Respectful Insolence

Selling homeopathy to pediatricians

ResearchBlogging.orgI’ve never been able to figure out how anyone who claims to be devoted to science and scientific medicine can take homeopathy the least bit seriously. None of it makes any sense scientifically. Its basic principal of the “Law of Similars” has far more basis in the concepts of sympathetic magic than anything that science has to say, while its concept that diluting a substance (with shaking–a homeopath will always tell you that the shaking is absolutely necessary!) far beyond the point where there is likely to be even a single molecule of the remedy left actually makes it more potent has no basis in any chemistry, physics, or physical laws known by science. Of course, that doesn’t stop homeopaths and homeopathy advocates from continuing to try to get their favored woo into whatever legitimate medical setting that they can. Indeed, they seem to think that homeopathy is already “proven” as useful medicine.

The other day, I came across a perfect example of this very attitude in the form of a “study” published in that repository of all things woo The Journal of Alternative and Complementary Medicine. Its title says it all: Why Pediatric Health Care Providers Are Not Using Homeopathic Antidiarrheal Agents.

Of course, a better question is: Why on earth should pediatricians use homeopathic antidiarrheal agents? If we’re to believe these investigators from the University of Rochester, it’s a travesty that they do not. Indeed, it starts from the very first sentence of the abstract:

Several randomized, controlled trials have demonstrated the efficacy of homeopathic agents for use in childhood diarrhea. However, this therapeutic innovation is not being routinely adopted.

Of course, this is a huge exaggeration. What the investigators neglect to mention is that, as for all “positive” trials of homeopathy these trials demonstrate small, equivocal effects that are of questionable significance from a clinical standpoint. Moreover, these trials all tend to have methodological flaws that render their results highly questionable at best. Indeed, as I described a year ago, the most recent such trial, despite being published in the same woo-friendly journal as this one, was a completely negative trial. In any case, the purpose of this study is evident right from the very beginning:

The study of the processes by which innovations are adopted, often termed “knowledge translation” when referring to the biomedical field, is a relatively new science. While some of the elements influencing the translation of scientific evidence into clinical practice are known, many remain unclear; it seems likely that multiple factors influence the adoption of proven therapies by health care providers.1-6 In this paper, we report on the results of a small study of clinicians’ reported knowledge, attitudes, and practices about homeopathic antidiarrheal agents, an approach for which evidence of efficacy exists, but that has not been widely adopted among children’s health providers.

[...]

Homeopathic antidiarrheal agents have been shown to produce statistically significant reductions in the duration and frequency of diarrheal stools in a small number of clinical trials conducted by one group of investigators. Although published responses to these findings were mixed, no similarly designed study has been published to refute the original evidence for efficacy.

And that, of course, is the problem with studies of woo shoehorned into the paradigm of evidence-based medicine. With no prior assessment of scientific plausibility, any “statistically significant” result is trumpeted as justification that woo works, which is exactly what these authors are doing. To make this argument, they decided to distribute a survey regarding patterns of usage of homeopathic remedies for diarrheal diseases. The survey was self-administered and, according to the authors, based on a review of the key literature, key informant interviews with experts in the management of childhood diarrheal disorders, and focus groups with pediatric and medical residents. The survey consisted of two sections, the first of which was designed to assess: (1) the degree of respondents’ adoption of homeopathic antidiarrheal agents and their reported attitudes about, and barriers to such use, (2) respondent demographics, and (3) respondents’ preferred media for the acquisition of knowledge about new or little-known therapies. These were found to be “barriers” to the adoption of homeopathic remedies in the 119 health care practitioners surveyed:

Of the potential barriers to homeopathic antidiarrheal agent use, the following were felt to be “major barriers” by the majority of pediatric health care providers: “don’t know how to use them” (83.6%), effectiveness (81.1%), safety (79.5%), not aware of them as a treatment option (73%), and limited regulation by the U.S. Food and Drug Administration (FDA) (61.3%). The remaining potential barriers were felt by most to be either a “minor barrier” or “no barrier”: over-the-counter status (90.8%), no need to decrease diarrhea (87.6%), insurance coverage issues (82.6%), cost (81%), perception of families toward homeopathic agents (78.4%), medicolegal concerns (72.5%), and perception of the medical community toward homeopathic agents (60.7%). When asked which of the potential barriers was the single most important barrier to homeopathic antidiarrheal agent use, the most common response was “not aware of them as a treatment option,” chosen by 32.4%. Other barriers chosen as the most important were the following: “don’t know how to use them” (21.3%), effectiveness (18.5%), safety (17.6%), limited regulation by the FDA (9.3%), and insurance coverage (1%).

I found it rather lacking that there was no option for “homeopathy is a load of pseudoscientific twaddle” as a response. That to me would have been the most appropriate “barrier” to any evidence-based practitioner’s adoption of homeopathy to treat children with infectious diarrhea. Most disingenuous, however, was the part of the study where the authors gave the respondents abstracts supposedly supporting the use of homeopathy to treat this disorder. First, let me just say that it was depressing that, before reading the abstracts, 23.5% of respondents thought that homeopathic remedies were “probably effective” at reducing diarrheal frequency and volume. If medical schools were doing their jobs, the number would be much lower. However, once respondents read these abstracts, 76.9% thought that homeopathy would be effective.

Depressing.

On the other hand, it’s not all bad. It turns out that only 3% of the respondents actually reported using homeopathic remedies for infectious childhood diarrheal diseases. That’s somewhat reassuring. Also reassuring was the report that not everyone viewed the abstracts presented as “evidence” for the efficacy of homeopathy as favorably as the investigators had evidently hoped:

Despite the marked change in sentiment regarding the efficacy of homeopathic antidiarrheal agents, 78.9% of respondents indicated that reading the abstracts did not make them more likely to use homeopathic antidiarrheal agents, and 65.1% continued to cite lack of efficacy as a major barrier to use, while 83.5% remained concerned about safety. When considering the level of evidence, 60.5% were concerned about the reproducibility of the results, given that the two abstracts were authored by the same investigators, and 60.5% were concerned about the small effect size, although generalizability to U.S. children was not a concern for 66.1%. The lack of cost-effectiveness data was a concern for 54.7% of respondents, while 46.4% were concerned about the lack of a theoretic basic science explanation for any reported efficacy.

I’m not sure whether I should be happy or sad that 46.4% were concerned about the lack of any sound theoretical basic science explanation for any reported efficacy. On the one hand, it would be nice if it were much higher. However, on the other hand, given how the new paradigm of “evidence-based medicine” denigrates basic science and scientific theoretical considerations compared to clinical trial evidence above all, perhaps I should be heartened that nearly half of the respondents nonetheless raised this particular issue.

So what was the conclusion of the investigators after analyzing the results of this survey? They express disappointment that homeopathy is a “minimally adopted innovation,” at one point calling it an “underadopted” innovation. Of course, I find it hilarious that they would refer to an unscientific modality based on prescientific concepts of vitalism and ideas of sympathetic magic would be referred to as an “innovation,” but in the topsy-turvy world of “complementary and alternative medicine,” I suppose it is. They also conclude that the evidence base for homeopathy needs to be improved. Well, duh! Of course, the problem is that the “evidence base” for homeopathy is about as good as it’s ever going to get. In actuality, the more rigorous the clinical trial, the less likely it is to demonstrate any sort of apparent “efficacy” for homeopathic remedies. If the investigators really want to improve the perception of efficacy for homepathic remedies, the last thing they want is to upgrade the evidence base for homeopathy. Of course what they consider to be an “upgrade” would be more trials showing efficacy and some sort of basic science suggesting a plausible mechanism. Well-designed studies, of course, are unlikely to find an “effect” due to homeopathy greater than that of a placebo, which, after all, is all that homeopathy is: An elaborate placebo. Moreover, there is no conceivable basic science study that wouldn’t involve demonstrating that huge swaths of our current understandings of physics and chemistry are wrong that could make the concepts behind homeopathy any more plausible than magic.

Of course, when it comes right down to it, this article is nothing more than a lamentation that more pediatricians don’t use homeopathy to treat diarrheal diseases and a suggested blueprint for how to sell them on homeopathy. It proceeds from the false premise that homeopathy is anything more than a placebo and then degenerates from there. In fact, given that this gem came out of the University of Rochester, it makes me wonder whether I should be adding this particular institution to my Academic Woo Aggregator.

REFERENCE:

Pappano, D., Conners, G., McIntosh, S., Humiston, S., Roma, D. (2007). Why Pediatric Health Care Providers Are Not Using Homeopathic Antidiarrheal Agents. The Journal of Alternative and Complementary Medicine, 13(10), 1071-1076. DOI: 10.1089/acm.2007.0651

Comments

  1. #1 Kurt
    March 31, 2008

    Another potential woo mine is the whole area of veterinary homeopathy.

    I didn’t even think of this area until I had a cat get sick and started reading brochures at the vet’s and also a little Googling.

  2. #2 Kurt
    March 31, 2008

    Another potential woo mine is the whole area of veterinary homeopathy.

    I didn’t even think of this area until I had a cat get sick and started reading brochures at the vet’s and also a little Googling.

    At least I think the pets are a bit ahead since I think they simply wouldn’t stand for some of the treatments that humans do.

  3. #3 DLC
    March 31, 2008

    Homeopathy has been shown time and time again to be a completely worthless waste of time, money and effort.
    Hippocrates would kick these charlatans in the groin, and water-board them with their own worthless solution of zero.

  4. #4 DLC
    March 31, 2008

    Homeopathy has been shown time and time again to be a completely worthless waste of time, money and effort.
    Hippocrates would kick these charlatans in the groin, and water-board them with their own worthless solution of zero.

  5. #5 Dianne
    March 31, 2008

    Mildly off-topic, but have you seen this yet? The perfect practical joke to play on a homeopath.

  6. #6 tincture
    March 31, 2008

    However, on the other hand, given how the new paradigm of “evidence-based medicine” denigrates basic science and scientific theoretical considerations compared to clinical trial evidence above all, perhaps I should be heartened that nearly half of the respondents nonetheless raised this particular issue.

    I thought “evidence-based medicine” was a good thing?

  7. #7 DrFrank
    March 31, 2008

    I’m with tincture here – would you care to elaborate on what you mean in that paragraph?

    My first guess would be that it’s a complaint about the tendency to give any treatment, no matter how crazy, a chance to prove itself in trials, rather than being able to say (as in the case of homeopathy) “I’m sorry, but that’s just bloody ridiculous”.

    Of course, I could be completely wrong: my telepathy skills have been really letting me down lately ;)

  8. #8 DrFrank
    March 31, 2008

    Also, I somehow feel that the happy green tick on the “blogging on peer-reviewed research” icon probably isn’t so appropriate for this article.

  9. #9 madder
    March 31, 2008

    Now, now. You folks are too hostile to the homeopaths. One day, some fine homeopath will realize that all they must do to treat diarrhea is to dilute their favorite “homeopathic antidiarrheal agent” in a nice electrolyte solution, and it will do the trick in many cases.

    As long as it’s administered by the quart.

    (/snark)

    I tried; I really tried to avoid the scare quotes. But I’m helpless- I just can’t avoid using them around the phrase “homeopathic [insert anything here] agent.”

  10. #10 Bill the Cat
    March 31, 2008

    Several randomized, controlled trials?

    That’s a lie on its face. It is impossible to conduct such a test of homeopathic remedies because the experimental group would get a harmless placebo just like the control group. That’s asking which is more healthful, a bag of air or a bag of air?

  11. #11 Militant Agnostic
    March 31, 2008

    Tincture – the failure to consider prior plausibility is a major flaw in evidence based medicine, since publication bias (the file drawer effect) results in positive studies being published while negative studies are not published. This creates a false impression of effectiveness. Homeopathy is the best example of this.

  12. #12 Citizen Deux
    March 31, 2008

    The first MD to proffer a homeopathic remedy to me for my children would get a guick boot to the head and a complaint to the governmental licensing board – not to mention a thorough “fisking” online.

    Having an MD is not immunization against gullibility or wooly thinking.

  13. #13 JackofAllTirades
    March 31, 2008

    Take a look around at your local Walgreens or CVS pharmacy. I once asked a pharmacist at a party (tongue in cheek) if copper bracelets really worked. Their reply? “Ask Larry’s brother. He said it works for him.” Unbelievable.

    What really gets me are the remedies that are next to legitimate OTC drugs with “Homeopathic” in small print? Shouldn’t the FDA be delivering some sort of smack-down for this? Does anyone have any ideas?

  14. #14 AnnR
    March 31, 2008

    I’ve had pediatricians tell me to quit giving my kids sweet juices and try a bland diet (banana, rice, applesauce, toast) in combating diarrhea.

    Is that Woo or homopathy?

  15. #15 Marcus Ranum
    March 31, 2008

    What’s the homeopathic remedy for diarrhea, anyhow?? Diluted baby poop? I can see why a “remedy” like that would be unappealing – even if it’s highly diluted.

  16. #16 Marcus Ranum
    March 31, 2008

    What’s the homeopathic remedy for diarrhea, anyhow?? Diluted baby poop? I can see why a “remedy” like that would be unappealing – even if it’s highly diluted.

  17. #17 Dr Aust
    March 31, 2008

    …!!?!…

    Are we REALLY sure this one isn’t a spoof? For a minute I thought I smelt April 1st. And the whole abstract reads like a send-up, using the consciously dry and neutral language of EBM journal-ity to describe nonsense.

    A really scary thought strikes me – what if it is the first in a series? Coming soon: “Why pediatric health providers are not using Reiki healing to treat kids with the squirts – a questionnaire study”

    On reflection, I don’t know whether to laugh or cry.

  18. #18 Alison
    March 31, 2008

    You know, “Homeopathic Antidiarrheal Agents” would be a great name for a band.

  19. #19 Alison
    March 31, 2008

    You know, “Homeopathic Antidiarrheal Agents” would be a great name for a band.

  20. #20 Calli Arcale
    March 31, 2008

    “Take a look around at your local Walgreens or CVS pharmacy. I once asked a pharmacist at a party (tongue in cheek) if copper bracelets really worked. Their reply? “Ask Larry’s brother. He said it works for him.” Unbelievable.”

    Wow. Of course, a good response to that might be “So you don’t know.” Because that’s basically what that answer means.

    The study itself has a offensive quality to it in that it essentially is framed like the question “how long has it been since you stopped beating your wife?” because it’s basic question is “what keeps you from prescribing this safe and effective treatment for your patients’ diarrhea?” Since the treatment is not effective, there can be no meaningful answer to the question as posed. Consequently, the results are meaningless to those who are actually interested in science.

    But the answers ARE meaningful to another group: marketers, or as some like to call them, marketroids. Marketroids are not interested in what works or doesn’t work; they’re interested in what is a barrier to selling their product. Now, products which work are generally somewhat easier to sell than products which don’t, but it’s easy enough to sell unproven and even totally ineffective treatments that the difference is scarcely significant. So this study was addressing exactly what they really wanted to study: not whether or not homeopathy is effective, but whether or not certain marketing strategies are effective (namely, whether or not the abstracts help convince doctors to prescribe homeopathic treatments) and which areas they might wish to target in future marketing efforts.

    I think there is probably a strong trend of this throughout CAM studies — studies oriented more towards marketing than science. The CAM practitioners may often be unaware of the difference between a product trial and a clinical trial, but this particular one smells too much of a marketing study. I think these researchers knew perfectly well what they were doing. Perhaps they believe homeopathy to work, or perhaps they don’t care, but either way, it studied precisely what they wanted to study — how to sell something that nobody can prove works.

  21. #21 Dangerous Bacon
    March 31, 2008

    Advocates of homeopathy don’t really want well-conducted, large-scale trials of their woo.

    What they’d prefer are more studies limited by small size and dubious methodology, from which they can cherry-pick the few that seem to show an effect. They can post these on websites or print more brochures listing just the studies that seem to support homeopathy (plus testimonials and deep philosophical musings about the pharmaco-spiritual-kinetic underpinnings of their craft).

    Works for other sorts of CAM too.

  22. #22 JackofAllTirades
    March 31, 2008

    Actually the BRAT diet (bananas, rice, applesauce, and toast) does work. It’s pretty much SOP amongst pediatricians and nurse practitioners.

  23. #23 DocMartyn
    March 31, 2008

    If homeopathy is that good, why is it not used for that most “Western” and invasive of the Medical Arts, Dentistry?
    I mean, you wouldn’t need to drill the tooth or drain the abscess; only take some plant material that has been diluted 10^100 times.

  24. #24 DocMartyn
    March 31, 2008

    If homeopathy is that good, why is it not used for that most “Western” and invasive of the Medical Arts, Dentistry?
    I mean, you wouldn’t need to drill the tooth or drain the abscess; only take some plant material that has been diluted 10^100 times.

  25. #25 Inquisitive Raven
    March 31, 2008

    Tincture: I think point of Orac using the scare quotes there was that the researchers calling it “evidence based medicine” doesn’t make it so.

    Orac: Are you sure you should have used the “peer reviewed research” icon and not the “pseudo-scientific douchebags” icon for this one?

  26. #26 Alison
    March 31, 2008

    You know, “Homeopathic Antidiarrheal Agents” would be a great name for a band.

  27. #27 dszy
    March 31, 2008

    What is a standardized scale of innovativeness?

  28. #28 Alan Kellogg
    March 31, 2008

    I see I have taught you well, young calculator; homeopathy aint nuttin’ but magic, and magic passed off badly as science. Though you do have to give homeopaths props for at least trying to make it appear to be science. Don’t see the creationists making even half the effort homeopaths do. :)

  29. #29 Regan
    March 31, 2008

    “Of course, the problem is that the “evidence base” for homeopathy is about as good as it’s ever going to get.”

    That’s pretty obvious, but it still had me spitting coffee on the keyboard.

    Thank you for this post.

  30. #30 Jerry Kindall
    April 1, 2008

    Strangely, one popular OTC remedy that does have clinical trials behind it and real active ingredients in it, Cold-Eeze, says “Homeopathic” right above the product name. It’s not homeopathic at all! Apparently the maker has found homeopathy to be a selling point with some customers. It bothers me because the product does seem to actually work, which will make the uninitiated believe there is some validity to homeopathy. The FDA apparently doesn’t bar companies from claiming their own products are quackery as long as they work. Crazy.

  31. #31 Shay
    April 1, 2008

    They are now advertising homeopathic pet remedies on TV.

    Anyone who treats an animal in pain with a homeopathic remedy should be bitten.

  32. #32 Shay
    April 1, 2008

    They are now advertising homeopathic pet remedies on TV.

    Anyone who treats an animal in pain with a homeopathic remedy should be bitten.

  33. #33 Lilly de Lure
    April 1, 2008

    Shay said:

    Anyone who treats an animal in pain with a homeopathic remedy should be bitten.

    Knowing how sensitive my dog can be to my moods and body language I suspect anyone trying it on her would be!

    (Sorry for the grouch but I’m a little sensitive on this issue – my dog suffers from Addison’s Disease and I don’t even want to think of the results if some woo had got their mitts on her when we first noticed her symptoms.)

  34. #34 Calli Arcale
    April 1, 2008

    Jerry Kindall, the same is true of Zicam. They’ve been hit with fines before for a) making medical claims without evidence and b) claiming to be homeopathic when in fact it actually contains zinc. The irony of that would be utterly hilarious if it weren’t for the fact that they basically just laid low for a bit and then went right back to it.

    My mother-in-law is a rather credulous person, and I was surprised to learn recently that she didn’t know what homeopathic meant. She had no idea it involved repeated dilution until there’s nothing left, nor that it’s been around for over a century. She seemed to think it was just another word for alternative medicine. I suspect her impression is fairly typical of homeopathy users.

  35. #35 Dr Aust
    April 2, 2008

    Calli Arcale wrote:

    “My mother-in-law … had no idea [homeopathy] involved repeated dilution until there’s nothing left… She seemed to think it was just another word for alternative medicine. I suspect her impression is fairly typical of homeopathy users.”

    Agree 100% Calli. Most people think it is just another Alt Therapy and have no idea what is in it (or not).

    The slightly more educated (e.g. Arts degree level) often think it is another word for “herbal”. I think the homeopaths deliberately encourage this misconception (at least in the modern era) by their repeated comment (AKA lie) that “homeopathy… uses remedies made of very dilute natural substances”.

    I actually find, when I ask my 1st yr B.Sc. or even Medical students, that they too commonly suppose “homeopathic” is a subvariety of “herbal”.

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