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