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RADIO SCIENCE UNIT
CASE NOTES
Programme 8 - 91Èȱ¬opathy
RADIO 4
TUESDAY 19/07/05 2100-2130
PRESENTER:
MARK PORTER
CONTRIBUTORS:
DAVID SPENCE
ELIZABETH THOMPSON
DAVID REILLY
JOANNA MAWER
CHARLOTTE ELLIS
PRODUCER:
PAULA MCGRATH
NOT CHECKED AS BROADCAST
PORTER
91Èȱ¬opathic medicine has been available in Bristol since 1852. The Bristol 91Èȱ¬opathic Hospital was commissioned in 1921, incorporated into the NHS at its inception in the '50s and continued catering for patients until just over 10 years ago when the old hospital was sold off and the department moved to this purpose built annexe next door where the doctors now see around 20 new patients a week. Referred in by GPs and hospital consultants with conditions ranging from chronic skin complaints, like eczema and psoriasis to breast cancer.
ACTUALITY
SPENCE
Hi Tim, I'm Dr Spence. Very nice to see you. So you've come from your GP - here we are, I've got the letter at the back. So tummy problems of one sort and another, so we'll come back to that in a minute. I don't know how much you know about homeopathic medicine.
TIM
I kind of know bits and bobs, I've got a little pamphlet at home basically about some of the different kind of types of stuff that I can get hold of.
SPENCE
Well I usually just say a word or two about it at the beginning, partly because it just will explain to you what we'll do during the consultation, because it's slightly different from me seeing you as an ordinary doctor ...
PORTER
Modern homeopathy is based on the work of Samuel Hahnemann who, as a young doctor in Germany, became increasingly disillusioned with orthodox medical practice at the end of the 18th Century. He developed the founding principle of homeopathy - that like cures like - something Hippocrates had first postulated some 2000 years earlier. Hahnemann tested a range of natural extracts to see what effect they had on the body - effects that would, in turn, decide what sort of ailments they could be used to treat. More than 200 years later his research still forms the basis of homeopathic practice today.
Consultant physician David Spence is the Clinical Director of the Bristol 91Èȱ¬opathic Hospital.
SPENCE
Probably the sort of easy examples are things like onion, for instance, which in sensitive people causes a streaming of eyes and nose. So we use medicine made from onion for patients who get hay fever, where they've got streaming of eyes and nose.
PORTER
So how do you know what to give for a specific set of symptoms, do you have a reference work that you turn to?
SPENCE
We have text books where all the drug signs and symptoms are recorded but we've then got to get the individual symptoms from each individual patient because what we're trying to do is stimulate their own system to heal themselves, to get their own healing mechanisms going.
PORTER
So is this on the belief that the symptoms that the body express are somehow related to the fact that they're trying to deal with the problem themselves - so your eyes stream because you've got hay fever and rather than cover it up, which we might do with conventional medicine using drugs, you actually want to enhance that effect slightly?
SPENCE
Yes, you're just trying to get the body's own healing mechanisms going and as you say many of the symptoms that we get when we're unwell are actually the body trying to deal with the problem for itself. And often with ordinary medicine - there's nothing the matter with ordinary medicine, let me say that very quickly, I'm an ordinary doctor - but we do tend to suppress things very often, whereas homoeopathically sometimes you're trying to enhance the body's healing efforts.
PORTER
Let's just pick another example of that. I mean looking at fever - my approach to fever, perhaps in a young child, might be to use something like paracetamol or ibuprofen or cooling to bring the fever down. How would your approach differ?
SPENCE
The approach would differ probably in that we might use something which would cause a fever, now one of the best known things that's often used for that is belladonna, which is made from deadly nightshade, which of course actually causes in toxic doses a situation with high fever and dilated pupils etc. And so you give a very small dose of that which seems to trigger the body defence mechanisms to get the healing mechanisms going more quickly.
PORTER
But homeopathic remedies aren't straightforward extracts are they, they're give in minute quantities.
SPENCE
I mean how that came about initially was that Hahnemann, this German doctor, found that he was making people very ill because he was giving pretty much ordinary doses and of course making people very ill in the first place. So he experimented with using smaller and smaller doses and preparing them in a particular way and found that he could retain what we call bioactivity even with very small doses and get rid of this phase of making things worse in the first instance.
PORTER
It's interesting you use the word drug, most people talk about a remedy, is that because you're a conventionally trained doctor, you regard these as drugs like any other drugs?
SPENCE
I do, I think that's partly me, to be quite honest with you, rather than anything else. A lot of homeopathic doctors, i.e. medically qualified people, still talk about remedies, I tend to talk about drugs and medicines, partly because I think patients are very used to that.
PORTER
This is one of the controversial areas of homeopathy of course, is that actually you're using remedies that don't contain anything but perhaps water or powder because traces are so tiny. Does that bother you that we've not been able to really get to grips with the underlying science?
SPENCE
Yes it bothers me in that I'm fascinated and will be fascinated when we eventually uncover and discover actually the mechanisms by which they work. It doesn't bother me in terms of not using them until that is known because I've learned I suppose from my own clinical experience, firstly as a GP, how useful and effective they are and because they're safe I was therefore happy to use them, even I don't actually know the mechanism.
PORTER
So Tim what did you think of the whole process?
TIM
Yeah it's kind of really thorough really, he kind of asked me lots of questions about things I wasn't really expecting, it was about me personally, myself.
PORTER
As opposed to a conventional doctor who'd be more interested in your symptoms.
TIM
Yeah basically, it would be more - it just literally wouldn't be a personal thing, it's more about me as a person and finding things that I liked and disliked and then he obviously kind of - he's going to look at that and put together something that's just specifically for me rather than a sort a general thing.
PORTER
Does that appeal to you - that rather than when you go into a conventional doctor you get a medicine for your bowel complaint, whereas now you're getting a medicine for your bowel complaint and you, as it affects you?
TIM
Yeah it was a lot more personal, a bit more personal, it was just a really long consultation, longer - like sometimes when I've been the doctor's it's just literally in, what's the problem, and then okay I'll give you this and then that's it.
THOMPSON
I think what homeopathy can do is it can look at things in a more complex way, it can look at the person's symptoms but them as an individual, it can look at their physical symptoms but it can also look at their emotional symptoms, their sleep disturbance, dreams. So these are all things that can make a difference to someone's quality of life.
PORTER
While much of the workload at Bristol is taken up by chronic, non life-threatening illnesses, the team also care for the more seriously ill - including people with cancer. Dr Elizabeth Thompson is a consultant homeopathic physician, and honorary senior lecturer at the nearby Department of Palliative Medicine at the University of Bristol. Helping patients with cancer makes up a sizeable part of her workload at the hospital.
THOMPSON
I think the issue of survival in cancer is a very contentious one. And in fact evidence has shown that those people using CAM therapies are no more likely to survive than people who aren't ...
PORTER
By CAM therapy you mean a complementary approach of some sort?
THOMPSON
Yeah. In fact some of the research has shown that survival is poorer in those people using CAM and that's quite complex because it may be that some people use it when they're very anxious or very desperate. But there's also some research to show that those people who can particularly apply themselves to certain holistic thinking sometimes can do better in terms of their quality of life, their day-to-day wellbeing. So I'm much more interested not in survival but about how people feel whilst they go through treatments and also if their disease recurs I like to feel that I've made a contract to just stick with them and stick with the whole process.
PORTER
Can you give me some examples of the sort of things you might be able to do to help people?
THOMPSON
If I think of some particular symptoms for patients with cancer they come with hot flushes, so I see lots of women with breast cancer and symptoms of oestrogen withdrawal, often because of the side effect of tamoxifen. And in fact one study that I did was working in the Glasgow 91Èȱ¬opathic Hospital, when I looked at a hundred consecutive patients attending the clinic then 80% were women, 20% were men, and of those 80% about 60% had symptoms of oestrogen withdrawal. And interestingly about 40% were referred directly by their oncologists because what we realise is that women have a difficult situation - HRT's not recommended, some of them don't want to go on more drugs that are recommended that treat flushes and so they think right let's try something like homeopathy. Another key symptom is fatigue, fatigue in cancer has a considerable burden on many patients and homeopathy seems to be a good treatment. A lady today said it was like a switch going on following her treatment and she just began dancing, which she hadn't done for three years, and her energy levels just came right up.
PORTER
Is there a problem using homeopathy alongside these conventional treatments, can people carry on having the conventional treatments - things like chemotherapy - if they're having homeopathy?
THOMPSON
Very much so. One of the things I say to people is it's not an either or, it is a complementary approach and in a way we value these extremely important treatments they're having, lifesaving treatments, but at the same time we want to say well what can we do to improve symptoms and improve quality of life? Yes there's more of a challenge, if you've got a drug in the system that's creating certain symptoms and you're trying to harmonise or restore functioning within the body, which you are trying to do with homeopathy, then you've got a slight juggle on your hands but one of the things that seems to work quite well is just to repeat the remedy, so, for example, if I'm seeing a child on no medication with migraine I'll give a single dose and if the remedy is good I might expect them to be migraine free for five months, six months. If I'm treating a woman on a daily dose of tamoxifen, undergoing chemotherapy, then I might need to give a weekly dose of a remedy.
PORTER
What about the evidence - in these days of evidence based medicines I as a GP am discouraged from prescribing any form of drug that hasn't got a good evidence base done on it, we have the National Institute for Clinical Excellence - NICE - who send us dictates on what we should and shouldn't be doing, how does homeopathy fit into that, because it's always been difficult with all forms of complementary medicine to get hard evidence?
THOMPSON
The evidence for homeopathy is confusing because what we've got with homeopathy is we've got lots of use of homeopathy but not that good an evidence base. Having said that it's not that we've got no evidence, we've got some evidence that ultra-molecular dilutions, which are that homeopathic remedies can have biological effects...
PORTER
This is basically the principle that although it appears to be nothing but water there is some sort of memory, if you like, for the molecule that was in there, so they do have some form of activity?
THOMPSON
Yes. Well you know we've got these over a hundred randomised control trials which have been subjected to various systematic reviews and metanalyses and again at the moment there isn't enough evidence to dismiss homeopathy. The problem with homeopathy is, for example, when I did a double blind trial of women with breast cancer and menopausal symptoms what we found is that we couldn't see a big difference between the treated group and the untreated group. Now the treated group had a consultation plus a homeopathic remedy, the untreated group had a consultation plus placebo ...
PORTER
A dummy remedy.
THOMPSON
But what we're realising is that first of all separating homeopathy into consultation and remedy is not how it occurs in reality. With the lady I've just seen I'm building a picture during the consultation of a remedy that might match her well but also she's becoming aware of themes and relationships that are quite important to her, so it maybe that that in itself is enabling and may have therapeutic effects. So then to try and look at a specific effect of the remedy when lots of non-specific effects of the consultation are occurring, it makes it more difficult if you then put it into the double blind trial. So what we're arguing is could we do pragmatic trials, where, for example, we compare women on a waiting list control who then start treatment - what was it like before treatment, what was it like after treatment? - and the women become their own controls rather than trying to separate the homeopathic consultation into consultation and remedy.
PORTER
So what you're saying is that as scientists, particularly conventional doctors, we've concentrated too much on looking for evidence that the homeopathic remedy is effective, more effective than a dummy placebo, when actually what we should be comparing is homeopathy in its entirety - the consultation, you explaining things to the patient, the patient may be making changes in their life and the remedy as well - and that you're convinced that all of those things together offer a significant improvement?
THOMPSON
Okay, spot on because what's happened is that people have wanted to say homeopathy is like a pharmaceutical compound and it isn't, it is a complex intervention.
PORTER
In your trial where you were trying to help women who were having hot flushes as a result of the breast cancer treatment tamoxifen, were you using the same homeopathic remedy in all of them?
THOMPSON
No the idea with what's called classical homeopathy where you're trying to match the medicine to the individual, it's also called individualised homeopathy, in fact you want lots of variabilities because we've got about 3,500 medicines, so the more variability the better you're doing your job.
PORTER
But Mrs Smith's hot flushes may not be the same as Mrs Bloggs - is that what you're saying - and therefore they have to have matched remedies for their particular problems?
THOMPSON
Exactly right. So you might have 10 people waiting in the outpatients but actually they're - they've all got hot flushes but their experience of hot flushes and them as an individual will all be different.
PORTER
Now what would you say to people who go along to their high street pharmacy, where you can buy homeopathic remedies, and they have let's say hay fever and they pick off a hay fever remedy, I mean presumably that's not the way it works?
THOMPSON
Well they might be lucky and they might be quite good at knowing themselves and they might flick through and they might just be spot on. The problem is that I find people who say - Oh I tried homeopathy and it doesn't work - and that's exactly what they've done. Now the likelihood of it working is really very low, you've got to be very lucky to walk in and just get the right remedy.
PORTER
There are four other NHS homeopathic hospitals or departments across the UK - at Tunbridge Wells, London, Liverpool and Glasgow - but only one has inpatient facilities. Dr David Reilly is consultant physician at the Centre for Integrative Care at the Glasgow 91Èȱ¬opathic Hospital where there have 15 inpatient beds. The unit admits around 500 NHS patients a year following referral from GPs and other hospital specialists.
REILLY
Maybe 60% of people would, for example, be in unremitting chronic pain and you might have flares of typical inflammatory diseases like rheumatoid arthritis, multiple sclerosis, ulcerative colitis, various emotional and stress-based problems, but typically a person would have a complex of both physical and emotional difficulties. One audit that we did and they had seen on average five hospital specialists and were on about 10 drugs, what do you do when the best of medicine is failing and people are still in distress and suffering? What do you do when evidence based medicine's been applied and failed? So what we're really doing is tackling the most complicated situations which are failing to be helped by other approaches.
PORTER
It must be very difficult dealing with patients in an awful lot of pain, has tried the very latest that modern medicine has to offer, and then comes to you as a in inverted commas "failure of therapy", what can homeopathy add to that and how effective is it proven to be?
REILLY
Well I think it's probably important to place homeopathy in a larger context. What we would call - what we're doing as integrative care, care which moves in the opposite direction of fragmentation, attempts to put people together. It's a very much a whole person model because typically you'll find an individual won't just have rheumatoid arthritis, they'll maybe have some side effects, they'll have fear in their mind do they have other diseases, they're under social pressure and they're not coping. And we have a multidisciplinary team that will take the whole situation into account, review the organic side of things, reinvestigate if we need to, review the conventional drug medication, consider whether a pallet of complementary therapies might have a role to play, maybe a physiotherapist might be combining Pilates with acupuncture, for example, and homeopathy - assess whether it has a role to play, nutrition but perhaps absolutely central is establishing a therapeutic relationship. And in one audit that we found 60% of the group had some quite deep traumatic process going on which wasn't being aired or shared within the medical system. Principally because we have head doctors and body doctors and if you've fallen through the net of general practice, which is where the chance of a whole person encounter really lies, and you're into the secondary care network system, as you know you're passed from one specialist to another. So we're very conscious that what we're doing we would just label medicine, rooted in a deep whole person perspective, bridging orthodox and complementary medicine and bridging mind/body medicine.
PORTER
But why is it David that that approach can only be offered from a hospital like yours, I mean why aren't we doing that in our conventional practice, on the conventional rheumatology ward?
REILLY
That would be my question, it's been my enquiry over the last 20 years has been based around that question. We've had a period of fantastic heady expansion I suppose from bimolecular medicine and reductionism and thank god for it and the benefits it's brought but everyone's recognising that meantime something's happened in terms of an increasing fragmentation of care and somehow the issue for me is not about complementary and orthodox medicine, it's about a re-evaluation of the basic powerful role of therapeutic relationship and therapeutic engagement. The clinical trials do suggest that there's a greater than placebo action, you know you can cut the cake different ways but about 200 trials, maybe 70% coming out better than placebo. But my interest in the end is not an individual therapy - orthodox or complementary medicine - it's the fact that there's an under-emphasis, as you're saying, on the therapeutic process and therapeutic engagement.
PORTER
I know David that there's been some financial pressures on the hospital, as there are in many parts of the NHS at the moment, and everyone has to justify their own existence. Now your beds have survived some recent cuts, what did you put to your authority to say that these beds are worth spending the money on, I mean do you have a good set of results to show that once these patients come into see you, you can actually make many of them better?
REILLY
About a year later over 70% are reporting some form of transformative change in daily quality of life. Substantial reductions in visits to GPs, drugs, new investigations and hospital admissions elsewhere. Paradoxically the conventional system that we're all in has become very busy but incredibly inefficient in that each of these patients - say let's take someone with back pain, unresponsive back pain, post surgery, yes maybe they've been to the rheumatologist and the neurosurgeon and the psychiatrist and the pain relief clinic, if you audited each of these incidents in the patient's journey they could said to be efficient but if you stand back and track the patient's journey itself you find an incredibly costly, inefficient pathway through the NHS. And we've been showing from our work that if you really want to talk costs in the NHS and we should, you need to cost patient journeys not incidents or events or treatments. And that the current model is actually grossly inefficient with over-fragmented care split among too many specialists. You bring the sort of model that I've described to you and you start to bring order and great efficiency into the care with better results and less cost involved. And that argument has been subject in Scotland to incredible public scrutiny in the last 12 months. All the way up to Parliamentary inquiry, media discussion, scientific debate and so on and in the end people have actually become persuaded by the value of the model and by the results that we've presented. And when Greater Glasgow health board withdrew the threatened removal of the beds it did so saying it was profoundly impressed with the quality of care and actually wished that some of those qualities could now be spread more widely through the system.
PORTER
Dr David Reilly from the Glasgow Homoeopathic Hospital.
Back in Bristol Joanna Mawer is waiting to see David Spence for a follow up appointment about a long term skin complaint - psoriasis. More conventional treatments have helped, but Joanna wasn't keen on using them day in day out.
MAWER
It's mainly been hydrocortisone creams have been prescribed ...
PORTER
Steroid creams.
MAWER
Yeah, it's not been too bad, it's been controlled by that, and with the scalp it's just usually been a shampoo but when you've been using that for a long time you come - you want to have a break from that really, you don't want to be using it for the rest of your life, so I was trying to find something that would perhaps prevent that I think.
PORTER
So you're concerned about the possible side effects of the long term use of those medicines?
MAWER
Yes, obviously knowing that steroid creams thin the skin, which isn't ideal obviously and just don't really feel that it's right to be using prescribed shampoo on long term use.
PORTER
So you raised the idea of going to see a homeopath with your GP, how did he or she respond?
MAWER
Oh fantastic, just said yeah willing to try anything really, if it's going to work then give it a go.
PORTER
And how did that differ from previous consultations that you'd had about your psoriasis?
MAWER
Oh it was very much a more holistic approach, I was quite - quite amazed at how intricate the interview about the treatment went, very much sort of thinking about you as a person, why you think you might have the psoriasis, whether there were any particular times it would occur. So it was very different, whereas my experience of going to the GP and saying that the psoriasis had flared up would just be a written prescription and that was it.
PORTER
They'd just look at the rash and not look at the patient underneath the rash.
MAWER
Yeah definitely. So yeah it was a very different approach which was - yeah I found quite interesting actually, the sort of depth that it went into.
PORTER
Was it therapeutic, just having that long consultation must be nice, to have somebody sit and talk to you for that length of time because you often rarely get more than eight minutes with a GP do you?
MAWER
No it's fantastic because you really felt that you could sort of get it all out in the open and say I think I've had problems with this and that I think might be a trigger for it as well. And perhaps makes you reflect on why you might be having it as well, rather than just trying to get it treated.
PORTER
Looking at you now your skin looks very good, has it made a difference - the treatment?
MAWER
I think so, I was just about to go and talk to the doctor about it but I think initially it got a lot worse and then it seems to have cleared up. So it seems to be more under control than it was, definitely.
PORTER
And what does your treatment involve?
MAWER
It was three powders to be taken in the morning for just those three days and that was it and then a follow-up appointment with the doctor afterwards.
PORTER
David, Joanna talked about taking her remedies just for three days, which I must say surprised me somewhat, I'd expect a chronic ongoing problem like psoriasis to need regular treatment.
SPENCE
Yes, I think that's actually very difficult for us as doctors to get hold of, you're quite right, because we're so used to doing the job for the body or trying to at any rate, that the concept of stimulating the body to do its own thing and in the first instance actually having to be slightly cautious about how you do that because if you stimulate too much for too long that's when you can get toxic effects from homeopathic medicines. Joanna had a remedy called corsticum [phon.], which actually is a potassium salt, so it's a chemical agent and made in homeopathic potency and was selected really because in its pharmacology, in the testing of it, it produces features which were very typical of the features that Joanna had, so it was a very individualised prescription for her.
PORTER
And they must make up quite a large part of your workload here I would have thought because certainly in general practice they're very difficult problem to deal with, we have lots of creams and potions but none of them are cures by any means, so we can keep symptoms under control but things tend to come back. Would you hope to be able to "cure", in inverted commas, people with conditions like Joanna's?
SPENCE
That's certainly the aim, I mean I think cure's always a very strong word in medicine, isn't it, I mean for me cure means that you've got rid of it and it'll never come back and I don't think one can reckon that you'll do that with a condition like psoriasis. I think you can hopefully stimulate the system, get it into remission and get it into long periods of remission but given the right or the wrong stresses, depending which way you like to look at it then it's quite likely it'll return.
PORTER
The homeopathic hospital's proximity to the medical school at Bristol means that students can learn more via a short clinical attachment to the department. An opportunity that medical student Charlotte Ellis grabbed with both hands. So what differences has she noticed between the clinics here, and the more conventional ones down the hill at the Bristol Royal Infirmary?
ELLIS
I think one thing is time, I think patients - especially new patients - have more time allotted for their first appointment, which I think patients find really helpful, they can really talk about anything that's bothering them at all, I think that's probably the main difference so far I've noticed.
PORTER
And what about the concept of the homeopathic remedy, that presumably is an alien one to you through the conventional training that you've had?
ELLIS
Yeah it is quite different, sometimes it can be hard to explain to other people, to patients, how it's different because some people see it as being - there's actually nothing in the remedy, so how can it possibly work, so yeah it is quite different to conventional medicine obviously as you know.
PORTER
How do you think your attachment here might affect your future? I mean you're one of tomorrow's doctors, is it something you might integrate into your own practice later in life?
ELLIS
Definitely, I think I'm quite interested in being a GP at the moment and so I think I'd definitely consider taking a course or something if patients were interested in receiving that kind of therapy.
PORTER
What about the opinions of your peers - is complementary medicine something that's being taken much more seriously now by tomorrow's doctors?
ELLIS
I think it seems to be, we do have lectures on it and obviously you get people that just think it's a bit of rubbish, to be honest, but I think generally people are becoming more aware of it and I think people are realising that patients might want this kind of therapy and so it's important for us to realise that and for doctors to take that on board.
ENDS
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