UCLAN CAM Review - Full Report

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UPDATE: July 15. The report of the UCLAN working party review of complementary medicine, as approved by the Academic Board last Thursday, has now been published. For the moment it is only on the staff intranet but I assume it will be public soon. UCLAN staff can find it at https://staff.uclan.ac.uk/9930.htm

UPDATE: July 17. David Colquhoun has now posted the full report and his own analysis of its conclusions.

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Here is my section-by-section commentary on the report of the UCLAN working party review of complementary medicine.

Section 1: Introduction

The review is framed as a response to "concerns expressed by some colleagues within the University" but it never explains what those concerns were/are. I would have liked to have seen responses to my seven specific complaints, which I set out here exactly as they were submitted to the review team.

1. Homeopathy is nonsense. There is no reason to think it could work. There is no good evidence that it works better than placebo for any condition. There is plenty of evidence that it does not work. To teach otherwise is to lie to our students, and to train them to lie to their patients.

2. Homeopathy is not science. It is not even non-science, it is anti-science because its laws contradict the dose-response relationship and ignore the Avogadro limit. It invokes a mystical energy known as the “life force” which cannot be detected scientifically. Its advocates disparage the scientific method and ignore or distort the results of scientific analysis.

3. Homeopaths have been caught out many times giving dangerous advice, promoting worthless remedies, claiming to be able to prevent serious diseases, disparaging scientific medicine and so putting patients at risk of serious harm or even death. Are UCLAN homeopaths guilty of this? If they are not, why are they so secretive about what they teach?

4. The Society of Homeopaths is not a fit body to participate in degree validations. UCLAN should have no dealings at all with a body which fails to enforce its code of conduct when members give dangerous advice, and which resorts to legal threats when criticised for this.

5. Chinese herbal medicines are complex mixtures of substances, few of which have been tested for safety or efficacy, and which may carry significant risks of harm. It is unethical for anyone at UCLAN to be involved in giving Chinese herbal preparations to patients until they have been properly assessed for safety and effectiveness.

6. Acupuncture may have some effects but they are certainly small (at best) and have nothing to do with Qi, meridians, yin & yang or non-existent “organs”. Such notions are unscientific and should not be taught as science. The same applies to many other nonsensical forms of CAM which UCLAN and associated colleges promote, including Bach flower remedies, cupping, moxibustion, auriculotherapy, therapeutic touch and astrological medicine.

7. Proper scientific testing of CAM is certainly possible if researchers are properly trained in the scientific method, but UCLAN’s CAM courses appear to contain virtually nothing about research design or statistics. Where there is genuine science content, it is often directly contradicted by the CAM content. This is unacceptable.

Nevertheless, I am delighted that UCLAN did take my complaints seriously, and I welcome this report. As you will see below, some of my points have been addressed, but some are still outstanding.

Section 2: Context

This short section mentions the "wider debate and controversies" around CAM, but again does not mention any specific examples. I would have like them to acknowledge the sterling efforts of David Colquhoun, for example, to force the disclosure of teaching materials, and the resulting embarassment when it was revealed that Westminter's CAM students are being told things like "Amethysts emit high yin energy" (UPDATE: July 17. DC has now posted a copy of the evidence he submitted to the review committee). Instead, the debate is described in rather dry fashion as relating to four themes: evidence/efficacy of CAM, suitability of CAMs as topics for university courses, the nomenclature of CAM degrees (specifically whether they should be called science), and the ethical/economic impact of CAM upon society as a whole.

Section 3: Method

The report explains that the review included a literature review (a list of papers is included later on, showing that some poor sod actually read much of Lionel Milgrom's epic series of inane quantum metaphor papers, which feat surely deserves a medal), some commisioned reports (which I would very much like to know more about), the preparation of a paper on the ethics of CAM by one of the reviewers (which I will also try to obtain), face-to-face meetings with interested parties (me included) and written evidence from a variety of individuals and groups.

Section 4: Consideration of Themes

Now we get to the meaty stuff! Each of the themes identified in section 2 is taken up in turn.

Section 4.1: Efficacy

Disappointingly, the reviewers decided that efficacy was outside their remit, due to the "volume and diversity of views". I think this was a mistake, since it undermines all their later comments about the importance of patient autonomy, which is only possible when patients are given adequate information on which to base their decisions.

Section 4.2: The Role of Universities in Society

I found this section unbearably waffly. There are lots of worthy statements about the importance of "critical thinking" but with no specific examples of what this means in practice it is impossible to say whether CAM students really develop these skills. There are lots of vague claims about the importance of "diversity" and of students being exposed to challenging ideas and debates, but, having ducked the efficacy question, there is no acknowledgement that some ideas have been completely discredited. Would the team argue that astronomy students must be taught astrology? Biologists, creationism? Would they really benefit from such "diversity"?

Somehow, this conclusion leads to the first recommendation in the report: that UCLAN should provide some postgraduate research scholarships to "suitably qualified" staff and students, with multidisciplinary supervisory teams, to "facilitate development of a broad range of research skills" and "contribute to the generation of knowledge in CAM". Fair enough, I suppose, although it would seem very unfair if scarce resources were diverted into CAM at the expense of other disciplines. There are certainly some CAMs where more research would be useful (if it is of high enough quality) and I would be happy to help develop these projects. I would draw the line at homeopathy, however, which has already been studied in quite enough detail to know that it is useless. Ho hum.

Section 4.3: Nomenclature.

Not much to argue with here! I do accept that defining "science" can be tricky, and that disciplines differ widely in exactly how "Sc" a BSc or MSc should be. My big problem with CAM degrees is that they are often antiscience, not just non-science, so I am very pleased with the recommendations here: that CAM degrees should be simply named "Bachelor with Honours in X" and called B (Hons) rather than BSc (Hons); and that there should be increased multidisciplinary input to CAM teaching so as to "facilitate greater exposure to subject expertise and different paradigms".

Section 4.4: Ethics

This is another somewhat waffly section, which takes two pages to explain that if you ignore the question of efficacy, there is no ethical reason not to teach CAM. However, the reviewers do note the need for patients to be protected from "lack of professional regulation, poor product quality assurance and inadequately trained practitioners". They therefore recommend that UCLAN should refrain from offering any CAM courses "until such disciplines have achieved statutory regulation status".

There are different ways of looking at this. One could say it is just passing the buck. It could also been seen as circular, since one major aspect of regulation is training of practitioners. Alternatively, one could look at the current level of disarray among CAMs regarding regulation: the dismal failure of the CNHC to attract members in any number (only a few massage therapists have joined so far) and the current implosion of the General Chiropractic Council following the ill-advised attack on Simon Singh, and conclude that most CAMs will never get their act together to meet the necessary standards.

Could this be the end of CAM courses at UCLAN? Watch this space...

Placebo Needles for Acupuncture Research

The biggest problem with acupuncture research is that it is very difficult to create a convincing placebo treatment for the control group to undergo. If participants can tell whether they have received acupuncture or not, the results of the trial are pretty much worthless as evidence. Similarly, it is important that the practitioner too should be unable to tell whether they have given real acupuncture or not. Many different sham treatments have been tried, but none had been particularly convincing until, in recent years, some dummy needles have been developed that do allow double-blinding (Park et al, 2002, White et al 2003).

I wanted to see these needles for myself, so I contacted Dong Bang Acuprime, who kindly sent me a few samples of their Park Sham Device to try out. They have helped develop and test these fake needles in order to improve the evidence base for acupuncture, and I really admire them for doing so. Few CAM enthusiasts are willing to put their beliefs to the test like this.

So here I am with my colleague Nikola Bridges, who is about to insert two needles into the plastic sleeves you can see attached to my hands with sticky pads. One needle is real, one sham, but at this point neither of us know which is which. When Nikola presses down on the needles, the real one will penetrate my skin, while the sham one will slide inside its handle, giving the appearance of penetration without actually going in. If the placebo is truly convincing, neither of us will be able to tell which is which until I turn my hands over, at which point the fake will fall out onto the table.

To see what happened next, watch this video before scrolling down to read on...

All in all, I was a little disappointed. The fake needle telescoped very easily while the real one took a lot of tapping to get down to the same extent, so it was fairly clear to Nikola which one was real. I couldn't feel much difference at first, after the initial insertion, but it was pretty obvious which one was real once it started to go in properly. The real needle also left a tiny but noticeable mark on my skin, and was obviously longer than the fake one when we took them out again. There is also still (a few hours later) a hint of pain in my left hand. Sadly, I have to conclude that the placebo was not 100% convincing.

Let's not be too negative, however. There were many flaws with my little experiment. In a real study, you would not have the same person experiencing both types of needle at the same time, so the contrast between needles would not be so apparent. If the acupoints were out of sight, such as on the patient's back, it would be harder (for the patient, at least) to tell what was going on. I am not sure if it is important that Nikola is NOT an acupuncturist and had not had any chance to practice the insertions (she is a neuroscientist and has plenty of experience with needles, just not this kind) but I think it would probably be even more obvious to an experienced needler which one was which. We were both a bit nervous, though! Maybe two single confident thrusts might have been harder to discriminate?

My conclusion is that it is very hard to maintain double-blindness in acupuncture studies, even with the best sham needles. I think it may be possible to do a good double-blind study with these, but both patient and practitioner would have to be very self-disciplined, to resist the temptation to break the blinding. Sadly, my experience suggests that it would be very easy to succumb.

References

Park, J., White, A., Stevinson, C., Ernst, E. & James, M. (2002). Validating a new non-penetrating sham acupuncture device: two randomised controlled trials. Acupuncture In Medicine, 20, 168-174.

White, P., Lewith, G., Hopwood, V. & Prescott, P. (2003). The placebo needle, is it a valid and convincing placebo for use in acupuncture trials? A randomised, single-blind, cross-over pilot trial. Pain, 106, 401–409.