David Reilly

Randomised controlled trial of homoeopathy versus placebo in perennial allergic rhinitis with overview of four trial series.

Abstract Objective: To test the hypothesis that homoeopathy is a placebo by examining its effect in patients with allergic rhinitis and so contest the evidence from three previous trials in this series. Design: Randomised, double blind, placebo controlled, parallel group, multicentre study. Setting: Four general practices and a hospital ear, nose, and throat outpatient department. Participants: 51 patients with perennial allergic rhinitis. Intervention: Random assignment to an oral 30c homoeopathic preparation of principal inhalant allergen or to placebo. Main outcome measures: Changes from baseline in nasal inspiratory peak flow and symptom visual analogue scale score over third and fourth weeks after randomisation. Results: Fifty patients completed the study. The homoeopathy group had a significant objective improvement in nasal airflow compared with the placebo group (mean difference 19.8 l/min, 95% confidence interval 10.4 to 29.1, P=0.0001). Both groups reported improvement in symptoms, with patients taking homoeopathy reporting more improvement in all but one of the centres, which had more patients with aggravations. On average no significant difference between the groups was seen on visual analogue scale scores. Initial aggravations of rhinitis symptoms were more common with homoeopathy than placebo (7 (30%) v 2 (7%), P=0.04). Addition of these results to those of three previous trials (n=253) showed a mean symptom reduction on visual analogue scores of 28% (10.9 mm) for homoeopathy compared with 3% (1.1 mm) for placebo (95% confidence interval 4.2 to 15.4, P=0.0007). Conclusion: The objective results reinforce earlier evidence that homoeopathic dilutions differ from placebo.

Primary Care Physicians and Complementary-Alternative Medicine: Training, Attitudes, and Practice Patterns

Background: Physician interest in complementary medicine is widely documented in many Western countries. The extent of level of training, attitudes toward legitimacy, and use of complementary therapies by US primary care physicians has not been extensively surveyed. We conducted a national mail survey of primary care physicians to explore these issues. Methods: Primary care specialties represented were family and general practice, internal medicine, and pediatrics. A total of 783 physicians responded to the survey. For the multivariate analysis, sample weights were assigned based on specialty. Assessments were done for training, attitudes, and usage for complementary medicine. Additional data collected included years in practice, specialty, and type of medical degree. Results: Biofeedback and relaxation, counseling and psychotherapy, behavioral medicine, and diet and exercise were the therapies in which physicians most frequently indicated training, regarded as legitimate medical practice, and have used or would use in practice. Traditional Oriental medicine, Native American medicine, and electromagnetic applications were least accepted and used by physicians. Conclusions: Many psychobehavioral and lifestyle therapies appear to have become accepted as part of mainstream medicine, with physicians in this study having training in and using them. Such therapies as chiropractic and acupuncture appear to be gaining in acceptance despite low training levels among physicians. Those in practice more than 22 years had the least positive attitudes toward and use of complementary therapies. Osteopathic physicians were more open than medical physicians to therapies that required administering medication or a procedural technique. In the multivariate analysis, attitude and training were the best predictors of use.

Outcome related to impact on daily living: preliminary validation of the ORIDL instrument

BackgroundThe challenge of finding practical, patient-rated outcome measures is a key issue in the evaluation of health care systems and interventions. The ORIDL (Outcome in Relation to Impact on Daily Living) instrument (formerly referred to as the Glasgow Homoeopathic Hospital Outcomes Scale or GHHOS) has been developed to measure patients views of the outcome of their care by asking about change, and relating this to impact on daily life. The aim of the present paper is to describe the background and potential uses of the ORIDL, and to report on its preliminary validation in a series of three studies in secondary and primary care.MethodsIn the first study, 105 patients attending the Glasgow Homoeopathic Hospital (GHH) were followed-up at 12 months and changes in health status were measured by the EuroQol (EQOL) and the ORIDL. In the second study, 187 new patients at the GHH were followed-up at 3, 12, and 33 months, using the ORIDL, the Short Form 12 (SF-12), and the Measure Yourself Medical Outcome Profile (MYMOP). In study three, 323 patients in primary care were followed for 1 month post-consultation using the ORIDL and MYMOP. In all 3 studies the Patient Enablement Instrument (PEI) was also used as an outcome measure.ResultsStudy 1 showed substantial improvements in main complaint and well-being over 12 months using the ORIDL, with two-thirds of patients reporting improvements in daily living. These improvements were not significantly correlated with changes in serial measures of the EQOL between baseline and 12 months, but were correlated with the EQOL transitions measure. Study 2 showed step-wise improvements in ORIDL scores between 3 and 33 months, which were only weakly associated with similar changes in SF-12 scores. However, MYMOP change scores correlated well with ORIDL scores at all time points. Study 3 showed similar high correlations between ORIDL scores and MYMOP scores. In all 3 studies, ORIDL scores were also significantly correlated with PEI-outcome scores.ConclusionThere is significant agreement between patient outcomes assessed by the ORIDL and the EQOL transition scale, the MYMOP, and the PEI-outcome instrument, suggesting that the ORIDL may be a valid and sensitive tool for measuring change in relation to impact on life.

The Puzzle of Homeopathy

Homeopathy is a branch of Western medicine that has mostly been rejected by Western orthodoxy for the last 200 years because of conceptual and scientific clashes. Homeopathy uses microdoses of potential toxins to provoke defense and self-regulatory responses, rather than the more orthodox approach of blocking body reactions. This approach hints at its clinical scope: it can help, at times resolve, conditions that are intrinsically reversible rather than mechanical problems, deficiencies, or irreversible breakdowns in body functions where it is only palliative. In recent years, there has been a renaissance of interest. Public demand has soared, and with it professional interest. Approximately 20% of Scotlands general practitioners have completed basic training. This is partly occasioned by public interest in complementary medicine and a sympathy with the more mind-body approach of homeopathy, and partly by recent scientific evidence. Some homeopathic dilutions are so extreme they are dismissed by critics as only placebo. Yet trials and meta-analyses of controlled trials are pointing toward real effects, mechanism of action unknown. Clinical outcome studies suggest useful clinical impact and excellent safety. There seems to be a potential to enhance patient care by integrating the two systems.

Length of consultations

Editor—Jenkins et al found that patients vary both in what they want from a consultation with their general practitioner and in what they get. They found a poor correlation between these and the length of the consultation. The catchy front cover headline “Consultations don’t have to be longer to be better” seriously overgeneralises these results. Some short consultations may be highly effective, but a systematic review earlier this year summarised a range of patient outcomes that are improved when doctors have more time. In one large English survey 12% of patients complained about having insufficient time with their general practitioner, but this figure rose to 30% when patients were seen for five minutes or less. It may be that the doctors need additional time in consultations—perhaps more than their patients. Medical practice has become more complex, and more needs to be done during the course of consultations. This may explain why clinical care is inferior in practices with short consultations. Patients may sometimes get what they want in short consultations—but they may not always realise that it isn’t good medical care. It is 16 years since David Morrell and I and colleagues published the first experimental study showing the limitations of short consultations. It is well past time to consign surgeries booked at intervals as short as five minutes to history. The current payment system for general practitioners encourages a “pack ’em in and sell ’em cheap” approach to general practice. This needs to be addressed in the contract currently being negotiated so that all general practitioners have time to offer their patients first class care.

The ''cash or care'' conflict in general practice - A cautionary tale with methodological reflections §

Considerable enthusiasm and good intentions in my luggage, I made myway back to Germany in 2005 after having worked at the Glasgow Center for Integrative Care (writes E.K.). It was time to set upmy own practice as a general practitioner (GP) in Germany. This is the cautionary tale of what happened, interwoven with reflections on what the outcome reveals about today’s practice of healthcare, and some methodological implications for Health Communication Research. In my preceding 9 years of clinical training, I realized that the panorama of diseases and medical challenge had dramatically shifted, but our response lagged behind. Today’s epidemics and everyday stories in general practice are long term conditions, degenerative problems like diabetes, heart disease, depression, anxiety, chronic pain, chronic fatigue, obesity. Embedded in social contexts and ways of living, these problems need approaches beyond the drug model. Good care needs people’s conditions to be seen in the context of their life, their inner narrative and their wider social system. Article history: Received 31 July 2010 Received in revised form 17 January 2011 Accepted 20 January 2011

No time to train the surgeons: golden age of surgical training didn't exist.

EDITOR—Four points strike me on reading the editorial by Chikwe et al and the responses on bmj.com.1 2 Firstly, there was no golden age of surgical training. We spent more time as “junior doctors.” Some staggeringly bad surgeons were appointed under the old system, as well as highly experienced and …