BMAS – a confession
OK, I think I had better confess before I go any further. I am GP and I have been on a British Medical Acupuncture Society (BMAS) course. I have been thinking of posting this for a wee while but I feel my hand has been forced as the BMAS has been dragged into the limelight by the good Dr David Colquhoun.
It was about 6 years ago and I was working for the Army seeing a lot of musculoskeletal medicine. I am not sure when the BMAS distanced themselves from meridians and such-like but I vividly recall a great deal of emphasis on it. Over the course of two days I was slowly and inexorably turned off – it felt a lot like an exercise in brain-washing. A group of susceptible individuals all herded together and then relentlessly bombarded by frightening well groomed zealots.
I found their unquestioning belief in acupuncture frankly creepy. I have noticed that there is a bit of a line with GPs that use acupuncture – it usually goes: “I don’t belief all that ear acupuncture/addictions/meridians stuff and I only use it for some musculoskeletal conditions”. That’s OK then. Oh, apart from the piss-poor evidence base, of course.
DC is, as PG Wodehouse might say, if not disgruntled, far from gruntled with the BMJ Group. The BMJ Group are launching a new journal – an acupuncture one. DC points out the evidence for the efficacy of acupuncture has been well summarised recently and it ain’t all that. (I won’t comment further – my copy of Ernst and Singh’s Trick or Treatment is on my bedside pile to be read.) DC highlighted that the BMJ suggest that their “brands stands for medical credibility”. Their opening gambit on the same page is:
The BMJ Group is an innovative, ethical and evidence-based company…
I refer readers back to this post if they want further evidence that the BMJ group is happy to sell their soul to the highest bidder. I can’t get too upset about all this – ultimately, BMJ Group is a company and one that wishes to turn a profit. However, there is an issue that their name lends credibility to the undeserving. If they position themselves in the market as standing for credibility and basing their strategies on ethical issues then I also think it is entirely fair that they deserve a kicking when they peddle complementary medicine and court Big Pharma. If they lay down with dogs then they can expect to get fleas.
Dr Adrian White is the editor in chief of the new BMJ acupuncture journal. There is a nice little summary of his position A Reappraisal of Acupuncture, 1998 on the BMAS site. I like this quote:
It also incorporates a modern approach to health care, which recognises the need to provide clinical trial evidence to back up anecdotal reports of acupuncture’s successes. Only by providing evidence can acupuncture stand alongside other therapies that are already established, and be judged by the strictest criteria of evidence-based medicine.
10 years later and evidence aplenty has been gathered. It doesn’t yet seem to have been quite enough for Dr White to have abandoned acupuncture. The DC post and subsequent discussion highlights the issues for all.
After my BMAS course I went home and I have never stuck an acupuncture needle in a soul. Honest. In the last few weeks I have come across a number of GPs who practice or support acupuncture. I find the unceasing creep of CAM into general practice worrying. Why do so many GPs love acupuncture and CAM?
On one level I am looking forward to the new journal – it should certainly provide me with plenty of opportunity to practice my critical appraisal as I take a close look at the papers. There is plenty of anti-woo going on across the blogs but I think it does deserve a vociferous and quite specific backlash directed at GPs who are running rough-shod over the medical evidence.
Acupuncture does seem to be quite a good placebo, though, doesn’t it? I don’t want to perform it myself, and I don’t think that the taxpayer should fund it, but I don’t mind if one of my patients wants to take themselves off to have some acupuncture and pay for it themselves.
It’s a bit like antidepressants for patients with mild-moderate depression: no different from placebo, but they often get swallowed in this context. Personally I try to resist prescribing them in mild-moderate depression, but a lot of such prescribing seems to go on. Starting an antidepressant is often followed by improvement (probably placebo effect or regression to the mean) which is valued by patients and reinforces doctor’s prescribing behaviour, even though the improvement is not scientifically attributable to the drug. I think this might be worse than acupuncture actually, as it is probably associated with more risk of adverse effects, and is funded by the taxpayer.
It’s interesting to speculate on why many doctors get so hot-under-the-collar about the evidence base behind acupuncture but aren’t so vocal about other things we do that are likely to be working by placebo effect. Is it because acupuncture is so “foreign”, so “alternative”, so “not me”? Whereas we have all felt secretly complicit in breaking the holy vows of EBM when we relent and write that prescription for the antidepressant, or the antibiotic for the viral URTI, in the setting of demand from the patient?
Sigh.
I’d go along with Brett, to some degree: if acupuncture is practised between consenting adults for self-limiting conditions that conventional medicine cannot help with, then I’m not too worried. (Though I still have qualms that vulnerable people, desperate for help can be charged sums, which though relatively modest, they can ill afford in the vain hope of relief.)
I also worry that it is tempting to overstate the range of conditions (or the extent to which) a placebo effect may be helpful, in the attempt to find a respectable argument for CAM interventions generally.
These modest quibbles aside, it’s when the taxpayer foots the bill, it creeps into academia, or explanations are given that promote a misunderstanding of how the body works (scientific principles, or what constitutes scientific evidence) that I’m unhappy.
I must say that after reading the RCN’s current guide (herbs and other CAM) on CAM and the menopause I do find it distasteful that medical professionals promote acupuncture (and other bits of wishful thinking) to their patients within a CAM-based context (talking about qi and meridians as if they were true, for example), whilst riding roughshod over the evidence.
I am certainly not going to pretend that I haven’t prescribed an antidepressant to a mild-moderate depression in the past. I would say that I have never prescribed one with the deliberate thought in my head that I was giving it as a placebo. I take your point that not everything we do has a clear evidence base and that is an obvious initial defence for CAM.
However, I do think that GPs are working to avoid prescribing antideps in these cases and antibiotics to sore throats. I am not aware of a vociferous and righteous lobby of GPs and patients who are demanding SSRIs or advocating antibiotics for sore throats in the face of the evidence. Or where unregulated practitioners can charge people for SSRIs or antibiotics.
And I am certainly not aware of the BMJ group setting up journals to publish the evidence (??promote the intervention) for interventions where the evidence is suggesting an absence of an effect. If you take my point.
Northern doctor,
It will not provide any answers, particularly, but I would like to recommend Dr. David Eisenberg’s ‘Encounters With Qi: Exploring Chinese Medicine’ (W.W. Norton, 1995). He was one of the first medical doctors to study in China and has subsequently set up an institute at Harvard to study Asian medical traditions. His view of why acupuncture doesn’t work in the West, was fascinating. You might find it of some interest. Although, it sounds like you have many books you would like to read, but don’t get the chance to read.
Best wishes,
metap.
Northern Doctor,
I do take your point. You are quite right that there is a difference between deliberately promoting a placebo intervention as something efficacious, and being reluctantly cornered into it when under ill-informed pressure.
While some of my colleagues do not seem to resist casual antidepressant or antibiotic prescribing, I think even they do not prescribe them believing that they are placebos. To the contrary, experience has taught them that patients tend to get better after they are prescribed. This seems to be more powerful than any number of randomised controlled trials. I suspect similar experiential learning underlies many practitioners’ beliefs in acupuncture. So I doubt these practitioners are setting out to deceive their patients. They are deceiving themselves, and then honest with their patients about their beliefs.
I don’t have a problem with the BMJ group publishing appropriate scientific articles about acupuncture, but I share your concern that in a dedicated acupuncture journal, there may be a temptation for the boundaries of science and promotion to blur.
It is an interesting area. I do agree that most individual practitioners of alternative medicine are not being deliberately deceitful. But I think, of all groups, GPs should have less excuse for falling into the trap of anecdotal medicine.
I also recognise that for practising clinicians it might be one of the biggest challenges that evidence-based medicine presents – the need to put aside the very powerful experiences of seeing patients get better (for instance with antibiotics for sore throat or acupuncture for whiplash) and embed one’s professional judgement in the evidence.
It can also be very difficult to convey the evidence when speaking to individual patients with a problem. You can almost see them glazing over and I suspect they are thinking “Yes, it might not work in your trials but it might work for me, so what the hell – this sore throat/painful neck is killing me”.