Cross Talk on the evidence base for quackery

In the last of his columns for 2007, Mike Cross reflects on the latest spat over alternative medicine and asks whether collecting information about patient perceptions of their treatment will undermine or bolster quackery. 



Newspaper editors know there are two sure-fire ways to stimulate readers' letters. One is to publish a call for the massacre of some furry, four-legged beast. The other is to subject alternative medicine to critical scrutiny.

The trouble with alternative medicine, as the stream of emails and blog comments generated by a recent round of newspaper comment reminds us, is that it sometimes works. A lot of people emerge from, say, homeopathic regimes feeling better than they went in (though their wallet may have lost weight along the way).

Objectively speaking, of course, the outcome is indistinguishable from the placebo effect, but that doesn't matter from the patient's point of view.

“I'd like to think that as e-health techniques arm clinicians with better information, and patients get more used to terms like "evidence base" and "risk", quackery will wither away.”

Given this occasional utility, and so long as the quacks aren't doing direct harm, the sensible response seems to be live and let live. It makes for a quieter life. And, as correspondents invariably point out, it's not as if scientific medicine has the cure for everything.

Show me the evidence

In the new age of 360-degree healthcare information being created by electronic health records, I wonder if this co-existence can survive. Personally, I'd like to think that as e-health techniques arm clinicians with better information, and patients get more used to terms like "evidence base" and "risk", quackery will wither away.

But information is always a double-edged sword, and not all the data that is going to be available through cradle-to-grave electronic records will deserve to be treated with equal weight.

Take, for example, the Department of Health's welcome and overdue plan to start logging patients' own perceptions of their health, before and after episodes of care. It's potentially a massively important addition to our evidence base. However the same methodological toolkit could be used to create an evidence base for quackery.

How will the electronic health record distinguish the two? Does it matter? And what about other subjective inputs about the effects of self medication, legal or otherwise?

Keeping a sense of balance

There are no simple answers, of course, and I know that thoughtful exponents of electronic health records have been saying so for years. The lesson from previous information revolutions, from Gutenberg to Berners-Lee, is that it is rash to be too precise in forecasting where such revolutions will lead.

Clearly it is the duty of all concerned to imbue personal evidence with something we journalists deal with all the time: a sense of balance. “The apparent boom in the alternative medicine business seems to suggest a trend in the opposite direction.”

One thought springs to mind, however. Much of our thinking about healthcare IT is predicated on the assumption that electronic records underpin a more equal relationship between doctor and patient, and that patients want that relationship.

Some of the most exciting uses of electronic records I have seen in the NHS have certainly been along these lines. For example, the patient-access pioneer

Dr Amir Hannan (a healthcare IT hero of mine) has described using the trust created by electronic records to persuade a reluctant patient to seek proper treatment for a cancer, rather than running off to a quack, or pursuing no course of action at all.

This is life-saving stuff. Not every GP is a Hannan, however, and not every patient is willing to be talked around. In fact, the apparent boom in the alternative medicine business seems to suggest a trend in the opposite direction.

As the excellent Dr Ben Goldacre, scourge of bad science, points out, the basic premise of alternative medicine is actually a throwback to Victorian paternalism. Patients place themselves in the hands of practitioners who must conceal the fact that their pills work no better than a placebo - trampling all over modern concepts such as informed consent.

Personally, I'd like to think that holistic, cradle-to-grave, shared electronic health records will make such paternalism even more obsolete than it is already. However, I suspect the outcome will be more complicated - and more interesting - than that.

To everyone considering such issues, a very happy new year.

About the author: Michael Cross is a freelance journalist specialising in healthcare informatics and e-government. He is a member of the British Computer Society.