Download Lectures on Biostatistics (1971). Corrected and searchable version of Google books edition
Download review of Lectures on Biostatistics (THES, 1973).
David Colquhoun
On July 1st. the journal Nature, published three reports that described genetic differences between people with schizophrenia and the rest of us. Nature held a big press conference, at the World Conference of Science Journalists, Many of the individual institutions involved in the studies also issued press releases. As so often in press releases, descriptions like “landmark”, “major step forward” and “real scientific breakthrough” were used liberally.
In short, there is no simple genetic basis for schizophrenia. The pooled results of the three studies gave 8,014 cases and 19,090 controls. A huge amount of genetic analysis was involved. Many thousands of small genetic differences were found between the schizophrenics and the controls, but no single mutation alone had much effect. There could be even more, because it is still not possible to sequence the entire genome of so many people. . In total, the effects of the many small differences might account for 30 percent of the disease risk. That’s more than the few percent that could be predicted before, though it’s still well short of the 70 or 80 percent figure that is often quoted for the genetic component of schizophrenia.
What is observed is a correlation between differences in the genome and having schizophrenia. The results don’t tell us directly about the cause of schizophrenia, and they don’t even (so far anyway) tell us much about the mechanisms that give rise to schizophrenia.
The reporting of this event makes a fascinating contrast in styles of scientific journalism. I’ll compare only two of the reports. One is by Steve Connor in the Independent (he of the recent contretemps). The other is by Nicholas Wade in the New York Times.
The headline sounds pretty hyped up to me, but headlines are often written by sub-editors, not by the author of the article. The article itself seems to be a pretty straight account that uses mostly quotations from the press releases. And it is accompanied by an irrelevant picture of a brain image, that’s alleged to show areas of the brain that contain dopamine receptors, though the work being discussed shows exactly that It’s not just a matter of a disorder in a transmitter system.. So the article is OK but it doesn’t contribute anything itself.
The fact of the matter is that the results of the gargantuan effort put into this study is to show how enormously complicated the problem is and just how little we understand, The prospect of inventing ‘cures’ looks almost hopeless in the face of such complexity. Nobody said it would be easy, but it has turned
out to be even harder than pessimists guessed. I would prefer a report that conveyed this reality better than the press releases do, and better than most of the hundreds of newspaper reports based on the press releases. There is one such report, that in the New York Times.
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The journal Nature held a big press conference in London Wednesday, at the World Conference of Science Journalists, to unveil three large studies of the genetics of schizophrenia. Press releases from five American and European institutions celebrated the findings, one using epithets like “landmark,” “major step forward,” and “real scientific breakthrough.” It was the kind of hoopla you’d expect for an actual scientific advance. It seems to me the reports represent more of a historic defeat, a Pearl Harbor of schizophrenia research. The defeat points solely to the daunting nature of the adversary, not to any failing on the part of the researchers, who were using the most advanced tools available. Still, who is helped by dressing The principal news from the three studies is that schizophrenia is caused by a very large number of errant genes, not a manageable and meaningful handful. The rationale behind the long search for schizophrenia genes was entirely justifiable. Since schizophrenia is highly heritable, it must have a strong genetic component. And it has long seemed possible that the responsible genetic variants underlying most common diseases would also be common. Natural selection gives us strong protection against diseases that strike before the age of reproduction. But its power to eliminate harmful genes is thought to wane sharply thereafter. So bad versions of genes that are bad only late in life could build up in the population, explaining why the common diseases that strike later in life are so common. And if researchers could identify the few major variants assumed to underlie each of these common diseases, from schizophrenia to heart disease to cancer, they could devise drugs to offset the genes’ effects. But nature is often a lot more complex than assumed. It now seems that the arm of natural selection is far longer than thought. It has reached way beyond our reproductive years and zapped most harmful genetic variants before they could get to be common in the population. That leaves relatively uncommon variants, lots and lots of them in each case, as the genetic cause of each common disease. In the last few years gene hunters in one common disease after another have turned up a few causative variant genes, after vast effort, but the variants generally account for a small percentage of the overall burden of illness. With most common diseases, it turns out, the disease is caused not by ten very common variant genes but by 10,000 relatively rare ones. Today it’s the turn of schizophrenia researchers to make the same discovery, though one perhaps more to be expected since schizophrenia is not good for reproduction. Schizophrenia too seems to be not a single disease, but the end point of 10,000 different disruptions to the delicate architecture of the human brain. Yes, that discovery is a landmark. The kind that says you have 10,000 miles yet to go. The march of science is not direct but two steps forward, one step back. This was the step back. But it was a completely necessary one. So the press release writers could have cast it as a noble defeat, were words like defeat a part of their vocabulary, or frankness their masters’ priority. |
This account may sound a bit pessimistic, but it also seems to me to be the most realistic of the lot.
Schizophrenia is not alone in proving to be a lot more complicated than one would have hoped. One of the most interesting outcomes of the genomic age has been to show that far simpler conditions than schizophrenia turn out to be not so simple after all. The simplest genetically transmitted diseases are those caused by mutation of a single amino acid in a single protein of known function. For example, one of the best understood receptors is the type of acetylcholine receptor that is responsible for transmitting an impulse from a motor nerve to a muscle cell, Curare blocks them and so paralyses voluntary movement, A rare form of muscle weakness, slow channel congenital myasthenic syndrome (SCCMS), is caused when one of the amino acids in the protein mutates. But it has turned out that there is not just one mutation. It would be nearer to the truth to say that each family that suffers from the disease has its own mutation. Each of the mutations has a rather similar effect on the function of the protein, but there is not just one SCCMS but dozens.
The same is true of mutations in the glycine receptor that cause the rare congenital condition, ‘startle disease’ (posh name, hyperekplexia), The glycine receptor mediates inhibitory actions in the spinal cord. It is blocked by strychine, Strychnine causes exaggerated reflexes and eventually tonic convulsions: your muscles tighten so you die with the risus sardonicus. Mutations in the glycine receptor that stop it working so well have an effect rather like strychnine. But rare though the disease is, at least 15 different mutations, each in a different family, have been found to produce similar effects. There is just one startle disease, but many.
Cystic fibrosis is even more complicated. Mutations in a single protein, with a function that is now quite well understood, can cause the disease. But every patient does not have the same mutation. Around 1500 mutations have been found in the 20 years since the gene was sequenced. And to make it still more complicated, the symptoms shown by two patients with the same mutation may not be identical. The effects depend, it seems, on the rest of the genetic make-up of the individual. There is a nice account in ‘The promise of a cure: 20 years and counting’..
The same pattern is repeated again and again. Schizophrenia is just a very extreme example of a common phenomenon Not so long ago it was the dogma was that the future of drug discovery lay in genomics and high-throughput screening, Richard Sykes, when head of GSK, put the vast resources of GSK into this approach. It did not really work (which might explain why he left GSK to become rector of Imperial College). Now we know why.
It turns out to be a bit more complicated than anyone had foreseen, and one suspects it will take a long time to sort it out.
Follow-up
There is some comment on the reports on the Nature web site.
As so often, there is a first class level-headed account of the facts and what they mean on the NHS Choices site.
Here is a short break from the astonishing festival of chiropractic that has followed the British Chiropractic Association (BCA) v Simon Singh defamation case, and the absurd NICE guidance on low back pain.
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Singh’s statement already has over 10000 signatories, many very distinguished, Sign it now if you haven’t already. And getting on for 600 separate complaints about exaggerated and false claims by chiropractors have been lodged with the General Chiropractic Council and with Trading Standards offices. |
 Click to sign |
The BCA has exposed the baselessness of most of chiropractic’s claims more effectively than any sceptic could have done.
The University of Westminster is seeing the light?
It is only recently that the University of Westminster suspended entry to degrees in homeopathy and remedial massage and neuromuscular therapy. Luckily for science, they have a new Dean who knows bullshit when she sees it. I suspect than she has been instrumental in starting to restore Westminster’s reputation. The job isn’t finished yet though. According to the UCAS site Westminster still offers
- Chinese Medicine: Acupuncture with Foundation (B341) 4FT Hon BSc
- Health Sciences: Complementary Ther with Foundn (B300) 4FT Hon BSc
- Health Sciences: Complementary Therapies (B255) 3FT Hon BSc
- Health Sciences: Herbal Medicine (B342) 3FT Hon BSc
- Health Sciences: Herbal Medicine with Foundation (B340) 4FT Hon BSc
- Health Sciences: Naturopathy (B391) 3FT Hon BSc
- Health Sciences: Naturopathy with Foundation (B392) 4FT Hon BSc
- Health Sciences: Nutritional Therapy (B400) 3FT Hon BSc
- Health Sciences: Nutritional Therapy with Foundn (B402) 4FT Hon BSc
With the possible exception of herbal medicine, which could be taught scientifically. all the rest is as delusional as homeopathy.
Rumour has it that Naturopathy may be next for the chop, so it seems appropriate to help the dean by showing a bit more of what the hapless students get taught. Remember that, according to Westminster, this is a bachelor of science degree!
Psychotherapeutic Approaches in Naturopathy 3CMW606
“This module is a core subject for BSc (Hons) Health Sciences: Naturopathy and option for BSc (Hons) Health Sciences: Complementary Therapies; BSc (Hons) Health Sciences: Therapeutic Bodywork; Graduate Diploma in Therapeutic Bodywork.”
Lectures 3 – 5 of this course are about the Theory and Application of EmoTrance.
EMOTRANCE? No I had never heard of it either. But it takes only two minutes with Google to discover that it yet another product of the enormous navel-gazing self-help industry. A new variant is born almost every day, and no doubt they make buckets of money for their inventors. You can download a primer from http://emotrance.com/. The web site announces.
“EmoTrance REAL energy healing for the 21st Century”
Here are three quotations from the primer.
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And then I thought of the lady in the supermarket whose husband had died, and I spend the following time sending her my best wishes, and my best space time quantum healing efforts for her void. It doesn’t matter how “bad”; something is or how old, it is ONLY AN ENERGY and energy can be moved with consciousness in quantum time, easily, and just for the asking. Is EmoTrance a Science? |
Now back to Westminster
Here are a few slides about EmoTrance
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So it is pure vitalistic psycho-babble. The usual undefined use of impressive sounding words like “energy” and “quantum” with no defined meaning. Just preposterous made-up gobbledygook.
Before getting to EmoTrance, the course Psychotherapeutic Approaches in Naturopathy (3CMW606) had a lecture on Flower Essences. The evidence says, not surprisingly, that the effects of flower essences is not distinguishable from placebo “The hypothesis that flower remedies are associated with effects beyond a placebo response is not supported by data from rigorous clinical trials.” (See Ernst Wien. Klin. Wochenschr. 2002 114(23-24):963-6). Here are two of the slides.
This last slide departs from the simply silly to the totally mad. Dowsing? Kinesiology?
Pendulums I’m told from more than one source that the use of pendulums is not uncommon. both in teaching and by students in the Westminster University polyclinic Apparently they provide an excellent way to choose a ‘remedy’ or make a diagnosis (well, I expect they are as good as the alternatives). If in doubt, guess.
Of course pendulums were popular with Cherie Blair who is reported to have taken her son Leo to a pendulum waver, Jack Temple, rather than have him vaccinated with MMR. At least her delusions affected fewer people than those of her husband (the latest Iraq body count is about 100,000).
Kinesiology was originally a word that applied to the perfectly sensible science of human movement. But Applied Kinesiology more often refers now to a fraudulent and totally ineffective diagnostic method invented by (you guessed) a chiropractor. It has been widely used by alternative medicine to misdiagnose food allergies. It does not work (Garrow, 1988: download reprint).
General Chiropractic Council It is a mind-boggling sign of the incompetence of the General Chiropractic Council that they manage to include kinesiology within their definition of “evidence based care”. Their definition is clearly sufficiently flexible to include anything whatsoever. The incompetence of the GCC is documented in superb detail on jdc325’s blog (James Cole).
Council for Healthcare Regulatory Excellence (CHRE) is yet another example of the network of ineffective and incompetent quangos that plague us.. It is meant to ensure that regulation is effective but utterly fails to do so. The CHRE is quoted as saying “[The GCC] takes its role seriously and aspires to, and often maintains, excellence.”. Like endorsing kinesiology and ‘craniosacral therapy’ perhaps? Quangos like the CHRE not only fail to ensure regulatory excellence, they actually endorse rubbish. They do more harm than good.
The reading list for the course includes the following books. I guess the vibrational medicine (whatever that means) was covered already in the now infamous ‘amethysts emit high yin energy‘ lectures.
Reading List
Essential:
Hartman S (2003) Oceans of Energy: The Patterns and Techniques of EmoTrance: Vol 1.DragonRising. ISBN: 1873483732.
Lynch V and Lynch P (2001) Emotional Healing in Minutes. Thorsons: London. ISBN: 0007112580Recommended:
Gerber R (2001) Vibrational Medicine for the 21st Century. Piatkus Publishers: London.
Gurudas (1989) Flower Essences and Vibrational Medicine. Cassandra Press: California, USA
Hartman S (2000) Adventures in EFT: The Essential Field Guide to Emotional Freedom Techniques. DragonRising. ISBN: 1873483635.
Hartman S (2004) Living Energy: The Patterns and Techniques of EmoTrance: Vol 2. DragonRising.ISBN: 1873483740.
Hartman S (2006) Energy Magic: The Patterns and Techniques of EmoTrance: Vol 3. Dragon Rising.ISBN: 1873483767.
Real magic.
Sylvia Hartman’s books seem to feature heavily in the reading list. I just got news of her latest effort
Welcome to a special update to the June 2009 newsletter to announce Silvia Hartmann’s latest book “Magic, Spells & Potions” is now available to pre-order from our site. The eBook edition will be released this Sunday, the most magical day of the year.
http://DragonRising.com/store/magic_spells_and_potions/?r=DR0609MSAP
If you do pre-order this exciting new book, not only will you be amongst the first to receive your copy, but you will also be entered into an exciting competition for Silvia Hartmann’s handmade copal amber magic pendant. Each paperback book pre-ordered will also be signed by the author and contain a unique blessing for the reader.
Because this is a serious book on real magic, potions and fortune telling if you are a beginner Silvia has provided ample sample spells and potions for you to practice working with before you start covering the advanced material.
What? No honestly, I didn’t invent that.
The idea that stuff of this sort is appropriate for a bachelor of science degree is simply ludicrous. I have no doubt that Westminster’s new dean can see that as well as anyone else. She has the delicate diplomatic job of extirpating the nonsense, I wish her well.
Follow-up
Des Spence, a general practitioner in Glasgow, has revealed a memorandum that was allegedly leaked from the Department of Health. It was published in the Britsh Medical Journal (17 June 2009, doi:10.1136/bmj.b2466, BMJ 2009;338:b2466). It seemed to me to deserve wider publicity, so with the author’s permission, I reproduce it here. It may also provide a suitable introduction to a forthcoming analysis of a staff survey.
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Re: The use of ‘note pads’ in the NHS and allied service based agencies. Hi, all care providers, managers of care, care managers, professions allied to care providers, carers’ carers, and stakeholders whose care is in our care. (And a big shout to all those service users who know me.) We report the findings from a quality based review, with a strong strategic overview, on the use of “note pads” across all service user interfaces. This involved extensive consultation with focus groups and key stakeholders at blue sky thinking events (previously erroneously known as brain storming). This quality assured activity has precipitated some heavy idea showers, allowing opinion leaders to generate a national framework of joined-up thinking. This will take this important quality agenda forward. A 1000 page report is available to cascade to all relevant stakeholders. The concentric themes underpinning this review are of confidentiality. Notes have been found on the visual interface devices on computers and writing workstations throughout the NHS work space. Although no actual breach of confidentiality has been reported, the independent external consultants reported that note pads “present a clear and present danger” to the NHS, and therefore there is an overarching responsibility to protect service users from scribbled messages in felt tip pen. Accordingly all types of note pads will be phased out in the near time continuum. A validated algorithm is also attached to aid this process going forward. This modernising framework must deliver a paradigm shift in the use of note pads. Care provider leaders must employ all their influencing and leverage talents to win the hearts and minds of the early adopter. A holistic cradle to grave approach is needed, with ownership being key, and with a 360 degree rethink of the old think. All remaining note pads must be handed over in the next four week ” note pad armistice” to be shredded by a facilitator (who is currently undergoing specialist training) and who will sign off and complete the audit trail. (Please note that the NHS’s email system blocks all attachments, so glossy, sustainable, wood based hard copies will be sent directly to everyone’s waste recycling receptacles.) Cite this as: BMJ 2009;338:b2466 |
Spence added a footnote, Note: The BMJ’s lawyers have insisted that I make it clear that this is a spoof, just in case you were wondering.
Here are a few more
| There is an initiative underway to determine what we do as an organisation in the realms of drug discovery. The intention is to identify internal and appropriate external capabilities to foster a pipeline of competencies that enable some of our basic research outputs to better impact healthcare. |
Follow-up
On 17th June 2009, 15 months after Singh’s article was published, the British Chiropractic Association (BCA) has finally produced its evidence (though only after enormous pressure from bloggers [download as pdf]..
Jack of Kent has already made some comments from the legal point of view.
As expected, the list of references they give is truly pathetic, The list of 29 references has nine about infantile colic, four about asthma (two of which refer to osteopathy not chiropractic). three about the safety of chiropractic (a contentious matter but not the point here) and three about the safety of non-steroidal anti-inflammatory drugs (an important matter but utterly irrelevant here).
Let’s look at the papers about colic. Most are in obscure alternative medicine journals, not easily available, but the BCA’s own synopsis is sufficient for now.
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Klougart N, Nilsson N and Jacobsen J (1989) Infantile Colic Treated by Chiropractors: A Prospective Study of 316 Cases, J Manip Physiol Ther,12:281-288. [ download thr reprint]. As evidence it is about as useless as the infamous Spence study so beloved of homeopaths. There was no control group at all. It simply follows 316 babies and found that most of them eventually got better. Well, they do, don’t they? It is a sign of the pathetic standard of research in chiropractic that anyone should think this paper worth mentioning at all.
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Mercer, C. and Nook, B. in the Proceedings of the 5th Biennial Congress of the World Federation of Chiropractic (1999) (so no peer review, for what that is worth). “Resolution of symptoms [of infantile colic] in 93% of infants treated with spinal manipulation”.. This sounds as useless as Klougart et al. Why only 93% one wonders? Every parent knows that 100 percent of babies stop crying eventually.
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Wiberg et al. J Manip Physiol Ther, 1999, 242 517 – 522. This one was randomised (but not blind) and showed that spinal manipulation was as effective as dimethicone for colic. [Download pdf]
I expect that all that means is that dimethicone doesn’t work either. -
Hayden & Mullinger (2006) Complementary Ther. clin. Prac. “This preliminary study suggested that cranial osteopathic treatment can benefit infants with colic”. So. (a) preliminary and (b) not chiropractic.
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Hipperson AJ (2004) Clinical Chiropractic 11, 122 – 129. A report of two case studies, so essentially worthless as evidence The journal isn’t even listed in Pubmed.
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Browning M. Miller, J. Clinical Chiropractic (2008) 11, 122—129 [download pdf] Comparison of the short-term effects of chiropractic spinal manipulation and occipito-sacral decompression in the treatment of infant colic: A single-blinded, randomised, comparison trial. This paper just compared two different chiropractic methods. It shows that both are equally effective, or equally plausibly, both are equally ineffective.
- Leach RA (2002) J Manip Physiol Ther, 25, 58 -62. Merely two case reports and they refer to usie of a mechanical device, not the usual chiropractic manipulation.
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Miller J (2007) Clinical Chiropractic 10, 139—146 Cry babies: A framework for chiropractic care [download pdf]. No evidence at all here. It isn’t a research paper.
- Nilsson N. 1985 Eur J Chiropr 33, 264 – 255 Infantile colic and chiropractic. “Respondents to a questionnaire revealed that 91% of of infants improved after 2 – 3 manipulations”. Again, no controls. So, babies stop crying, eventually.
That seems to be the best they can do. What they don’t do is mention any of the papers that contradict their claims. They cite Sackett et al. (1996) as their criterion for what constitutes evidence, That paper says “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence”. That means all the evidence. So why, for example, is there no mention of Olafsdottir et al. (2001), “Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation”. That is one of the few really good papers in the area. It compared chiropractic treatment of babies for colic with placebo treatment (the nurse just held the baby for 10 minutes (the time the chiropractor took). The conclusion was
Conclusion Chiropractic spinal manipulation is no more effective than placebo in the treatment of infantile colic. This study emphasises the need for placebo controlled and blinded studies when investigating alternative methods to treat unpredictable conditions such as infantile colic.
More on this dishonest selectivity can be found at Holfordwatch.
No doubt there will soon be more analyses of what passes, in the eyes of the BCA, for evidence, The nine papers they cite for colic are truly pathetic. Not a single one of them amounts to anything that would be recognised as evidence in the real world. And papers that do provide real evidence are not mentioned.
Follow-up
As always, the blogs provided a very fast response to a document that appeared only late last night. And, as always, these unpaid people, working in their spare time, have done a far better job than the suits at the BCA (or NICE).
Here are some of them.
“A Review of The BCA’s Evidence for Chiropractic”. Martin on The Lay Scientist.
“The BCA have no evidence that chiropractic can help with ear infections” on Gimpy’s blog.
“Examining the BCA’S ‘Plethora’ of Evidence”. Unity, at Ministry of Truth.
“British Chiropractic Association and The Plethora of Evidence for Paediatric Asthma”. On Evidence Matters
“BCA Statement Baffles Blogger”. James Cole on jdc325’s Weblog
“Careful, BCA, you might slip a disk. The British Chiropractic Association may need to hire a chiropractor to work on themselves: they’re shoveling so hard they’re likely to hurt their backs.” In the US magazine, Discover.
“British Chiropractic Association (BCA) demonstrate what evidence-based medicine isn’t” at Holfordwatch. This one shows nicely how the BCA fail to apply their own standard of evidence, based on Sackett et al. (1996).
“The BCA’s worst day”. “Today has not been a good day for the British Chiropractic Association”. Jack of Kent summarises the demolition, in 24 hours, of the BCA’s ‘evidence’
Laurie Taylor says it all.
Could this bit (dated 18 June) in Laurie Taylor’s saga of the University of Poppleton possibly have been inspired by the Singh affair?
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Sweet smell of success Our campus burst into colour last week as members of the Department of Aromatherapy, led by Professor Gwendolyn Frisson, paraded round the former administrative block happily waving bunches of wild carrot, devil’s claw, cinnamon leaf and lime blossom. What sparked the herbal celebration was the news of a full retraction from the journalist on the Poppleton Evening News who had described the department in print as “a hotchpotch of untestable propositions and unproven medical interventions”. The journalist in question, Simeon Rainbow, explained in his published retraction that he’d had time to reflect on the department’s reaction to his original article and now fully recognised that there was no better way of deciding upon the scientific validity of practices such as aromatherapy than by threatening anyone who denied such validity with an enormously costly libel action. Professor Frisson said that she welcomed the retraction. She would now be able to return with renewed enthusiasm to her research on the beneficial effects of grated angelica root on patients with advanced encephalitis. |
A flood of complaints against chiropractors has arrived at the General Chiropractic Council (GCC) in the wake of the British Chiropractic Association (BCA) v Singh affair. It is really rather beautiful that people have put some such enormous effort into writing complaints for no gain to themselves.
My own paltry two complaints to the GCC produced an interesting reaction. Yesterday I was told by the GCC
“Under the provisions of the General Chiropractic Council (Investigating Committee) Rules
2000 (“the Rules”), the Committee is required to invite you to make a statement of evidence in relation to your complaint by way of statutory declaration or affidavit. If you wish to, you can discuss your complaint with a solicitor who acts on behalf of the Committee who could help you draft a statement of evidence that meets the requirements of the Rules. The General Chiropractic Council will pay for the Investigating Committee solicitor’s costs and will reimburse you for any fee you subsequently pay for having your witness statement sworn at a location convenient to you.”
Naturally I shall take up this offer. If the same offer is made to everyone who complained (must be approaching 600), the legal fees incurred by the GCC would presumably be enough to bankrupt them. No wonder they are wriggling.
Here is a letter sent by the GCC’s Chief Executive and Registrar, Margaret Coats, a couple of days ago. It reached me by more than one route, but it is already on the web anyway, on Richard Lanigan’s site, Told you the General Chiropractic Council would find a way to dismiss the complaints. “Protecting the public” my arse! Protecting themselves more like it.. (The GCC has been under attack from within for some time, though mainly because some chiropractors think it regulates too much, not too little)
The bit that is especially interesting is para 2
In quangos like the GCC, complaints don’t necessarily get considered at all. First they go to an investigating committee (IC) which has to decide if there is a ‘case to answer’. Now the GCC wants that criterion to be changed to ‘realistic prospect of success’. Given the GCC’s attitude to evidence it is hard to imagine that any complaint will have a ‘realistic prospect of success’.
The second idea is even more grotesque. The GCC want to be able to dismiss without consideration rafts of complaints where in their opinion, referral to the Professional Conduct Committee (PCC) ‘is not required in the public interest. Or, more likely, not required in the interests of the GCC.
Will the Privy Council acquiesce in this disgraceful attempt to evade complaints? Wel, until January 2008, Graham Donald was a senior civil Servant at the Privy Council bit he now works for the GCC. That must help.
The GCC has been contacted by several Trading Standards Offices too, after complaints made to them about chiropractors. . A response was sent by the GCC on 5 June [download the whole response]. It includes
“It is important to emphasise that the GCC doesn’t claim that chiropractors ‘treat’ asthma, headaches (including migraine) and infant colic. It is possible that chiropractic care may help to alleviate the symptoms of some of these conditions.”
What on earth is that meant to mean?
One hopes that Trading Standards officers are too smart to be taken in by weasel words like that.
The attitude of the GCC to evidence is amply illustrated by the fact that they have said that the rather crude myths known as craniosacral therapy and applied kinesiology fall within their definition of evidence-based care.
Any organisation that can say that is clearly incompetent.
Follow-up
Homeopathy has become boring, so I’ll keep this short.
It’s clear that the public have rumbled the fraud and that homeopathy is heading back to where it was in the 1960s, a small lunatic fringe on the High Street.
All university ‘degrees’ in homeopathy have closed their doors in the last two years.
Even Peter Fisher sounds increasingly desperate in his attempts to defend it.
If it were not for the unconstitutional interference in politics of the Prince of Wales, homeopathy would probably have sunk even further. Princes who meddle like that should be allowed to cool off in the Tower of London. I can’t understand why his mother doesn’t restrain him before he destroys the monarchy altogether.
The homeopathy industry reminds me of the cigarette industry. Now that they are discredited at home, they turn to exploitation of countries where they get less critical attention.
The most advanced fantastists of the homeopathy business met in the Netherlands on 6th and 7th June to hear about “Homeopathy for Developing Countries”. I was invited to attend by no less a person
than Kate Birch (q.v.). The programme included the following.
- Treating AIDS in Tanzania
- Treating malaria in Tanzania
- Treating malaria in Ghana
- Treating malaria in Kenya (the notorious Abha Light Foundation)
- “Homeopaths from Earth without borders” in Africa and South America. Chagas disease.
- Bhaktapur International Homeopathic Clinic, Nepal.
In my view people who exploit third world countries, to spread the myth that you can cure malaria and AIDS with sugar pills, deserve to be convicted of manslaughter, just as in the case in Australia of the homeopaths who allowed their daughter to die of Eczema (see Bogus therapy for real diseases: more homeopathic killing.
My experience of homeopaths is that most of them are desperately sincere about their delusion. It is a surreal experience to listen to them talking amongst themselves about everything from curing a pigeon’s broken wing to curing cholera with their magic pills. At least in Australia, it seems that sincere delusion is not a sufficient excuse for killing people.
It is little consolation that we are dealing here with the extreme wing of fantasists. Remember that when homeopaths in London were caught recommending sugar pills for malaria prevention, Peter Fisher said something not far short of what I say.
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“I’m very angry about it because people are going to get malaria – there is absolutely no reason to think that homeopathy works to prevent malaria and you won’t find that in any textbook or journal of homeopathy so people will get malaria, people may even die of malaria if they follow this advice.” Peter Fisher. Clinical Director of the Royal London Homeopathic Hospital and Homeopathic Physician to the Queen |
.A group of young scientists has written an admirable letter to WHO to ask them to prevent this sort of wickedness. Sadly, in the past, WHO has proved itself to be so stifled by political correctness in this sort of area, that is has given some very bad advice). Let’s hope they do better this time.
At least, one might think, a meeting like this is free from the pressures of big Pharma that have caused such corruption in the clinical world. Or are they? The sponsor list at the end looks like this.
More information at Homeopathic “cures” for malaria: a wicked scam and here, and on many other blogs. Just Google “homeopathy malaria”.
Follow-up
Peter Dixon is a chiropractor. He is chair of the General Chiropractic Council (GCC). He was also a member of the hotly-disputed NICE low back pain guidance group that endorsed (you guessed it) the use of chiropractic, a decision that has led to enormous criticism of the standards of the National Institute of health and Clinical Excellence (NICE).
As a consequence largely of the decision of the British Chiropractic Association (BCA) to sue Simon Singh for defamation, there has been an unprecedented interest taken in the claims made by chiropractors in general.
Peter Dixon has a problem because something like 600 individual complaints about unjustified health claims have been sent to the GCC. Even when a web site does not claim to be able to benefit things like asthma and colic, a phone call may reveal that claims are made in private (one of the many complaints to the GCC concerns such behaviour by two practices belonging to, ahem, Peter Dixon Associates).
The crucial question is, as always, one of evidence. The BCA claim to have a plethora of evidence for their claims, but they have been strangely reluctant to produce it. In fact evidence is cited on the “Your first visit” page on Dixon’s site.
At the bottom we see “How effective is Chiropractic?”.
That sounds very impressive indeed: . ” . . . patients who received chiropractic treatment improved by 70% more than those given hospital out-patient.”
But hang on. If we look at the paper, Meade et al., 1990 [download reprint], we see that Figure 2 looks like this.
Several things jump out. First, the Oswestry disability index scale runs for 0 to 100, but scores are plotted only from 0 to 35, so the size of the effects are exaggerated. Second, there are no error bars on the points. Third there is essentially no advantage for chiropractic at all when all patients are taken together (top graph). Fourth, and most important, the patients who were followed up for two years (bottom graph) seem to show a slight advantage for chiropractic but on average, the effect is 7 percent (on the 100 point scale, NOT 70 percent as claimed on the web site of Peter Dixon Associates.
What sort of mistake was made?
The abstract of the paper itself says “A benefit of about 7% points on the Oswestry scale was seen at two years.” How did this become “improved by 70% more”?
It could have been simple a typographical error, but that seems unlikely, Who’d boast about a 7% improvement?
Perhaps it is a question of relative versus absolute change. The Figure does not show the actual scores on the 100 point scale, but rather the change in score, relative to a questionnaire given just before starting treatment. If we look at the lower part of the Figure, restricted to those patients who stayed with the trail for 2 years (by this time 28% of the patients had dropped out), we see that there is a reduction in score (improvement) of about 10 points on the 100 point scale with hospital treatment (not a very impressive response). The improvement with those sent to private chiropractic clinics was about seven points bigger. So a change from 10 to 17 is a 70 percent change. What’s wrong with that?
What’s wrong is that it is highly misleading, as relative changes often are. Imagine that the hospital number had been 7 points and the chiropractic number had been 14 (both out of 100). That would mean that both treatments had provided very modest benefits to the patients. Would it then be fair to describe the chiropractic patients as have improved by 100 percent more than the hospital patients, when in fact neither got much benefit? Of course it would not. To present the results in this way would be highly deceptive.
Put another way, a 70% increase in a trivial effect is still pretty trivial.
That isn’t all either. The paper has been analysed in some detail on the ebm-first site. The seven point difference on a 100 point scale, though it may be real, is too small to be ‘clinically significant’ In other words the patient would scarcely notice such a small change. Another problem lies in the nature of the comparison. Patients were, quite properly, allocated at random to chiropractic or to to hospital treatment. BUT the comparion was very from blind. one group was treated in hospital. The other group was sent to private chiropractic clinics. The trivial 7 point difference could easily be as much to do with the thickness of the carpets rather than any effect of spinal manipulation.
What this paper really tells you is that neither treatment is very effective and that there is little to choose between them.
It is really most unfortunate that the chairman of the GCC should show himself to be so careless about evidence at a time when the evidence for the claims of chiropractors is under inspection as never before. It does not add to their case for criticising Simon Singh and it does not add to one’s confidence in the judgement of the NICE guidance group.
Follow-up
The Pain Society revolt. A letter has been sent from several distinguished members of the British Pain Society to its President and Council.
“We, the undersigned, call upon the President of the British Pain Society to issue a statement to NICE and to the press condemning outright the conclusions of the recent UK National Institute for Health and Clinical Excellence (NICE) guidelines . . .”
The sigificance of this letter is that the present president of the British Pain Society is Professor Paul Watson who was a member of the NICE guidance group that produced the recommendations which have engendered such criticism. He was clinical advisor to the guidance group. There is a video of Paul Watson talking about back pain, that seems to me to illustrate very well the problem with the guidance. He says it is a huge problem (everyone knows that) and that something must be done, but he doesn’t say what. There is no admission that, in very many cases, nobody knows what to do. It is exactly this sort of hubris that that makes the NICE report so bad,
One caustic comment on the letter says
“We are led by a physiotherapist! A Professor who cannot even interpret straight forward evidence when it is presented to him on a plate.
Who’s going to be the next BPS President? A Hospital Porter?”
This is another short interruption in the epic self-destruction of chiropractors. In a sense it is more serious. One expects quacks to advocate quackery. What you don’t expect is that the National Institute of Clinical Excellence (NICE) will endorse it. Neither do you expect the Medicines and Healthcare products Regulatory Agency (MHRA) to betray its mandate to make sure that medicines work.
The saga of the NICE low back pain guidance has been the subject of a deluge of criticism, It seems doubtful that the guidance can survive, not least because of its absurd endorsement of chiropractic, at a time when chiropractic is undergoing self-immolation as a consequence of the persecution of Simon Singh by the British Chiropractic Association (see here, and here, and here, and here and thousands of other sites).
The other betrayal has come to the for after the MHRA approved highly misleading labelling of a homeopathic preparation. At the time,
in 2006, when the principle was approved by the MHRA, just about every scientific organisation, even the Royal Society, condemned the action. What was discouraging that the clinical organisations all stayed silent. It is still a mystery why the MHRA made this enormous mistake, Some said that European regulations required it, but that is quite untrue, as Les Rose has shown. It appears to have been the result of a pusillanimous MHRA bowing to pressure from a deeply unscientific Department of Health (a letter from Caroline Flint at the time borders on the surreal).
On 20 May 2009, the British Medical Journal printed an article Drugs agency grants its first licence to homoeopathic product by Deborah Cohen (available free). The comments were mostly highly critical of the MHRA. The BMJ asked, as it does from time to time, for my comment to be converted to a letter
for the print edition. That isn’t freely available, so here it is.
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Published 9 June 2009, doi:10.1136/bmj.b2333 LettersHomoeopathic product licenceMHRA label seems to be illegalThe strap line for the Medicines and Healthcare products Regulatory Agency (MHRA) is “We enhance and safeguard the health of the public by ensuring that medicines and medical devices work and are acceptably safe.” Yet the MHRA has made mockery of its own aims by ignoring the bit about “ensuring that medicines work” and allowing Arnica 30C pills to be labelled: “a homoeopathic medicinal product used within the homoeopathic tradition for the symptomatic relief of sprains, muscular aches, and bruising or swelling after contusions.”1 This label should be illegal anyway because the pills contain no trace of the ingredient on the label, but this deceit has been allowed through a legal loophole for a long time now. If you sold strawberry jam that contained not a trace of strawberry you’d be in trouble. But I can see no legal loophole that allows the manufacturers of Arnica 30C to evade the provisions of the Consumer Protection from Unfair Trading Regulations 2008. One of the 31 commercial practices which are in all circumstances considered unfair is “falsely claiming that a product is able to cure illnesses, dysfunction, or malformations.” The consumer protection laws apply to the way that “the average consumer” will interpret the label. The average consumer is unlikely to know that “used within the homoeopathic tradition” is a form of weasel words that actually means “there isn’t a jot of evidence that the medicine works.” Since there is not the slightest evidence that Arnica 30C pills provide symptomatic relief of sprains, etc, the labelling that the MHRA has approved seems to be illegal. The MHRA is not selling anything itself, so I presume that it won’t find itself in court, but anyone who follows its advice could well do so. Cite this as: BMJ 2009;338:b2333 David Colquhoun, research professor1 University College London, London WC1E 6BT Competing interests: None declared. References |
It is, I suppose, just a sign of the chaos that reigns in the multiple agencies and quangos responsible for ‘regulation’ that one arm of government proposes action that a different branch would consider illegal. That is an inevitable consequence of trying to regulate something without first deciding whether it is nonsense or not. The Department of Health appears to be quite incapable of grasping this simple and obvious fact.
Follow-up
Health: best treatments. The Guardian seems to the be picking up BMJ stories and ran this one.
That isn’t my title. It is the title of a post by Richard Lanigan, with whom I’ve been corresponding. He has a major grudge against the General Chiropractic Council. And in particular he is disaffected about the GCC’s chair, Peter Dixon, about whom he has written a lot, I can’t judge the details of his complaints, but they are laid out in detail on his blog, http://chiropracticlive.com/
Particular interest attaches to his recent revelation of a letter that was sent on July 8th to its members by the McTimoney Chiropractic Association. The McTimoney sect of chiropractic are the ‘true believers’ in the most mystical codswallop aspects of the subject. Oddly enough their College has been validated by the University of Wales, I’ve put in a Freedom of Information Act reguest to the University of Wales to see how that happened. Watch this space.
My interpretation of this letter is that it is as near as you can get to an admission, by chiropractors themselves, that many chiropractors make claims that are against the law. And worse still, that the McTimoney Chiropractic Assocation is well aware of that.
News travels fasts in the blogosphere. This item has already appeared today on The Quackometer, The Lay Scientist and Gimpy and on Zeno’s blog. Let’s hope that the news spreads far and wide.
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Date: 8 June 2009 09:12:18 BDT Subject: FURTHER URGENT ACTION REQUIRED! Dear Member If you are reading this, we assume you have also read the urgent email we sent you last Friday. If you did not read it, READ IT VERY CAREFULLY NOW and – this is most important – ACT ON IT. This is not scaremongering. We judge this to be a real threat to you and your practice. Because of what we consider to be a witch hunt against chiropractors, we are now issuing the following advice: The target of the campaigners is now any claims for treatment that cannot be substantiated with chiropractic research. The safest thing for everyone to do is as follows.
When you have done that, please let us know preferably by email or by phone. This will save our valuable time chasing you to see whether it has been done.
CHECK ALL ENTRIES CAREFULLY AND IF IN DOUBT, CONTACT THE RELEVANT PROVIDER TO REMOVE YOUR INFORMATION. CHECK OUR PREVIOUS EMAILS FOR SPECIFIC ADVICE AND KEY WORDS TO AVOID. KEEP A LOG OF YOUR ACTIONS.
5. Be wary of ‘mystery shopper’ phone calls and ‘drop ins’ to your practice, especially if they start asking about your care of children, or whiplash, or your evidence base for practice. IF YOU DO NOT FOLLOW THIS ADVICE, YOU MAY BE AT RISK FROM PROSECUTION. IF YOU DO NOT FOLLOW THIS ADVICE, THE MCA MAY NOT BE ABLE TO ASSIST YOU WITH ANY PROCEEDINGS. Although this advice may seem extreme or alarmist, its purpose is to protect you. The campaigners have a target of making a complaint against every chiropractor in the UK who they perceive to be in breach of the GCC’s CoP, the Advertising Standards Code and/or Trading Standards. We have discovered that complaints against more than 500 individual chiropractors have been sent to the GCC in the last 24 hours. Whatever you do, do not ignore this email and make yourself one of the victims. Some of our members have not followed our earlier advice and now have complaints made against them. We do not want that to happen to you. Even if you do not have a website, you are still at risk. Our latest information suggests that this group are now going through Yellow Pages entries. Be in no doubt, their intention is to scrutinise every single chiropractor in the UK. The MCA Executive has worked tirelessly over the last week keeping abreast of development and contacting at risk members. We have decided that this is our best course of action to protect you and the Association at this time of heightened tension. This advice is given to you solely to protect you from what we believe is a concerted campaign, and does not imply any wrongdoing on your part or the part of the Association. We believe that our best course of action is simply to withdraw from the battleground until this latest wave of targeting is over. Finally, we strongly suggest you do NOT discuss this with others, especially patients, Firstly it would not be ethical to burden patients with this, though if they ask we hope you now have information with which you can respond. Most importantly, this email and all correspondence from the MCA is confidential advice to MCA members alone, and should not be shared with anyone else. Please be aware that the office phone lines are likely to be busy, so, if you need our help, please send an email to the office and we will get back to you as soon as we can. Yours, Berni Martin MCA Chair. Best wishes, Nicki Nicki Choules-Rowe Administrative Officer – Executive Liaison McTimoney Chiropractic Association Crowmarsh Gifford Wallingford OX10 8DJ Tel : 01491 829494 |
Follow-up
The deleted pages are here. Thanks again to quackometer, here is where you can see the pages that might have been taken down as a result of McTimoney’s letter. I hope they won’t grumble. Really, they sjould never have put them up if they weren’t true, should they?.
Latest from ABC News (Australia)
Parents guilty of eczema baby manslaughter
The baby girl had severe eczema and died of septicemia in 2002. After a four-week trial the Supreme Court jury took less than two days to reach its decision. The Crown argued the couple did not seek conventional medical treatment for their child, instead treating her with homeopathic drops. The defence argued the couple were not warned about how sick the child was by medical staff who examined her. Thomas and Manju Sam sat in the dock with their arms around each other, crying as the verdict was read out. Thomas Sam’s brother, who was in the public gallery, collapsed sobbing and was taken outside. Both were granted bail with strict conditions ahead of their sentencing hearing. |
How many times does one have to say it. Sugar pills can kill.
They kill when give given to prevent malaria
They kill when given to treat AIDS
Young scientists have condemned it. Their excellent efforts were reported in The Guardian and in the Times). Anyone with half a brain condemns it.
Most homeopaths I’ve met are genuine people who really believe their own fairy tales. Is being genuinely deluded absolve you from blame? Not in Australia, it seems.
Follow-up
The battle for freedom of speech is under way.
| Simon Singh is a great science writer and communicator. He is author of The Big Bang, The Code Book, Fermat’s Last Theorem, and, with Edzard Ernst, Trick or Treatment. They are superb books (buy from Amazon). |  |
When Singh had the temerity to express an honest opinion, based on the evidence, about that very curious branch of alternative medicine known as chiropractic, the British Chiropractic Association sued Singh for defamation.This was their substitute for producing evidence for their bizarre claims.
Chiropractors seem to be particularly fond of litigation, perhaps because they are so short of evidence. Having had legal threats from them myself, I know how scary it can be, Luckily I was saved by a feisty a journal editor. Singh wasn’t so lucky. The history is recounted here,
The legal aspects of the case are being described by the lawyer who writes under the name of Jack of Kent. He has regular updates on progress.
Put briefly, Libel: A very expensive remedy, to be used only when you have no evidence. Appeals to alternative practitioners because truth is irrelevant
The iniquitous nature of England’s libel law has been described eloquently by Nick Cohen, in the Observer. It is used regularly by rogues and criminals from all over the world to silence their critics. All they need is money. Truth is irrelevant. It is a disgrace to a civilised country.
The cost of defamation cases in the UK is vastly greater than in any other country in Europe:: look at the graph.
With enormous courage, Simon Singh has decided to appeal against the ruling by Mr Justice Eady. Scientists and journalists everywhere should rally to support him, if they value the right to express an honest opinion without being bankrupted by a law court. Singh is taking a great risk on behalf of anyone who values freedom of speech.
The charity, Sense abour Science (SaS), has started a campaign to Keep the Libel Laws out of Science.
Read the statement about the campaign on the SaS site, and the current list of signatories. The list of supporters is already very impressive. It includes, for example, professor Lord (Martin) Rees, president of the Royal Society and Astronomer Royal, to Dr Philip Campbell Editor-in-Chief of Nature, David Starkey Historian, Stephen Fry Broadcaster and Author and Baroness Helena Kennedy QC Barrister.
You can sign the statement yourself there. Do it. Now!
You can also get code for the button (above) to link your own web site to the campaign.
In 1894, a local Iowa newspaper, The Davenport Leader, wrote of the founder of chripractic, D.D. Palmer, thus.
“A crank on magnetism has a crazy notion hat he can cure the sick and crippled with his magnetic hands. His victims are the weak-minded, ignorant and superstitious, those foolish people who have been sick for years and have become tired of the regular physician and want health by the short-cut method he has certainly profited by the ignorance of his victim. His increase in business shows what can be done in Davenport, even by a quack.” [quoted in Rose
Shapiro’s book, Suckers]
Today, in the UK, no newspaper would dare to express an opinion like that.
We all hope that Singh will win the appeal. But even if he doesn’t win in the law courts, he will have scored an enormous moral victory. What’s more, chiropractic is now under scrutiny as never before. There is going to be a chiro-fest that will make the British Chiropractic Association rue the day that it decided to use legal bullying in place of reason.
They may even have signed their own death warrant.
Follow up will be posted here regularly
Follow-up
There is a good roundup of activity up to June 3rd here.
The Wall Street Journal (June 4th) discusses the case under the title Britain Chills Free Speech.
British Medical Journal editorial by Evan Harris (Lib dem member of parliament and doctor), Science in Court
Bait and switch. Oh dear, oh dear. Just look at British Chiropractic Association tell their members to hide their sins from prying eyes.
Excellent round-up of the recent outburst of writing about “chiroquacktic” (Tut, tut, is there no respect?).
Dr Crippen writes “NICE recommends a cure for all known disease” [Ed some exaggeration, surely]
On 23rd May 2009, the Financial Times magazine published a six-page cover story about pseudo-scientific degrees by Richard Tomkins. The online version has the text but doesn’t do justice to the prominence that it was given. The print version had a much better title too, The Retreat from Reason. This article, which was some time in gestation, appeared shortly afte the last degree in homeopathy in the UK closed its doors. So perhaps it should have been called The Return of Reason. What’s interesting is that it has become commonplace for the mainstream newspapers to print articles like this and to dump some of their whackier lifestyle articles.
The print version had a much better title too, The Retreat from Reason, with a two-page spread..
They published the entire ‘Patients’ Guide to Magic Medicine‘ as a sidebar on page 4.
To these has now been added, inspired by Jack of Kent,
Libel: A very expensive remedy, to be used only when you have no evidence. Appeals to alternative practitioners because truth is irrelevant
One part of the article that I particularly enjoyed is this.
George Lewith, professor of health research at the University of Southampton’s medical school, is also director of the Centre for Complementary and Integrated Medicine, a private practice with clinics in Southampton and London’s West End, so it is no surprise that he is ready to speak out in support of complementary therapies. In fact, Southampton University – a member of the elite Russell Group – does not offer degree courses in complementary medicine, but Lewith defends the idea of offering them in principle, on the basis that, done properly, they produce better-trained practitioners. “Without the new universities’ involvement we might be faced with the quackery we saw in the 1940s and 1950s, when these people were outside medicine and were practising in an alternative fringe culture,” he says.
Sorry George, you are still an “alternative fringe culture”. And universities are realising that, and shutting down courses all over the place.
A response in the Finacial Times
The FT published one response in its letter column, A bilious attack on complementary medicine.
“Sir, Like many journalists, Richard Tomkins has been over-impressed by the scientific credentials of Professors David Colquhoun and Edzard Ernst as they carry on their absurdly over-stated, arrogant and irresponsible campaign against complementary medicine (“The retreat of reason”, May 23)”
and then the trump card
“Absence of evidence is not evidence of absence”
That’s the line used by quacks again and again and again (see, for example, integrative baloney @ Yale). I guess they have never heard of type 1 and type 2 errors. But that is a bit technical for homeopaths, so put it more simply. There is a quite remarkable absence of evidence for tooth fairies. So they must exist. Get it?
The letter is from Allen Parrott of Yeovil. Could that be the Allen Parrott of the British Acupuncture Accreditation Board? If so he is “is an adult educationist who was Dean of Adult and Community Education at Yeovil College and a lecturer in the School of Education at Exeter University. As well as his work for the Board, he is currently working as an educational adviser for the Kent, Surrey and Sussex Deanery in the NHS.”. So no reason to worry about the standards of education in Yeovil, then.
The first post was NICE falls for Bait and Switch by acupuncturists and chiropractors: it has let down the public and itself.
That was followed by NICE fiasco, part 2. Rawlins should withdraw guidance and start again.
Since then, something of a maelstrom has engulfed NICE, so it’s time for an update.
It isn’t only those who are appalled that NHS should endorse voodoo medicine on the basis of very slim evidence who are asking NICE to rethink their guidance on low back pain. Pain specialists are up in arms too, and have even started a blog, ‘Not Nearly as NICE as you think …‘, to express their views. Equally adverse opinions are being expressed in the Britsh Medical Journal. A letter there is signed by over 50 specialists in pain medicine. It ends thus
“Because of these new guidelines patients will continue to experience unnecessary pain and suffering and their rights to appropriately individually tailored treatment have been removed on the basis of a flawed analysis of available evidence. We believe the guidelines do not reflect best practice, remove patient choice and are not in our patients’ best interests.”
In a contribution headed “NICE misguidance”. Dr Michel Vagg ends
It seems to me that this guideline has been used as a propaganda vehicle to allow cherry-picked evidence to be enshrined as doctrine. This is an abuse of the guideline development process . . . ”
I have to say, though, that it seems to me that some of these people are promoting their own interests as much as chiropractors and acupuncturists. The evidence that spinal injections produce worthwhile benefits seems to be as thin as the evidence that chiropractic and acupuncture produce worthwhile benefits. But no doubt the injections are good for the budgets of PCTs or private practice doctors.. Could it perhaps be the case that some of the clinicians’ anger is being generated by doctors who are rushing to defend their own favourite ineffective treatment?
Why, oh why, can’t either NICE or the pain consultants bring themselves to state the obvious, that nothing works very well. The only thing that can be said for most of the regular treatments is that although they may not be much more effective than acupuncture or chiropractic, at least they don’t come with the intellectually-offensive hokum that accompanies the latter. Very sensible attempts have been made to identify the cause of low back pain [reviewed here], Occasionally they succeed. Mostly they don’t.
One clinician’s letter deserves special attention because it goes into the evidence, and the costs, in some detail. Its conclusions are very different from those in the NICE guidance.
The letter, a Review of NICE guidance, is from Dr C.J.D. Wells [download the whole letter]. He is a pain relief consultant from Liverpool.
Let’s look at some highlights.
Wells points out the absurdity of the cost estimates
“In the pricing section, they estimate that this will require an increase of facilities so that 3,500 patients can be treated instead of 1,000 at present (again see comments on pricing). This is not many treatments for the 20 million sufferers, of whom we can estimate that at least 2 million will have significant long-term disability and psychological distress”
And that is without even costing all the secondary costs of miseducating a new generation of students in fables about “Qi”, meridians, energy flow, subluxations and innate intelligence.
“The abysmal ignorance of the committee is reflected in the poor overall advice. So if you have a committee with special interests in Exercise, Manipulation, PMP’s, and Surgery, and you call an expert on Acupuncture, you get advice to use Exercise, Manipulation, Acupuncture, PMP’s and Surgery. Amazing.”
Another pain consutant, Charles Guaci, says in a comment in the Daily Mail.
I am a Pain Consultant of 30 years experience, have published two books (one translated into different languages).
NICE never asked me for my opinion.
This is the most ridicuculous pseudo-scientific document I have ever seen.
The panel consisted of a surgeon, psychologist, osteopath, acupuncturist a physiotherapist and an academic; not one pain consultant! The conclusions are simply a means of increasing the employment of their friends!
All evidence submitted to NICE was ignored.
It is almost certain than unless NICE rethink their ideas that Pain Consultants will be seeking a judicial review as well as full disclosure of how the panel arrived at their bizarre findings under the Freedom of information act.
Patients should realise that they are being taken for a ride.
Despite the outcry from opponents of magic medicine and from pain specialists, the assessment by the normally excellent NHS Choices site was disappointing. It made no mention at all of the secondary consequences of recommending CAM and described the assertions of the guidance group quite uncritically.
The reputation of NICE
NICE has been criticised before, though usually unjustly. In the past I have often supported them. For example. when NICE said that treatment of dementia with anticholinesterase drugs like galantamine was ineffective, there was a great outcry, but NICE were quite right. There is little or no rationale for such treatments, and more importantly, very little evidence that they work. But patients, especially when they are desperate, have greater faith in drug treatments than most pharmacologists, They want to clutch at straws. A bit like the NICE guidance committee, faced with a bunch of treatments most of which are almost ineffective, clutched at the straws of acupuncture and chiropractic. But this time it isn’t only the patients who are cross. It is most of the medical and scientific world too.
One interpretation of these bizarre events is that they represent a case of medical/scientific arrogance. Ben Goldacre wrote of another aspect of the same problem thus week, in Dodgy academic PR [download the paper on which this is based].
The first job of a scientist is to say openly when the answer to a question is not known. But scientists are under constant pressure to exaggerate the importance of their results. Last year we published an article which I feel may, if verified, turn out to be the second most important that I have ever been an author on. Because it happened to be published in Nature (not because of its quality), a press release was written (by an arts graduate!). It took some argument to prevent the distorted and exaggerated account being imposed on the public. This is typical of the sort of thing reported in Goldacre’s column. I reported a similar case a while ago, Why honey isn’t a wonder cough cure: more academic spin.
If NICE does not reconsider this guidance, it is hard to see how it can be taken seriously in the future. I hope that when NICE’s director, Professor Sir Michael Rawlins, returns from his trips abroad, he will find time to look at the case himself.
Indirectly, then, it can be argued that NICE’s bizarre guidance is just another manifestation of the management of science being passed from the hands of scientists into the hands of administrators and spin experts. It is yet another example of DC’s rule
Never trust anyone who uses the word ‘stakeholder’
Some bone-headed bureaucrat decides that any charlatan or quack is a ‘stakeholder’ in the provision of NHS care and gives them a quite disproportionate say in how taxpayers’ money is spent. The bureaucrats are so busy following processes and procedures, ticking boxes, and so deficient in scientific education, that they failed to notice that they’ve been caught out by the old trick of used car salesmen, bait and switch.
The consequences
The expected consequences have already started to materialise. The Prince of Wales’ Foundation for Magic Medicine is jubilant about having been endorsed by NICE. And I’m told that “The chiropractors have now just written letters to all health boards in Scotland asking for contracts for their services to deal with back pain”.
There could hardly have been a worse time for NICE to endorse chiropractic. We are in the middle of a storm about free speech because of the disgraceful action of the British Chiropractic Associaton in suing one of our best science writers, Simon Singh, for defamation because he had the temerity to express an opinion, Of course, even if the BCA wins in court, it will be the overall loser, because chiropractic claims are now being scrutinised as never before (just look at what they told me).
Follow-up
A much-cited paper. The paper that is most often cited by chiropractors who claim to be able to cure colic by spinal manipulation is Klougart N, Nilsson N and Jacobsen J (1989) Infantile Colic Treated by Chiropractors: A Prospective Study of 316 Cases, J Manip Physiol Ther,12:281-288. This is not easy to get hold of but Steve Vogel has sent me s scanned copy which you can download here. As evidence it is about as useless as the infamous Spence study so beloved of homeopaths. There was no control group at all. It simply follows 316 babies and found that most of them eventually got better. Well, they do, don’t they? It is a sign of the pathetic standard of reaearch in chiropractic that anyone should think this paper worth mentioning at all.
June 6 2009. More flak for NICE from the Royal College of Anaesthetists, and more adverse comment in the BMJ. And of course the blogs. for example, “If this is “evidence based medicine” I want my old job back“.
“Acupuncture on the NHS: a dangerous precedent”: a good analysis at counterknowledge.com.
June 6 2009, Comment sent to the BMJ. The comment was submitted, as below, early on Friday 5th June. The BMJ said it was a “sensitive issue” and for the next five days lawyers pondered over it.
Underwood and Littlejohns describe their guidance as being a “landmark”. I can only agree with that description. It is the first time that NICE has ever endorsed alternative medicine in the face of all the evidence. The guidance group could hardly have picked a worse moment to endorse chiropractic. Chiropractors find it so hard to find evidence for their practices that, when one of our finest science writers, Simon Singh, asked to see the evidence they sued him for defamation. I suggest that the guidance group should look at the formidable list of people who are supporting Singh, after his brave decision to appeal against this iniquitous persecution.
Of course I’m sure this bizarre decision has nothing to do with the presence on the guidance group of Peter Dixon, chair of the General Chiropractic Council. Nevertheless, I am curious to know why it is that when I telephoned two of the practices belonging to Peter Dixon Associates, I was told that they could probably treat infantile colic and asthma. Such claims have just been condemned by the Advertising Standards Authority.
The low back pain guidance stands a good chance of destroying NICE’s previously excellent reputation for dispassionate assessment of benefits and costs. Yes, that is indeed a landmark of sorts.
If NICE is ever to recover its reputation, I think that it will have to start again. Next time it will have to admit openly that none of the treatments work very well in most cases. And it will have to recognise properly the disastrous cultural consequences of giving endorsement to people who, when asked to produce evidence, resort to legal intimidation.
Eventually, on Wednesday 10 June the comment appeared in the BMJ, and it wasn’t greatly changed. Nevertheless if is yet another example of legal chill. This is the final version.
Underwood and Littlejohns describe their guidance as being a “landmark”. I can only agree with that description. It is the first time that NICE has ever endorsed alternative medicine in the face of all the evidence. The guidance group could hardly have picked a worse moment to endorse chiropractic. Chiropractors are so sensitive about criticisms of their practices that, when one of our finest science writers, Simon Singh, queried the evidence-base for their therapeutic claims they sued him for defamation. I suggest that the guidance group should look at the formidable list of people who are supporting Singh, after his brave decision to appeal against an illiberal court ruling in this iniquitous persecution.
One wonders whether this bizarre decision by NICE has anything to do with the presence on the guidance group of Peter Dixon, chair of the General Chiropractic Council. I am also curious to know why it is that when I telephoned two of the practices belonging to Peter Dixon Associates, I was told that chiropractic could be effective in the treatment of infantile colic and asthma. Similar claims about treating colic have just been condemned by the Advertising Standards Authority.
The low back pain guidance stands a good chance of destroying NICE’s previously excellent reputation for dispassionate assessment of benefits and costs. Yes, that is indeed a landmark of sorts.
If NICE is ever to recover its reputation, I think that it will have to start again. Next time it will have to admit openly that none of the treatments works very well in most cases. And it will have to recognise properly the disastrous cultural consequences of giving endorsement to people who, instead of engaging in scientific debate, resort to legal intimidation.
Bait and switch. Oh dear, oh dear. Just look at this. British Chiropractic Association tell their members to hide their sins from prying eyes.
Excellent round-up of the recent outburst of writing about “chiroquacktic” (Tut, tut, is there no respect?).
Dr Crippen writes “NICE recommends a cure for all known disease” [Ed some exaggeration, surely]
Two days ago I wrote NICE falls for Bait and Switch by acupuncturists and chiropractors: it has let down the public and itself
Now the official ‘guidance’ is out, and it is indeed quite as bad as the draft.
The relevant bits now read thus.
- Offer one of the following treatment options, taking into account patient preference: an exercise programme, a course of manual therapy or a course of acupuncture. Consider offering another of these options if the chosen treatment does not result in satisfactory improvement.
- Consider offering a structured exercise programme tailored to the person:
- This should comprise of up to a maximum of 8 sessions over a period of up to 12 weeks.
- Offer a group supervised exercise programme, in a group of up to 10 people.
- A one-to-one supervised exercise programme may be offered if a group programme is not suitable for a particular person.
- Consider offering a course of manual therapy, including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks
- Consider offering a course of acupuncture needling comprising up to a maximum of 10 sessions over a period of up to 12 weeks.
The summary guidance still doesn’t mention chiropractic explicitly, just a coy reference to “spinal manipulation”. At a time when the British Chiropractic Association is busy trying to suppress free speech via the law courts, I guess it isn’t surprising that they don’t like to use the word.
The bias in the recommendations is perhaps not surprising because the guidance development group had a heavy representation from alternative medicine advocates, and of people with a record of what, is, in my view, excessive tolerance of mumbo-jumbo.
Royal College of General Practitioners (RCGP) played a large part in writing the guidance. That is an organisation thar has steadfastly refused to make any sort of sensible statement of policy about magic medicine. It isn’t long since I was told by a senior person at the RCGP that there was nothing odd about neuro-linguistic programming. That does not bode well.
Professor Martin Underwood, Professor of Primary Care Research Warwick Medical School, University of Warwick. Underwood chaired the guidance development group. Martin Underwood is also a GP in Coventry See also the British Osteopathic Association. Underwood was lead author of the BEAM trial (download reprint). It is well worth reading the comments on this trial too. It was a randomised trial (though not, of course, blind).
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Our main aim was to estimate, for patients consulting their general practitioner with back pain, the effectiveness of adding the following to best care in general practice: a class based exercise programme (“back to fitness”), a package of treatment by a spinal manipulator (chiropractor, osteopath, or physiotherapist), or manipulation followed by exercise Conclusions |
In other words, none of them worked very well. The paper failed to distinguish between manipulation by physiotherapists, chiropractors and osteopaths and so missed a valuable chance to find out whether there is an advantage to employing people from alternative medicine (the very problem that this NICE guidance should have dealt with)
Steve Vogel, another member of the guidance development group, is an osteopath. Osteopathy has cast off its shady origins better than chiropractic, but it remains a largely evidence-free zone, and is still usually classified as alternative medicine.
Peter Dixon DC FCC FBCA is chairman of the General Chiropractic Council and founder of Peter Dixon Associates. They run six chiropractic clinics. The claims made by these clinics on their web site are mostly related to musculo-skeletal conditions (not, all spine-related however). But they also include
“Chiropractic is also suitable for relieving the symptoms of stress, and optimizing the way the body works is one of the best ways of enhancing health and wellbeing.”
I wonder how they could justify that claim? Then we get
A chiropractor is always willing to discuss individual conditions or answer questions in order to assess whether chiropractic may be of benefit.
Thanks for the invitation. I accepted it. After the first two phone calls, I had learned all I needed.
The first of Peter Dixon’s clinics that I called, was asked about my son who was suffeiing from perpetual colic. I asked for advice. I was put through to the chiropractor. Here are some extracts from the conversation.
“I think now it’s termed irritable baby syndrome. . . . . We’ve found chiropractic is very effective for colic . . . . £50 up to 3/4 hour which would involve taking a case history, examining the baby, with regard to seeing how the joints in the spine work because often colic is down to, er um, faulty movement patterns in the spine. We deal with an awful lot of things to do with the frame -how the spine moves -and it’s often problems with the way that the bones of the spine move in infants and babies that is the underlying cause in colicky symptoms. . . usually on the whole, I’ve shot myself in the foot by saying this in the past, if there are -um when I say back problems they’re usually temporary issues -when they are there the response for most babies is quite quick . . . it depends on how it’s related to what’s gone on in the birth process -there is usually some traumatic cause and it usually sets up a problem in the upper neck or the mid-back and that will drive those colic symptoms. . . . Yes it’s quite a straightforward thing we just check the baby’s spine and see if it’s problem we can deal with or not.”
Yes, I think you just shot yourself in the foot again. I have no idea in what fraction of cases a chiropractor would fail to claim that it was a case that they could deal with. At least that possibility was envisaged. But when I asked where he’d refer me to in such case I was told it might be a result of bottle feeding -“what they consume”. So I expect it would have been sent to some sort of “nutritional therapist” who would have used one of their usual battery of unreliable tests for food allergies.
I tried a second clinic in Peter Dixon’s empire and asked if chiropractic could help with asthma.”It can do, depending on what type of asthma you have". After some questions I was asked
“Do you have any general aches and pains otherwise, any tension .problems round the rib cage or thoracic spine . . . There are two things we’d look as chiropractors as to whether we could help or not and that would include the tension round the rib cage -in any type of asthma you’ll become tight round the rib cage and merely by keeping that area loose you’d help to stop the asthma from becoming quite as bad. And the second part is we’d look at the neck area with you to see if there is any restriction there -which houses the nerve supply to the lungs which can be indicated in some asthma cases also.”
I was invited to come for a free screen, so I asked if it usually worked quickly, “It depends what the problem is but you’d need a course I suspect”. £45 for the first appointment then £28 per session. “In most cases you’d need to look at a six to eight session course”.
Would anyone with experience of crying babies or of asthma like to comment on these proposed treatments? They are not my idea of evidence-based treatments and I find it quite surprising that someone who sponsors them is thought appropriate to write guidance for NICE.
This sort of ‘sting’ always makes me feel a bit uneasy, but it seems to be the only way to find out what actually goes on. And what goes on has all the appearance of classic bait and switch. You go in for your backache, and before you know where you are you are being sold a course of treatment to stop your baby crying.
Media follow-up after the NICE announcement
Sadly, I heard that the Today programme (my favourite news programme) was pretty wet. if only their science reporting was as good as their politics reporting.
The 27th May was certainly pretty busy for me, Apart from a couple of local paper interviews, this is what happened,
Sky News TV. Richard Suchet and two cameraman came to UCL and filmed a lot of stuff out of which a 20 second clip was used. And then they grumble that they don’t make money.
BBC TV 6 o’clock News. Similar, but at least only two people this time. Both TV stations spent ages showing pictures of people having needles pushed into them and very little time discussing the problems. A pathetically bad attempt at science reporting. Radio, on the whole, did much better
BBC Three Counties Radio (09.20) Host Ronnie Barbour, The daytime talk shows may be appalling to some of us, but the hosts did a far better job of airing the problems than TV [download the mp3].
Radio 5 Live Victoria Derbyshire [download the mp3]
BBC Radio Sheffield (12.05) was the best talk show by far. First speaker was Steve Vogel, the osteopath from the guidance development group. Although invited by the rather sensible host, Rony, to respond to the idea that a secondary consequence of the guidance would be to introduce hocus-pocus, he steadfastly refused to answer the question. At the end a rather sensible GP summed up the view from the coalface. [play the mp3]
Radio 4 PM programme This excellent early evening news programme is run by Eddie Mair. It was the best interview yet. The other side was put by Martin Underwood, chair of the guidance development group [play the mp3]
Underwood said “the evidence shows that it [acupuncture] works”. I disagree. The evidence shows that acupuncture, in a non-blind comparison with no acupuncture shows a small, variable additional effect that doesn’t last and is of marginal clinical significance, That is not what I call “works”. Underwood then indulges in the subgroup analysis fallacy by asserting that a few people get a large benefit from acupuncture. Or perhaps a few people just happen to get better that day. I was not convinced.
More 4 News TV 20.20 was an interview, with the other side being put by my old friend, George Lewith.
During the introduction, an acupuncturist. Lisa Sherman, ‘explained’ acupuncture in the usual sort of utterly meaningless words that illustrate perfectly the problem.
George Lewith said that “we don’t have a good pretend form of acupuncture”. “We don’t have a good placebo and we can demonstrate that acupuncture is literally twice as effective as conventional care”. The first is simply nonsense: huge efforts have gone into developing good controls in acupuncture studies (see, for example, Barker Bausell’s book, Snake Oil Science). And I hope that George will send the references for his “twice as effective” claim. It seems to me to be nothing short of preposterous.
My conclusions
So what went wrong?
One problem could be regarded as medical arrogance. The fact is that the problem of low back pain has not been solved, either by drugs or anything else. It is a failure of medicine (and of pharmacology). That should be the premise of all discussions, and it smacks of arrogance not to tell people straight out. Of course there are some cases when causes can be identified, and perhaps remedied, usually by surgery, but these are the exceptions not the rule.
One consequence of the inability of medicine to help much is that patients get desperate, and willing to try anything. And of course if they happen to have a remission, that is attributed to the treatment, however preposterous that treatment may have been. Conditions like back pain that come and go unpredictable are a gift for quacks.
Another consequence, for researchers rather than patients, is to clutch at straws. Even small and inconsistent effects are seized on as ‘successes’. This phenomenon seems to be part of the reason for the NICE guidance. Another reason is, almost certainly, the grinding of axes by some of the people who wrote it.
What should be done now?
Professor Sir Michael Rawlins is a sensible chap. He cares about evidence, But it does seem that in this case, he might have taken his eye off the ball, for once. In my opinion, he should restore the reputation of NICE by withdrawing this guidance and starting again.
Follow-up
An interesting document has come my way. It shows the responses of the guidance group to the consultation on the draft guidance. Many people made comments not unlike mone, but they were all brushed aside in a way that looks to me rather partisan. The document appears to have vanished from NICE’s web site, but you can download it here.
Friday 29th May. The Times prints a letter from two consultants in pain medicine, Joan Hestor and Stephen Ward. It says, inter alia
“As experienced pain specialists we feel that NICE has lost its way in publishing these guidelines.”
“We are saddened that NICE has chosen to ignore our important role and promote seemingly unworkable and for the most part clinically ineffective treatments”
Friday 29th May. NICE has had a good reputation in the USA for its important, and usually high-quality, attempts to assess what works and what doesn’t. That makes it all the sadder to see it condemned already from the USA for its latest effort. The excellent Yale neurologist, Steven Novella, has written about it on his Neurologica blog.
Friday 29th May. A correspondent points out that the costings of the guidance can be found on the NICE web site. Table 1 has a strong air of make-believe.
The Daily Mail (29 May 2009). Their article quotes serious criticisms of NICE.
Dr Ron Cooper, past chairman of the group and a consultant pain specialist in Northern Ireland, said: ‘I have never known so many pain medicine specialists to be so furious. More patients will end up having more expensive surgery, which is unnecessary, risky and has worse results.
‘NICE made it difficult for us to submit evidence to a committee on which there was not one experienced pain physician.
‘The guidelines will make us the laughing stock of Europe, Australia and the U.S. where pain specialists will continue to have full access to a wide range of treatments.’
Chirowatch suspended. 30 May 2009. The invaluable chiro-watch site, http://www.chirowatch.com, run by Dr Canadian physician, Dr Tom Polevoy, has been “suspended”. In fact the whole of his domain, healthwatcher.net, has been disabled. It seems that this was the result of a legal threat to his ISP, not by chiropractors this time, but by William O’Neill of the Canadian Cancer Research Group, which is far from being what the respectable-sounding title suggests, according to Dr Stephen Barrett. The site will be back soon, I’m told. Meanwhile you can read the suspended page here, and the only result of their hamfisted bullying will be to vastly increase the number of people who read it. You can read lots more at Quackwatch’s chirobase and at ebm-first.
A new blog, Not as NICE as you think appeared on May 30th. It is written by a pain physician, Stephen Ward. and is devoted to pointing out the serious problems raised by NICE’s guidance. It starts with the (very critical) World Institute of Pain Press Release.
British Medical Journal has more flak for the NICE guidelines
And the BMJ has published a letter signed by 50 consultants in pain medicine, NICE guidelines on low back pain are flawed.(this will probably appear as a letter in the print edition of the BMJ).