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Old 12th September 2008, 01:00 AM   #1
wilks
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Brian Kaplan on Homeopathy and evidence based medicine

I have been wearily arguing with a couple of homeopaths on another forum for a couple of weeks now but today one has posted this link to a blog by Brian Kaplan
http://drkaplanarticles.blogspot.com/
in which Kaplan moans about the medical establishment attacking "homeopathy for not being evidence-based, the obvious implication is that orthodox, conventional medicine is indeed based on reliable evidence."

He has found this from the BMJ
http://www.clinicalevidence.com/cewe.../knowledge.jsp
a pie chart showing the current knowledge about treatments that work.

He obviously thinks this trumps all arguments (as will the homeopaths I am talking to) because "only 15% of orthodox interventions are definitely evidence based."

I think he is being ridiculous because 44% of treatments are beneficail, likely to be beneficial or a trade of between benefits and harms (which sounds pretty good to me), whereas homeopathy has little proof of benefit at all. Plus, at least medicine is looking at its faults and addressing them.

But I would be really interested to know what people cleverer than me make of this - and grateful for any points to further my side of the argument. Thoughts anyone?
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Old 12th September 2008, 02:32 AM   #2
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Is that link genuine? If I try to access any article from the BMJ homepage then I have to register and pay, but this link is entirely free and I can't access this link from the BMJ homepage either.
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Old 12th September 2008, 02:49 AM   #3
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Older BMJ articles are free aren't they?
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Old 12th September 2008, 03:31 AM   #4
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I did find it again by googling "BMJ clinical evidence" and the going to 'about us' and then 'how much do we know' - but I'm not sure how to get to it from the main BMJ page.
All that seems to be free to view but if you want to go further and look at conditions, for example, then you have to register and pay.
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Old 12th September 2008, 03:49 AM   #5
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It appears that it is a real BMJ publication. It also seems that BMJ is free after a year, and some recent articles are free; I don't know what criteria are used.

I pay little attention to claims concerning how much of medicine is evidence-based because they make no difference to questions about quackery. The cited page is of doubtful use because there is no explanation concerning how the data were collected and judged.

There is medical knowledge that is so deeply rooted in anatomy and physiology that testing it against an untreated control seems unethical. I recall that a pathologist at Harvard (120 years ago) autopsied people who had presented with a certain set of symptoms and found they all had burst appendices. He recommended appendectomy for people with those symptoms. The results were dramatic and the procedure became routine despite the fact that the level of evidence for it was low-level. One wonders where appendectomy fits on the pie chart.
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Old 12th September 2008, 04:44 AM   #6
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Originally Posted by wilks View Post
I have been wearily arguing with a couple of homeopaths on another forum for a couple of weeks now but today one has posted this link to a blog by Brian Kaplan
http://drkaplanarticles.blogspot.com/
in which Kaplan moans about the medical establishment attacking "homeopathy for not being evidence-based, the obvious implication is that orthodox, conventional medicine is indeed based on reliable evidence."

He has found this from the BMJ
http://www.clinicalevidence.com/cewe.../knowledge.jsp
a pie chart showing the current knowledge about treatments that work.

He obviously thinks this trumps all arguments (as will the homeopaths I am talking to) because "only 15% of orthodox interventions are definitely evidence based."

I think he is being ridiculous because 44% of treatments are beneficail, likely to be beneficial or a trade of between benefits and harms (which sounds pretty good to me), whereas homeopathy has little proof of benefit at all. Plus, at least medicine is looking at its faults and addressing them.

But I would be really interested to know what people cleverer than me make of this - and grateful for any points to further my side of the argument. Thoughts anyone?
NOTE: The figures in the pie chart change as information is added to the BMJ database, in case you were wondering why the numbers quoted by Dr. Kaplan are different from the numbers in the article.

BMJ Clinical Evidence is a collection of reviews by experts on specific topics, and it includes a GRADE for each treatment. The pie chart summarizes the grades for all the treatments evaluated in the database and is based on randomized controlled trials of good or high quality (or systematic reviews of RCT's). When they say that 46% are of unknown effectiveness, what they are saying is that there haven't been good quality randomized controlled trials addressing the effectiveness of that treatment in a specific condition. That doesn't mean that there is no evidence for the effectiveness of a treatment. It just means that the evidence is less than the highest grade - fair quality RCT's, observational studies, uncontrolled trials, animal experiments, etc.

Whether or not good information exists for a particular treatment depends upon its relative importance as a clinical question. Resources are allocated toward asking those questions that are frequently asked and are of clinical importance. So the treatments for which we have less than ideal information are also more likely to be conditions that are uncommon or relatively trivial. Treatments for heart disease, cancer, diabetes and stroke are heavily researched; treatments for vitiligo, not so much. It may be that 10% of the treatments in the list represent 85% of the practice of medicine. And good quality evidence may exist for most of that 10%.

Also, the point of evidence-based medicine is for the available evidence to lead practice. The presence of a treatment listing in that database does not mean that that treatment is in common use. In particular, treatments for which evidence is sparse or which the evidence shows to be harmful, are also less likely to be used or have been discarded.

Linda
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Old 12th September 2008, 05:37 AM   #7
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Where's that article about the double-blind, randomised controlled trial of whather or not a parachute is beneficial if you jump out of an aeroplane, again?

Rolfe.
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Old 12th September 2008, 05:56 AM   #8
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Originally Posted by Rolfe View Post
Where's that article about the double-blind, randomised controlled trial of whather or not a parachute is beneficial if you jump out of an aeroplane, again?

Rolfe.
It started well, but then group B were terrible at returning their post-jump paperwork.
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Old 12th September 2008, 06:14 AM   #9
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Thanks Linda, that's very helpful

I would presume that treatments that are a trade off between benefits and harms would include those such as chemotherapy for cancer and insulin for diabetes?
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Old 12th September 2008, 06:30 AM   #10
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Some references (from here):

http://www.ncbi.nlm.nih.gov/sites/en...t_uids=7623571

http://www.ncbi.nlm.nih.gov/pubmed/9639610

http://archderm.ama-assn.org/cgi/content/full/137/6/771

Rolfe and JJM have a good point, in that the BMJ database won't bother including the bleedin' obvious.

Linda
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Old 12th September 2008, 06:35 AM   #11
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Originally Posted by wilks View Post
Thanks Linda, that's very helpful

I would presume that treatments that are a trade off between benefits and harms would include those such as chemotherapy for cancer and insulin for diabetes?
They're more likely to be about the use of antacids for chronic dyspepsia, aspirin in fibromyalgia, or various anti-itch creams in xeroderma (dry skin) - ambiguously effective symptomatic treatments for non-life threatening conditions.

Linda
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Old 12th September 2008, 06:35 AM   #12
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I just checked out a couple of the free ones, to give you a taste as to what sort of treatments might be in each group:

Acute otitis media:

Quote:
Likely to be beneficial:
Non-steroidal anti-inflammatory drugs

Trade off between benefits and harms:
Antibiotics

Unknown effectiveness:
Paracetamol
Atopic Eczema:

Quote:
Beneficial:
Topical steroids

Likely to be beneficial:
Control of house dust mite

Unknown effectiveness:
Dietary manipulation
Prolonged breast feeding in predisposed infants
Dietary restriction during lactation in mothers of predisposed infants

Unlikely to be beneficial:
Combinations of topical antimicrobials and steroids

Last edited by Professor Yaffle; 12th September 2008 at 06:37 AM.
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Old 12th September 2008, 07:42 AM   #13
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Originally Posted by wilks View Post
IHe obviously thinks this trumps all arguments (as will the homeopaths I am talking to) because "only 15% of orthodox interventions are definitely evidence based."
OK, let's ignore Linda's posts for a second and assume that everything he says is entirely correct and interpreted correctly. That leaves us with 15% of orthodox interventions that are definitely evidence based compared to 0% of homeopathic interventions that are evidence based.

I'm confused as to why he thinks this is a point in homeopathy's favour.
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Old 14th September 2008, 04:39 AM   #14
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A link to the BMJ article was posted on the comments to Ben Goldacre's piece about the Rath libel case. There's a brilliant response.
Originally Posted by apgaylard
Not knowing everything is no excuse for ignoring what we do know.

By the way, that was one hell of a long week.
Originally Posted by Dr Kaplan on 10th August
My next blog will be a final word on this. There is a limit to how much time I am prepared to read, think and talk about those who wish to control and coerce people whom they think are unable to think for themselves. In that blog, which will appear within a week, I will expose the incredible hypocrisy of the attacks on homeopathy using a simple pie diagram. After that, this voice will address other important medical issues of the day. However the challenge of a duel still stand, Prof. Ernst...
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Old 14th September 2008, 08:30 AM   #15
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Originally Posted by Cuddles View Post
OK, let's ignore Linda's posts for a second and assume that everything he says is entirely correct and interpreted correctly. That leaves us with 15% of orthodox interventions that are definitely evidence based compared to 0% of homeopathic interventions that are evidence based.

I'm confused as to why he thinks this is a point in homeopathy's favour.

From my personal experience with the alternative crew I'd say because of the unknown, harmful and dangerous effects and side-effects of the "school medicine".

On a related note, one prominent cam practitioner in a recent Finnish radio program stated that:

Quote:
British Medical Journal published in their march 2007 number information about how well school medicine has been studied:

No idea of the efficacy in 46% of the treatments that school medicine uses.

Most likely no effect OR harmful effects in 4%.

So in conclusion 50% of the treatments that school medicine uses have either no idea of the efficacy, most likely have no effects or are even harmful. So this is where the problem lies. The society pays for all the treatments of school medicine, so in effect half of the budget we use for the treatments in school medicine is wasted. THIS is the REAL PROBLEM, if we could spare even a little amount of this and direct it for example in the research of CAM treatments the situation would be totally different, we need to see the forest from the trees.

..and in a few minutes another one joins the club and says:

Quote:
..so how much is there science in the school medicine, according to this study only 50%. A professor in our University in Helsinki once said that half of the school medicine renews in 5 years and no one knows which half! There is an awful lot of Nobel prizes still to give.

..and the other one continues:

Quote:
..according to a study published in a Finnish magazine, a knowledgeable patient is a thread to the doctor.

Etc. etc.

No wonder people are confused
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Old 14th September 2008, 11:45 AM   #16
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And there I was, thinking that "school medicine" was a term peculiar to Homeoproofer...
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Old 14th September 2008, 12:14 PM   #17
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Originally Posted by Mojo View Post
And there I was, thinking that "school medicine" was a term peculiar to Homeoproofer...

If only that was true, every single even slightly new age, yoga, cam, hare krishna, etc. person in Finland I know (and that's a lot) uses the term
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Old 14th September 2008, 01:49 PM   #18
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Originally Posted by Mojo View Post
And there I was, thinking that "school medicine" was a term peculiar to Homeoproofer...
So it means medicine that has to learnt as opposed to any old tosh that can be made up. Glad they can see the difference.
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Old 14th September 2008, 02:05 PM   #19
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Golly!
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Old 15th September 2008, 02:15 AM   #20
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[quote=Professor Yaffle;4030099]I just checked out a couple of the free ones, to give you a taste as to what sort of treatments might be in each group:

Thanks Professor Yaffle - and to the other posters for their comments too.
I'm beginning to get an idea now of how this is put together and what the categories mean

I can't say that my homeopaths understand though - I can't get past their basic assumption that most of medicine is out to make people ill. I've been arguing the point for days and I'm going around in circles now.

I'm frustrated as these are basically nice people who really believe in what they are doing but for some strange reason have been completey turned against medicine. I can't help but feel that it is an incredible shame that they put all their energy and 'wanting to help people' into something as useless as homeopathy.
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Old 15th September 2008, 03:02 AM   #21
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Originally Posted by wilks View Post
I'm frustrated as these are basically nice people who really believe in what they are doing but for some strange reason have been completey turned against medicine. I can't help but feel that it is an incredible shame that they put all their energy and 'wanting to help people' into something as useless as homeopathy.

I'm pretty much in the same position..

The best I can do is to learn even more about these things, and, when the opportunity comes, make my case as clearly as possible whenever discussing the issues. I remain optimistic.
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Old 1st October 2008, 12:13 PM   #22
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Hi everyone. It's high time I posted - I've been registered here long enough. I arrived at this thread courtesy of Dr Kaplan's post of today's date, which links to it. (I see I can't post the link but it's the same as the one in the OP).

Quote:
I really had a few good laughs while browsing at one of the internet homes of the disciples of scientism as they squirmed to defend the fact that orthodox medicine can hardly claim to be evidence based – as is clearly illustrated in the pie baked by the BMJ’s handbook of clinical evidence.
Unsurprisingly, he ignores Linda's very helpful first post in this thread and focuses entirely on the 59% he is conceding as "more or less evidence-based" or, rather, on the remaining 41% that isn't.

Quote:
So what you are admitting is that almost half of what is considered as scientific medicine is actually equivalent to garbage. Rather than attack homeopathy first (and there are legitimate areas of weakness but we have never made any claim that homeopathy is such a broad spectrum panacea as the worshippers at the orthodox medical temple insist we have), why don't you focus on the at least 41% of ‘scientific medicine’ that clearly does no good at all – but is not even politely accused of ‘not being based on evidence’?

Once that is cleared up, feel free to throw stones at the houses of homeopathic doctors and other people against whom you clearly are impressively biased.
Am I missing something here? How does any of this prove that homeopathy isn't a total crock and those that prescribe and use it aren't woefully deluded? This guy may have qualified as a proper doctor but his critical thinking skills don't seem any better than the half-educated wannabes we see all over the web who think that attacking "allopathy" is the best way to defend the indefensible, once they realise that their anecdotes about how it "works for them" don't stand up.
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Old 1st October 2008, 12:35 PM   #23
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Originally Posted by MollyMac View Post
Am I missing something here? How does any of this prove that homeopathy isn't a total crock and those that prescribe and use it aren't woefully deluded? This guy may have qualified as a proper doctor but his critical thinking skills don't seem any better than the half-educated wannabes we see all over the web who think that attacking "allopathy" is the best way to defend the indefensible, once they realise that their anecdotes about how it "works for them" don't stand up.

It doesn't. But it's all he's got.

Last I heard, 59% was slightly greater than 0%.
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Old 1st October 2008, 01:20 PM   #24
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I can see why he doesn't allow comments, but I'm surprised he actually linked to this thread so that others can read it. That he chose to ignore valid criticisms seems to indicate that he is aware they are justified. But doesn't he realize that others will read them?

He is still promoting the idea that 1) a treatment's listing means that it is in common use (an obviously false assumption), 2) that fair quality RCT's, observational studies, uncontrolled trials, animal experiments, etc. are considered "equivalent to garbage" (talk about shooting yourself in the foot) and 3) that the proportion of treatments listed in any way corresponds to the proportions that are used in practice (another obviously false assumption).

I agree with him that the priority of medical doctors should be to continue to work towards answering important clinical questions with good quality evidence. However, surely this includes rejecting the idea of wasting resources on a system of therapeutics which has more than sufficiently demonstrated that it has no instrinsic value?

Linda
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Old 1st October 2008, 01:54 PM   #25
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Originally Posted by MollyMac View Post
Unsurprisingly, he ignores Linda's very helpful first post in this thread and focuses entirely on the 59% he is conceding as "more or less evidence-based" or, rather, on the remaining 41% that isn't.
Thanks for saying that. Sometimes I wonder "is this thing on?"

Also, note that he misunderstood what Wilks said and that 41% doesn't correspond to any real grouping of the information (I wouldn't bother to repeat it).

Linda
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Old 2nd October 2008, 12:13 AM   #26
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Originally Posted by MollyMac View Post
I arrived at this thread courtesy of Dr Kaplan's post of today's date, which links to it.
Thanks for posting that MollyMac.
I have never before written anything that has become the subject of a blog post - I must have irritated him (glows with pride)
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