I am quite proud of my medical school. The dedicated faculty and dynamic curriculum produce graduates of excellent clinical skill with a strong sense of service. Initially I was too focused on coursework to pay much mind to the student-run interest group in “cross-cultural and integrative medicine” and the occasional extracurricular CAM event. More recently, however, I noticed that such events had become a highly-publicized, monthly occurrence. It was still very much outside the official curriculum, but the discussion was one-sided with no public debate.
In addition to the student group on my local campus, we have a “CAM institute” that boosts CAM across the wider university. The CAM institute is a major sponsor of events organized by the student group in addition to producing its own lecture series and publications. The events hosted by either group are of two types. The first kind is an activity for med students that essentially functions as stress management: a yoga instructor leads free sessions between lectures once a week, and free herbal tea or massages are offered during final exam week. Who can complain about that? The massages are quite popular. The second kind of event is a lecture or workshop on a particular CAM modality.
Topics have included acupuncture, aromatherapy, homeopathy, naturopathy, osteopathy, and Reiki. The lecturer is a practitioner of the modality in question, sometimes an MD who “integrates” the CAM into standard practice. These lectures are publicized more widely than any type of event on campus, with color posters littering the hallways from the parking deck to the hospital cafeteria. As a rule I avoid the “hands-on” workshops with, for example, Reiki masters and craniosacral manipulators, but I have attended several lectures first out of curiosity but increasingly in frustration at the lack critical analysis. After the second time I listened to a visiting MD promote homeopathy, I was moved to publish a critique in our student newspaper and finally start a public debate.
Campus-wide emails and posters announced for weeks the upcoming guest lecture by Dr. Larry Baskind, pediatrician and instructor for Center for the Education and Development of Homeopathy. The title of the lecture was “Clinical Homeopathy in Medicine” and the advertisements said:
Dr. Baskind will discuss basic principles of homeopathy, review cases from his practice, and suggest some useful homeopathic and herbal medicines for the upcoming cold and flu season. … Dr. Baskind has found that homeopathic (and herbal) medicines can be very effective treatments for a variety of complaints that a busy pediatrician sees in practice on a daily basis. When knowledgeably prescribed, these medicines are inexpensive, safe to take, and beneficial to patients.
Searching Google for Dr. Baskind, I found a video of him recommending Oscillococcinum, a homeopathic flu remedy derived from duck liver (insert quackery pun here), on the website of its manufacturer. In the promotional video, he describes Oscillococcinum as a safe, easy, over-the-counter way for parents to treat children at the first sign of flu. The viewer may be heartened to hear him stress the importance of flu vaccine and of medical treatment for flu complications. Immediately following that advice, however, he asserts (emphasis mine): “What I find most impressive is that Oscillococcinum has been available for 65 years. … 14 million people around the world treat themselves with Oscillococcinum for the flu.” Apparently less impressive than the marketing numbers are the data he references at the end of the video, which are not accessible on PubMed and were criticized for “suspiciously round numbers” by the Cochrane review. Appeals to age and popularity rather than decent data while glossing over the fundamental implausibility of homeopathy was a good preview of Dr. Baskind’s lecture.
The talk took place in the largest hall of the medical school, which to my dismay was filled rather more than it was for most course lectures. Hopefully, I told myself, the high attendance was due to the impressive spread of wraps and salads. (Most extracurricular lectures necessarily use pizza or subs to entice busy med students, and the CAM events can be often counted on for a free lunch of exceptional quality.) If AMSA thinks I should be “Pharm-free“, I thought, then I will be “CAM-free” to stay impartial, so I brought my own food.
The speaker was comfortable and charming before the audience. He assured us that he always follows evidence-based medicine (EBM) when possible, praising vaccines and antibiotics as proof of this commitment. However, he finds that EBM has nothing to offer for many common complaints brought by his patients, such as viral infections, and he feels compelled to do something. Therefore he looks to homeopathy to pick up the slack when EBM fails. He showed with a chart how often in a given month, according to a review of his patient records, he has no EBM recommendation for a patient’s chief complaint. (These frequencies of EBM failure were the only data presented during the hour.)
Dr. Baskind freely acknowledged, with a knowing grin, that the 200-year-old theory behind homeopathy strains credulity. He then explained all about similars and infinitesimals anyway, without suggesting any more plausible mechanism. Pointing out the problem with Avogardro’s number he all but admitted that there is no trace of the original ingredient, and yet he still claimed that the particular pill he selects for a particular symptom has a specific effect that is clinically significant. Sprinkled through his description of which remedies address which symptoms were anecdotes about happy patients. From my article in the student newspaper:
Why does Baskind believe in homeopathy? He expresses incredulity that so many people could believe in it for so long if it were not effective, but the “old and popular” practices of bloodletting, racism, and astrology suggest that mass delusion is certainly plausible. He is comforted because FDA regulates the manufacture of homeopathic products, but of course “not contaminated with melamine” is a far cry from “proven safe and efficacious by Phase III clinic trials.” He puts great faith in reports of patients whose symptoms improve after taking homeopathic drugs, but the primary rationale for using EBM is that such uncontrolled observations cannot distinguish correlation from causation. His anecdotes are rife with possible confounding effects, such as regression to the mean or concomitant EBM therapy, so how can we know? Randomized controlled trials (RCTs) are the appropriate way to evaluate such complex interventions.
Homeopaths often deny the power of RCTs to analyze homeopathy because homeopathy’s mechanism is mysterious. The history of scientific medicine belies this excuse. Although the value of hygiene, for example, met resistance from physicians who relied on tradition and personal experience, incontrovertible data won the day even before the germ theory of infectious diseases was available to explain them. Similarly, the famous trial showing that lemons cure scurvy saved many lives before ascorbic acid and lysyl hydroxylase were identified.
Baskind’s claim that RCTs are ineffective because different people respond differently to homeopathy is odd because this is true for many drugs, perhaps through genetic variation in target receptors or liver enzymes. Rather, RCTs are the solution to this problem; carefully controlled studies allow us to identify which groups respond best to which interventions even if we do not understand why (e.g., particular hypertension drugs for African Americans). If his “chronic reactional modes” have validity, then Baskind can assign subjects into appropriate groups and thereby increase the power of a homeopathy study.
Homeopathy should not be adopted into modern medicine until it meets the same standards of science-based care as other disciplines. Baskind neither showed nor referenced data for the specific efficacy of homeopathy, probably because only low-quality trials show positive effects. Given the implausible tenets of this pre-scientific philosophy, “placebo” is the null hypothesis and the burden of proof is on homeopaths. I celebrate the ICAM call for research into old and popular treatments, but such drugs should not be used on patients before good research shows them efficacious.
When the talk ended, I raised my hand to ask my question, carefully prepared in advance to challenge without sounding presumptuous or rude. (Please remember: I am a medical student confronting a lecturing physician in a packed hall.) I asked, “How do you respond to physicians who believe the effects of homeopathy are explained by placebo?” He dismissed such physicians as obviously having never tried homeopathy before. I have noticed this theme previously in CAM apologists, effectively “you can’t knock it until you’ve tried it.” Does experiencing a possible placebo effect firsthand make a human being more objective about it? Probably not.
I spoke up again, with less grace this time since I was not prepared for his response, saying that surely we physicians and students do not each need to try every drug or intervention personally; rather we rely on collective wisdom in the form of evidence-based guidelines. Baskind responded with a story about a woman with unexplained symptoms that improved after homeopathic treatment. It seems his primary reason for using homeopathy is not “we have good evidence (or theory) that it works” but rather “we’d hate to send patients home empty handed.”
My article earned me words of thanks from a few students, those skeptical but too busy to care much. One grumbled “someone had to say it.” Only secondhand did I hear about classmates who were unhappy about the article, though no one responded to my arguments in person or in public. In fact, one particularly friendly leader of the integrative medicine group thanked me for being respectful in my disagreement and invited me to attend an upcoming presentation by a naturopath! More on that to come.
Thanks to my article I found a sympathetic professor and some likeminded students who want to invite a skeptical physician to speak on campus, either as a counterbalance to the deluge of CAM speakers or to participate in an organized debate. Any interest from SBM writers or readers in the NYC area?