In the current edition (June) of the American Journal of Medicine, there is an exchange in the letters section between myself and Profs. Baum and Ernst about a misleading reference to me in the journal.

The origin of the exchange is their attack on homeopathy published in the journal in which their first reference appears to imply that I am an individual ‘claiming that those wanting to carry out the trials are in the pocket of the pharmaceutical industry and are part of a conspiracy to deny their patients tried and tested palliatives.’

Their original article can be read here, my letter here and their reply here.

It’s interesting how they go on to deny funding by Big Pharma or conflict of interest when I have earnestly pointed out that I have never accused them of this.

Anyway my reason for blogging on this is to clarify – at least for readers of this blog – my exact position on homeopathy, EBM, Ernst and Baum, ‘nannies’ and NHS homeopathy.

1. In general I support Evidence Based Medicine (EBM) as a useful but stern test of medical efficacy. Much of both orthodox and CAM fail to pass it as I’ve pointed out many times and employed a Pie Man to deliver the message that most medical interventions are far from fully evidence based.

2. I have indeed used the word ‘hypocrisy’ in relation to those who use EBM as a blunt instrument to attack homeopath exclusively (note how Ernst and Baum cunningly leave out that word in their reply to my letter) If EBM is to be used as a referee on a level playing field, much of both conventional medicine and CAM are going to have to receive red cards – not just homeopathy. I don’t support this approach but consider it hypocritical to use it only against homeopathy and CAM.

3. With regard to ‘nannies’ , the nanny state and people thinking for themselves: This has nothing to do with EBM but everything to do with the NHS, democracy and liberty. You can only get NHS homeopathy if your GP sends you to another NHS doctor who uses homeopathy and takes responsibility for his/her interventions. Ernst and Baum want to stop this process from happening. In other words they seek to thwart (rather than attempt to dissuade) qualified doctors on the NHS from sending patients to other doctors (who happen to practise homeopathy in addition to conventional medicine) on the NHS . I think that’s playing the role of ‘nanny’.

4. As for ‘conflict of interest’ I have always warned that it is grossly unethical for anybody to criticise anybody else of this without producing a smoking gun. My philosophy and attitude to medicine and health is very different to that of Baum and Ernst but I have never accused them of conflict of interest. In their reply they say: Some might think that Kaplan might have a conflict of interest himself in so fiercely defending homeopathy, but we don’t, as we are sure he practices in good faith and that his very success is reflected in the support he enjoys from his clients.

How kind and reconciliatory of the professors. This is a remark almost subtle enough to be classified as Provocative Therapy! Actually I refer to the people who consult me as ‘patients’ and my ‘fierce defence’ has always been of NHS homeopathy as provided for at present by a by-law of the United Kingdom. How ‘some might think’ defending existing legislation in this country to be a conflict of interest is beyond me. Baum and Ernst then kindly point out that they personally don’t think this. Thanks guys, some of my best friends are professors who use EBM as a blunt instrument, not to use on the whole of medicine, but to attack homeopathy more or less exclusively.

Anyway I find myself ranting a bit like Lenny Bruce when he was going through all those ridiculous obscenity trials in America. Even he ceased to be funny after a while but if you read the transcripts of those trials now, we see how right he was at the time.

Actually I am very grateful to The American Journal of Medicine. Instead of printing fawning and concurring missives in relation to the article by Ernst and Baum, they unexpectedly chose only to publish my letter.

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Critics of homeopathy (and CAM) repeat endlessly there is ‘no evidence’ that they work beyond placebo and therefore homeopathy should not be funded by the NHS.

This disingenuously gives the entirely false impression to the public that all NHS-funded medical interventions are obviously evidence based. This is not only false, it is light years from the truth.

The Pie Man exists to remind critics of homeopathy and CAM that most interventions employed by doctors (on the NHS and elsewhere) are certainly not evidence-based. As always I defer to the British Medical Journal’s highly-esteemed handbook called Clinical Evidence.

The reason I’m writing about the Pie Man today is that the figures have changed. Unfortunately for people like Edzard Ernst, Michael Baum, Simon Singh, Ben Goldacre et al, that use EBM (evidence based medicine) as a tool to attack homeopathy and CAM exclusively, the case for orthodox medicine being evidence-based just got a whole lot worse.

Here is the Pie Man as first published a year ago.

Critics of homeopathy (and CAM) repeat endlessly there is ‘no evidence’ that they work beyond placebo and therefore homeopathy should not be funded by the NHS.

This disingenuously gives the entirely false impression to the public that all NHS-funded medical interventions are obviously evidence based. This is not only false, it is light years from the truth.

The Pie Man exists to remind critics of homeopathy and CAM that most interventions employed by doctors (on the NHS and elsewhere) are certainly not evidence-based. As always I defer to the British Medical Journal’s highly-esteemed handbook called Clinical Evidence.

The reason I’m writing about the Pie Man today is that the figures have changed. Unfortunately for people like Edzard Ernst, Michael Baum, Simon Singh, Ben Goldacre et al, that use EBM (evidence based medicine) as a tool to attack homeopathy and CAM exclusively, the case for orthodox medicine being evidence-based just got a whole lot worse.

Here are the the latest figures from Clinical Evidence which makes the Pie Man look like this:

And here are a comparison of those figures

Proportions of Commonly-used Treatments supported by Good Evidence

March 2009 Today

Beneficial 13% 11%
Likely to be beneficial 23% 23%
Trade off between benefits and harm 8% 7%
Unlikely to be beneficial 6% 5%
Likely to be ineffective or harmful 4% 3%
Unknown effectiveness 46% 51%

This means the big loser in recent changes are treatments proven to be incontrovertibly beneficial (15% loss of its share) and the big winner was ‘Unknown effectiveness’ (gain of nearly 10%).

So next time you hear a doctor criticise homeopathy for lacking evidence, know that s/he is a doctor in a glass house throwing stones and ask him or her quietly what % of conventional interventions on the NHS are fully evidence based.

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The Pie Man has the noble duty of delivering this pie chart to those who jeer at homeopathy and CAM because they consider them to be less than evidence-based. In the name of truth and beauty*, the Pie Man attempts to make it clear that most of common conventional medical interventions are far from evidence-based in the hope that people in glass houses will be less inclined to throw stones.

The pie (or pie chart) is baked (or compiled) by no less an authority than the British Medical Journal’s Clinical Evidence, a publication that could hardly be described as ‘alternative’.

What I’d like to point out today is that the pie changes as the evidence does or does not roll in to support common orthodox medical treatments.

Let’s have a look at some of the ways the pie has changed since the Pie Man first emerged some months ago.

Interventions of Proven Benefit: A fall from the embarrassingly low figure of 13% to 12%. Single figures soon? I find it amazing to read of the attacks on homeopathy by the likes of Baum and Ernst in the light of this figure in particular.

Interventions of Unknown effectiveness: another embarrassing shift – UP from the huge figure of 45% to 49%. ie: half of conventional medicine treatments are of ‘unknown effectiveness’. Side effects are far from ‘unknown’ though and obviously far more common with regard to orthodox medication than gentle homeopathic remedies whose most fierce critics would have to agree very, very rarely produce any side effects.

*When old age shall this generation waste,

Thou shalt remain, in midst of other woe

Than ours, a friend to man, to whom thou say’st,

“Beauty is truth, truth beauty,” – that is all

Ye know on earth, and all ye need to know.

(from Ode to a Grecian Urn by John Keats)

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The Pie Man has been alerted to an article in the American Journal of Medicine by the erstwhile Edzard Ernst and Michael Baum, his co-signee of the notorious letter (inappropriately written on NHS note paper) to Patient Care Trusts (PCTs) all over the UK. In the letter – as you can see – they attempt to persuade these trusts (comprising mainly non-doctors) to thwart the desire of NHS GPs to send patients on the NHS to NHS medical qualified doctors practising homeopathy in NHS hospitals! I’ve written of this before and mentioned how I would have tolerated them writing to GPs to dissuade them from making these referrals but am abhorred by their attempt to go over GPs’ heads.

Anyway in this article in the AJMed. the two honourable and esteemed Disciples of Scientism (my words for them and the  other signees of the above-mentioned letter) once again lash out at homeopathy, this time in a crude and lazily written ‘article’. I have no intention of discussing their regurgitation of the same stuff they have been spouting for a long time but as they cite me personally, I feel I must respond.

Reference 1. in their article comes at the end of a paragraph that ends with a sentence that says ‘These individuals have a conflict of interest more powerful than the requirement for scientific integrity and yet defend themselvesby claiming that those wanting to carry out the trials are in the pocket of the pharmaceutical industry and are part of a conspiracy to deny their patients tried and testedpalliatives.’1

And the reference given is: 1. Kaplan B. Hypocrisy of attacks on homeopathy to be exposed soon. Available at: http://www.wellsphere.com/general-medicine-article/hypocrisy-of-attacks-on-homeopathy-to-be-exposed-soon/31269. Accessed April 3, 2009.

Now I can prove that I’ve not touched that article since April 3 so if you read what I said there, it will be crystal clear that it does not support the reference, thus illustrating just one aspect of how poor an article this is. I have never claimed that these professors are ‘in the pocket of the pharmaceutical industry and are part of a conspiracy to deny their patients tried and tested palliatives’. Perhaps Ernst just fingered me as what he thought of as an example of such an individual and pressed the speed-type button on one of the references he has on me. However  in the end I must admit defeat and take off my hat to these two eminent professors. It is no mean feat to get a lazily-written, supercilious diatribe, high on opinion and low on facts like this published in a prestigious medical journal. A colleague of mine has just had a brilliant riposte to the article turned down by AJMed – no surprises there! Perhaps he can be persuaded to put some of his excellent points in the comments section here.

So all that’s left to me is to order the Pie Man to deliver this pie to both Ernst and Baum. Ernst knows of this pie and once made a pathetic attempt to ‘refute’ it in his column in Pulse. To him I say: Meet me anywhere at any time for a debate on this. To Prof. Michael Baum, please study the pie carefully.  It was baked by the British Medical Journal after all.

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The third person to be visited by The Pieman can come as no surprise to anyone. It is fellow doctor, Prof. David Colquhoun, a man who won’t mind me saying has devoted huge amounts of time and effort to attempt to debunk various forms of Complementary and Alternative Medicine (CAM). His website,  is as fine a testament to what my mentor Eric Ledermann termed naïve realism as you can find on the internet. His arrogant and insulting attacks on homeopathy and any form of CAM that he personally does not consider to conform to his exclusively mechanistic view of medicine, is something to behold. This is a man of strong views – blinkered as these views may be.

Alas this has been a rather bad week for the professor as he watched the NHS irrationally and inexplicably (in his opinion I’m pretty sure) endorse and make available acupuncture (a ridiculous form of therapeutics inexplicably used by billions of Chinese for 5000 years) this week. And in New Zealand, clearly another country whose citizens are incapable of logical deduction, the New Zealand Medical Journal reports that 65% of patients who participated in a survey at a GP surgery had used homeopathy and 92% believed it had helped them! What is is the antipodal world coming to? Clearly participants in this survey must have been suffering from the sequalae of nasty rugby related head injuries. They need psychiatric medication (ECT if necessary) to rescue them from their fugue and make them realise that they have not nay could not have been helped by homeopathy.

In an article criticising degree courses in CAM, published on Ft.com,  Colquhoun features prominently along with fellow professorial pie recipient, Edzard Ernst.

Here are some choice quotes (taken from that article) from the honourable professor:

On Homeopathy: “One thing every scientist would agree on is that homeopathy is garbage, and it’s therefore very offensive to us that people are offered BSc degrees in it.” (Every scientist? I don’t think so Prof. Try reading the well-known professor of physics, Fritjof Capra’s The Turning Point just for starters.)

On Homeopaths: “it is ethically objectionable for doctors to lie to their patients about the efficacy of treatments” (When Edzard Ernst made a similar allegation I challenged him to a duel. Homeopaths may be deluded in your opinion Prof. but they believe in the efficacy of their treatments and therefore your oft repeated slur is untrue, vulgar and  grossly insulting.

On Prince Charles: “He’s an absolute bloody menace on this.” (In the brave days of old people – even doctors – would have been beheaded at the Tower of London for a lot less than this!)

The article then makes the usual mistake of criticising homeopathy as being non-evidence based and implying that conventional medicine is largely based on reliable evidence. This is simply not true as George Lewith is quoted as saying in the article, as the majority of commonly used and prescribed medicines are far from evidence-based – as has been clearly stated by the BMJ’s Clinical Evidence.

So sorry Prof. Colquhoun, but the time has come for you personally to be visited by The Pieman. And don’t try to dodge his pie by saying that ‘most treatments’ prescribed by doctors are evidence based (as I heard you say at the UCL debate). This pie baked by the BMJ clearly states that it classifies ‘commonly used’ treatments. The opportunity has arrived for you to examine the pie and accompanying notes in the BMJ’s Clinical Evidence at close quarters. Bon appetit!

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In my last post, I warned that anybody using ‘lack of evidence’ as a club with which to bash homeopathy or other well-established complementary medical approaches exclusively – will be visited by the Pie Man.

The Pie Man exists purely to bring closer to the attention of these critics that a mere 13% of commonly used conventional interventions are backed by solid evidence. His job is simply to deliver a pie produced by the British Journal of Medicine’s handbook, Clinical Evidence – as orthodox a medical publication as you can hope to find on the planet.

It is perhaps no coincidence that the first (free) delivery of the pie goes to Professor Edzard Ernst (Chair of complementary medicine, University of Exeter) who was extensively quoted in both the BBC’s health column Scrubbing Up and the widely read GP journal Pulse.

In Scrubbing Up he attacks ‘Integrated Medicine’ (the use by doctors of alternative approaches alongside orthodox medicine) and uses lack of evidence to attack and ridicule this combined approach which attempts to make available to patients the ‘best of both worlds’ in medicine.

Who decides what therapy is “appropriate”? The doctor? The patient? The healer? And on what basis?

Medicine does not work like this; treatments cannot be based on opinions about appropriateness, they are based on evidence of effectiveness and safety.

And again in the article in Pulse he is quoted (among other attacks on complementary approaches) as saying:

Why not use only the many CAM treatments that are backed by good evidence?

….I submit that using unproven or disproven treatments in routine general practice is unethical (GMC ethics code) and is likely to lower the standard of care.

But why does he not simply say: ‘Why not use only those treatments that are backed by good evidence’? It appears that he feels that it his duty as a Professor of Complementary Medicine to use lack of evidence exclusively to attack complementary and alternative medicine (CAM) and not his duty as a doctor to demand its implementation in conventional medicine! Worse than this, much of what he writes leaves the impression with the reader that all or at least most of commonly used orthodox medical interventions are indeed based on good evidence. Unfortunately for him this is simply not true and there is definitely evidence to quite the contrary. Professor Ernst has professed his love of evidence in medicine so it’s obviously vital that he acquires knowledge of such important scientific evidence. He is obviously unaware of vital evidence about the effectiveness and safety of conventional medicine. This information is succinctly represented in the pie and thus the Pie Man is instructed to bring the pie closer to Prof. Ernst’s attention.

The Pie Man is proud to announce that his first free delivery is to Professor Edzard Ernst.

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Welcome to my new column The Pie Man Strikes Again!

Now what has a Pie Man got to do with medicine? What has a Pie Man got to do with the holy grail of evidence-based medicine?

Allow me to explain…

There are some doctors around today so eminent that I’ve dubbed them Physicians of the Utmost Fame (apologies to Hilaire Belloc) who have seen fit contemptuously to trash various forms of alternative and complementary medicine using the term ‘evidence-based medicine’ as a blunt instrument with which to club any alternative health intervention they consider not to be backed by reliable evidence.

So what’s wrong with that?

It’s not wrong at all except for one little flaw. By selectively bashing homeopathy and alternative medicine with a club called ‘lack of evidence’ they leave the public with the impression that all or at least most orthodox medical interventions are ‘evidence-based’. But nothing could be further from the truth. In fact only 13% (sic – ‘thirteen per cent’) of orthodox medical interventions are backed by solid evidence that they are of definite benefit. Another 23% are ‘likely to be beneficial’.  And ‘likely to be beneficial’ is what most health practitioners think of their work but for those whom I’ve dubbed The Disciples of Scientism, that is simply not good enough ‘evidence’! And as for the remaining 64% of commonly used treatments (the BMJ’s words not mine) it seems to me that you hope and pray for good effects rather than side-effects!

And from where do I get these figures? Nay, not from the British Journal of Quackery nor from the American Journal of Snake Oil and other Panaceas. No, these figures have been lifted from a pie chart published by the highly regarded Handbook of Clinical Evidence (page 2) published by the totally orthodox and highly regarded British Medical Journal.

I’ve drawn attention to this pie before but the critics of homeopathy have not taken sufficient notice and continued in their jeering and condescending criticism of homeopath and other complementary therapies. So in the name of truth, honesty and justice in medicine as well as the health benefits of laughter, I’ve employed a Pie Man to bring this pie a little closer to the faces that continue selectively to attack homeopathy and other complementary interventions for not being ‘evidence based’.

I think it would be unfair to throw this pie at anyone without due warning so the Pie Man will choose to ignore previous indiscretions and hypocritical attacks using ‘evidence-based medicine’ as weapon. But from now it’s no holds barred and no pies spared.

Watch this space to see who is first to be served by the Pie Man.

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