as yourself, are implicitly asking for licensed pharmaceuticals to be replaced with your untested alternatives at who know what cost to patients in terms of adverse reactions and failures of efficacy.
Telling us real drugs can cause harm is not the point. We know that. You are proposing an alternative and implying it is equally effective and much less hazardous but as evidence of that, you have diddly-squat.
Take “Devil’s claw” as an example. Would you care to compare its efficacy and safety profile with a licensed NSAID?
“In my herbal medicine course I’ve done units on research methods, pathophysiology, differential diagnosis, diagnostic skills, phytochemistry, pharmacy and formulation. ”
All to no avail in the absence of safety and efficacy data. Your little knowledge simply serves to make you a dangerous thing precisely because you think you are equivalent to a doctor working with proper pharmaceuticals.
Dangerous Conventional,
I think you may be attempting a derail of DC’s original article. This was not about the efficacy of herbal remedies or the hazards of conventional medicine (both of which have been addressed elsewhere) but about the refusal of Universities to discuss what they are teaching at degree level. Do you agree that it is wrong that they should attempt to keep this secret, rather than engage in open discussion? If you are confident about the course material you have been given, would you be happy to submit it to scrutiny here and elsewhere?
Snore.
Did you actually read my last comment, Dangerous Conventional? Or the link to the Jobbing Doctor’s blog that I posted?
I’ve read the Pirmohamed paper several times. Posting a chunk of the abstract does not impress.
If someone finds their arthritis makes their life utterly miserable, then they may well be prepared to accept the finite but predictable added risk of cardiovascular events from diclofenac/Voltarol. The patient has a choice. Alternatively, they can try to persevere with lesser painkillers with something stronger (like diclofenac) “up their sleeve” for breakthrough pain on particularly bad days. But if that isn’t doing it for them, they need something stronger to enable them to function.
That is the point – to allow the person to do what they need/want to do in their daily life. That is what the doctors are aiming to achieve. It is not a cunning plot to stuff NSAIDs into everyone for the hell of it.
If you really did a Pharmacy degree I am amazed that the concept of “risk benefit trade off” seems not to have made any inroads into your thinking.
Implying that the problems of chronic pain and its effects on peoples’ lives are all going to be magically taken care of by wonderful risk-free natural remedies just suggests you are away with the fairies.
Of course, we know what the world would be like if these fools and dilettantes had their way. We don’t need to speculate, we’ve seen it. Picture London in 1900. We can go back to sanitoria full of consumptives and septic wards where people can rot from readily treatable bacterial infections.
But, yes, to return more strictly to the subject of this blog post, Dangerous Conventional, here is a simple challenge: send DC some of your course documents. Something fairly specific like a description of the evidence for the uses, benefits and risks of one or two individual herbs. I’m sure he would be happy to comment on the material and reduce it to ‘fair comment’ quotable chunks that offend nobody’s copyright. His e-mail address is on the front page, but here it is
d[dot]colquhoun[at]ucl[dot]ac[dot]uk
I’ve broken it up so naughty automated systems can’t spot it, but insert . for [dot] and @ for [at]
Dr Colquhoun,
I was very very upset to learn that Napier University has removed many important courses from its BSc (Hons) Herbal Medicine course since I graduated. Gone is Biochemistry, Pharm and Tox, Botany, and advanced Plant Science. Thank goodness I attended the course when I did. I also took Genetics and Molecular Pathology as my ‘options’. I would imagine students are not offered these classes, now.
I was also never offered ‘tongue and pulse’ diagnosis. Would that I had been!!! What a laugh.
I’m aggrieved that a program that showed so much possibility has now just turned into another ‘alternative’ health course.
Very sad.
@Dr Aust
I am still amazed that you don’t understand the shortcomings of isolated molecules being made into medicines. Because there are shortcomings. Many. It would help to make modern medicine better if physicians were willing to admit the shortcomings of modern pharmaceuticals. Perhaps pharmaceutical medicines would really begin to benefit people….
I am also amazed that you attack people on the basis that you perceive that your training and practice is superior to others. As I pointed out on another thread, I recently diagnosed a patient with Ehlers-Danlos Syndrome. This person had never been investigated for this in almost 70 years of multiple hospital visits. Yet the symptoms this person suffers are classic, and I look forward to them being diagnosed by skin and blood test later this month.
The NHS is a good system of medical practice. I have worked within it. But it is not perfect, and GPs, nurses, and consultants do not always do the best they can do in their job. They rarely look at a person’s lifetime history (which is how I picked up the connective tissue syndrome).
It would be nice if allopaths were willing to admit the shortcomings of their practice, rather than being arrogant and patronising to their patients and the public in general.
All the best,
NAWD
NAWD
That last comment I posted wasn’t directed at you, but specifically at “Dangerous Conventional”., whose ill-informed remarks you can read above. But since you posted:
Haven’t we just been discussing them? No- one denies unwanted effects occur.
As DC has often said, the main upside of modern pharmacology is the ability to conduct reproducible trials, and dose consistently, and know what you are giving. With herbal mixtures you never really know for sure. I agree completely with you (and with Edzard Ernst) that standardized products are mandatory, and far better than better than random garden stuff. But the much-vaunted “multi-component synergism” that herbal medicine people go on about has rarely (ever?) been demonstrated. It is mostly just a convenient get-out.
If one picks the right period of medical history one can actually find direct competition between herbal preps and the isolated active component. An example is c. the early 1950s w. Rauwolfia extract vs. reserpine for hypertension. The isolated stuff won out because it was predictable, and reproducible, and titratable, and thus far easier to use.
BTW, re “your training and practise”, I am a professional bioscientist, not a medic – my wife is the one with the medical degree. And to repeat, what I was attacking in the last slightly tetchy comment was “Dangerous Conventional”‘s ridiculous remarks.
I rather gather you think I don’t read your comments before posting about you – but I am convinced you don’t actually read mine before posting about me.
PS I hope you are right about the EDS. And good pick-up if you are. No-one says “lifetime not-picked up diagnoses” do not happen. Obviously for rare things, or for things where awareness in the past has been poor, it is more likely. The oldest person Mrs Dr Aust diagnosed with Coeliac in her days in hospital medicine was nearly 80, for instance. But a central difference, I would say, is that conventional medicine preaches (and practises, though imperfectly) a “watch for your own errors of assumption and false cognition” mantra. I would contrast that with much Alt.Med. Fine, you may be an exception. But haven’t we already established via your interest in scientific (phyto) pharmacognosy etc that you are not typical?
PS NAWD, several of the modules you mention do still appear in the brochure DC linked:
Click to access FHLS_CommHealth_HerbMed_15092004103945.pdf
[…] training solution. Corporate Instructional Designer and Educational Technology Grad Student. Not much Freedom of Information at University of Wales, University of Kingston, Robert Gordon Univer… – dcscience.net 10/20/2009 It seems very reasonable to suggest that taxpayers have an […]
NAWD said,
“As I pointed out on another thread, I recently diagnosed a patient with Ehlers-Danlos Syndrome. This person had never been investigated for this in almost 70 years of multiple hospital visits.”
Dr Aust said,
“I hope you are right about the EDS. And good pick-up if you are. No-one says “lifetime not-picked up diagnoses” do not happen. ”
NAWD also said,
“I had a consultation this week with a woman who has suffered (very badly) with joint problems since she was about 8 years old. After my consultation, I did a short bit of research, and it is my feeling that she has had undiagnosed Ehlers-Danlos syndrome for her whole life and she has never been diagnosed by an NHS doctor. Mainly because she grew up in India and hates the NHS system. She has refused to go and get a diagnosis.”
So, Dr Aust, actually it doesn’t look like the dear old NHS dropped the ball on this one.
I’d like to see NAWD deal with some of the points I made previously;
1. “It is also a zone devoid of any properly assessed balance of risk versus benefit. Your cabinet contents are probably only relatively “safe” because they do almost nothing at all and have little scope to cause significant harm, so your risk/benefit ratio is calculated as small/trivial. Both numerator and denominator are probably tiny, but the ratio could still be astonishingly large.”
2. “The reason you can write a post like that is because the data exist. There are no equivalent data for herbals. The aggregate cost of harm done by NSAIDs is going to be a big number because they are hugely widely used. The current aggregate cost of herbals and similar pseudomedicines cannot be huge because their current market is small. However, there is no quantifying of their risk/benefit. Advocates of CAM, such as yourself, are implicitly asking for licensed pharmaceuticals to be replaced with your untested alternatives at who know what cost to patients in terms of adverse reactions and failures of efficacy.
Telling us real drugs can cause harm is not the point. We know that. You are proposing an alternative and implying it is equally effective and much less hazardous but as evidence of that, you have diddly-squat.
Take “Devil’s claw” as an example. Would you care to compare its efficacy and safety profile with a licensed NSAID?”
3. “Of course, we know what the world would be like if these fools and dilettantes had their way. We don’t need to speculate, we’ve seen it. Picture London in 1900. We can go back to sanitoria full of consumptives and septic wards where people can rot from readily treatable bacterial infections.
But, yes, to return more strictly to the subject of this blog post, Dangerous Conventional, here is a simple challenge: send DC some of your course documents. ”
And finally, NAWD said,
“I am still amazed that you don’t understand the shortcomings of isolated molecules being made into medicines. Because there are shortcomings. Many. It would help to make modern medicine better if physicians were willing to admit the shortcomings of modern pharmaceuticals. Perhaps pharmaceutical medicines would really begin to benefit people….”
I’d echo what Dr Aust said and ask you produce some robust evidence that an alleged synergy exists within botanical products that renders them inherently both efficacious and harmless. Like Dr Aust, I have seen this asserted many times, but I have never seen anyone able to substantiate their rather high-flow rhetoric on this subject.
Badly Shaved monkey wrote:
Thanks BSM, hadn’t remembered the bit about “patient didn’t want to get investigated”.
Of course, some diagnoses don’t get made because they are simply difficult ones to make. One has to start somewhere, so medical students are routinely taught the straightforward stuff, including:
(aka “When you hear hoofbeats, think horses, not zebras”)
But as one of my GP friends put it:
“As you get more experienced you see that people can present with common things in uncommon ways, and with uncommon things in common ways… so you realise you actually don’t know as much as you thought you did”
– see some of NAWD’s earlier comments.
The real point for me is that this kind of thinking is clearly seen as a good, and is discussed and promoted, in conventional medical science. You can find articles and even books telling doctors about common errors in their thought processes, based on actual evidence.
Where, I wonder are the equivalents for CAM practitioners? Do they ever even admit to errors? My clear impression is that the only way a homeopath would ever admit to an error is if the “patient” dropped dead – and sometimes not even then.
Gosh, what a huge pile of Zebra droppings to deal with tonight…..
I will start by saying that I am an orthodox practitioner with 4 years of clinical medical training and 2 years of clinical training in a busy surgical environment. I’m not an expert on anything, but I have seen and treated a lot of things within the hospital environment and within my own practice. I do not use ‘tongue and pulse diagnosis’, or any other rubbish. I just use plain old medical case studies and counselling.
@ BadlyShaved Monkey: The medicine that I practice was THE medicine before the turn of the 20th century. All of these treatments cannot be rubbish. There are many plant-based medicines that are recognised as being effective. Many of them have been made into modern pharmaceuticals, even if they have been standardised or molecules have been isolated from the original plant. As I have said in many past posts, give me a cohort to test! I would love to do a clinical test with 1000, 10,000, 20,000 people using plant-based medicines. The NHS will simply not allow it. Your opinion that there is no evidence base for herbal medicine means exactly that. There is no evidence base because we are not allowed to do broad clinical trials. I look forward to the day when we can test these plant medicines in a clinical setting.
Also, my patient who ‘refused to go and get a diagnosis’ was told by her consultant that she was mentally ill and that there was nothing wrong with her despite the fact that she had very serious symptoms. She was told she had ‘hysteria’. If you read up on EDS then you might understand how this could happen. I don’t blame her for not trusting a doctor after her experiences. It was absolutely one of the worst cases of malpractice I have ever heard of in this country. I was horrified.
Harpagophytum procumbens is not my first choice as an anti-inflammatory. I don’t use it and I question its efficacy. That doesn’t mean that the other 400 herbal products available don’t work.
And to both of you, I would happy to admit any errors I make. I’m not a homeopath, I don’t support that therapy.
Yes, I have people for whom what I do doesn’t have a good effect. That is 2 out of 100 people I have seen in the last 3 years. I apologised to them (more than a GP does) and offered to help them in any way I could otherwise. I’ve never heard of a doctor doing that.
“I will start by saying that I am an orthodox practitioner with 4 years of clinical medical training and 2 years of clinical training in a busy surgical environment.”
Am I right to infer that this is a circumlocution that means your initial qualification was as a nurse?
The rest of your unreflective response only adds to my concern.
You said;
“The medicine that I practice was THE medicine before the turn of the 20th century.”
That was exactly my point. The desire implicit in CAM is to replace proper medicine and the precise effect of that would be to return us to 19th century levels of medicine. You seem to rather relish the prospect, but I find it appalling and, as I said, you would have us back to sanitoria full of dying consumptives and septic wards full of patients rotting from simple bacterial infections. You are only relatively harmless while you practice on the margins of a health system offering useful treatments to sick people.
You have also obscured the point I have been trying to make and you have reiterated that obfuscation twice.
You said;
“All of these treatments cannot be rubbish.”
“Harpagophytum procumbens is not my first choice as an anti-inflammatory. I don’t use it and I question its efficacy.”
I don’t think anyone rational is saying that the efficacy of “All” herbal remedies is exactly zero. We are questioning whether the efficacy of very many of them is more than trivial, but you have utterly missed the point about risk/benefit ratios and that is deeply worrying. Do you really not understand the concept that small risk/trivial benefit makes a pharmaceutical agent unacceptable? You have been very proud of your education in medical matters, but if this concept has not been effectively grasped you are simply a danger to the public and the only thing that limits that danger to some degree is that near-lack of biological action of the materials you prescribe.
I asked you to demonstrate an ability to tackle these issues with a single practical example. I gave you Devil’s Claw to consider.
You said;
“I don’t use it and I question its efficacy”
The fact that you don’t use it is irrelevant. As a competent herbalist you should have readily to hand the evidence to show the efficacy of one commonly used herbal preparation. The fact that your non-use of it is your first reason for not being willing or able to comment flags up a serious concern that you think that personal anecdotal experience with a medicinal product is the primary means by which you should draw conclusions as to its efficacy and safety. This is fallacious under all circumstances, but is particularly dangerous when it comes to the risk side of the balance. If you used a product that caused 1% of your patients to develop liver failure or one in 10,000 to die within a month of use through direct toxicity, your personal experience could never ever make this so apparent to you as to cause you to reconsider.
You said that, with respect to Devil’s Claw, you “question its efficacy”. So do I, but I am not prescribing it or its equivalents to real patients. You are. On what basis do you questions its efficacy? What is your evidence? Having turned to that you should then turn again to the issue of risk and show some ability to meaningfully engage with the issue of risk/benefit assessment.
NAWD
“I have people for whom what I do doesn’t have a good effect. That is 2 out of 100 people I have seen in the last 3 years. I apologised to them (more than a GP does) and offered to help them in any way I could otherwise. I’ve never heard of a doctor doing that.”
I initially missed the import of that. You have just claimed 98% efficacy for your treatment. You surely cannot think this equates to 98% efficacy for your remedies, but the way you said it and the context in which you said it implies that you do. A figure like that would be implausible for many conventional drugs. The remedies you use have effects that range from zero to small and the simple fact that you make a claim such as this shows that you are hopelessly conflating the effects of regression to the mean, spontaneous recovery and placebo effect with any putative therapeutic effect. Has your course really not given you the tools to deal with this problem? If it has, and to return to the primary focus of this topic, it would be a public service to show us the course materials that have served this purpose.
On the subject of those materials, I noted your listing of the subjects you have been taught, which included
“Biochemistry, Pharm and Tox, Botany, and advanced Plant Science. Thank goodness I attended the course when I did. I also took Genetics and Molecular Pathology as my ‘options’. ”
and this raises another issue, the ‘bait and switch’ of CAM. (http://www.sciencebasedmedicine.org/?p=156) Start in the realms of the plausible then move into the realms of fantasy.
Many CAM therapies ‘give good narrative’. As has been said elsewhere of homeopathy, it is a system of excuses masquerading as medicine. CAM therapists like a good story and all the biochemistry and physiology that you get taught are narratives based in real science, but once you move into the evisdence base for the actual remedies you head off into the world of anecdote and wishful thinking. Look again at your standard herbal medicine texts having been presented (rather late in the day) with this concept and see whether you can find for yourself where these transitions occur.
I looked up “Acupuncture” on RGU’s website and was delighted to see this paper appear:
http://publicoutputs.rgu.ac.uk/CREDO/open/additionalpublication.php?id=3134
Ironic that the paper (by an RGU academic) concludes “real” acupuncture is no better than “sham” or control for controlling pain.
@interestedreader
Thanks. The equivalence of ‘real’ and sham acupuncture is something that has been shown time and time again. Yet the conclusion is never that acupuncture is a sham, but, as in this case, that “further research is merited.”
Odd uh?
[…] single request for information about course materials in quack medicine that I have ever sent has been turned down by […]
[…] A recent post described the problems of finding out what exactly is taught on these courses: Not much Freedom of Information at University of Wales, University of Kingston, Robert Gordon Univer… […]
[…] The Chiropractic “degrees” from the McTimoney College of Chiropractic are also validated by the University of Wales by an equally incompetent, or perhaps I should say bogus, procedure. More details can be found at The McTimoney Chiropractic Association would seem to believe that chiropractic is “bogus”, and in a later post, Not much Freedom of Information at University of Wales, University of Kingston, Robert Gordon Univer…. […]
Outstanding piece of work, David!
With your permission, I’d like to use an excerpt for my website — the part about Kingston.
[…] still Pro Vice-Chancellor (Learning, Teaching and Enhancement). He was the person who totally failed to notice that Jacqueline Young had been a laughing stock for years before his committee solemnly approved her […]