A New Low for SMA

(Posted on the Singapore MD blog)

"Should doctors check the daily horoscopes of their patients?"

(Posted on the Singgapore MD blog)

Lipstick on a Pig 4

(Posted on the Singapore MD blog)

Lipstick on a Pig 3

(Posted on the Singapore MD blog)

Lipstick on a Pig 2

Reading this letter to the ST Forum...

TCM practitioners not exempted from duty to provide proper medical care

WE REFER to Dr Ong Siew Chey's letter on Thursday ('Certifying TCM practitioners: It opened Pandora's box').

Although Western medicine is the mainstream health-care service in Singapore, traditional medicine services such as traditional Chinese medicine (TCM) remain popular and are increasingly gaining public acceptance.

The Traditional Chinese Medicine Practitioners Act was enacted to safeguard patients' interests and safety, and to ensure an acceptable standard of TCM practice is maintained.

Singapore does not have double standards regarding medical practice. Every professional group has different qualifications, training requirements and scope of practice. TCM practitioners, by virtue of their training and practice, are not the same as Western medical practitioners. In the same way, nurses, pharmacists and other health-care professionals are also different. Therefore, not all health-care professionals could be viewed in the same way.

China's health-care practices and regulatory frameworks are different from Singapore's due to its historical and political development. While we have taken reference from China in the way TCM is regulated here, we are also developing our brand of regulatory framework, as Singapore is one of the first countries outside of China, Hong Kong and Taiwan to regulate TCM.

We have much to learn and a long way to go, as the regulatory framework for TCM is still in the infancy stage compared to the regulatory framework for Western medicine. As a matter of fact, the current Singapore TCM regulatory framework has taken reference from the regulatory framework as set out in the Medical Registration Act and the Dentists Act, in particular, with regard to the disciplinary powers of the TCM Practitioners Board over TCM practitioners.

This is not a case where TCM practitioners enjoy any exemption from their obligation to provide proper and adequate medical care. If any TCM practitioner is found guilty of misconduct or improper behaviour, he will be dealt with by the TCM Practitioners Board.

We thank Dr Ong for his feedback, and welcome feedback and ideas from the TCM community, the health-care family and the public to make our TCM regulatory framework one of the best in the world.

Chuo-Ng Peck Hiang (Mrs)
Executive Secretary for Registrar
TCM Practitioners Board


reminded me of this post I wrote more than a year ago.

Now Mrs Chuo-Ng is factually correct in many of the statements she made: TCM is "popular and... increasingly gaining public acceptance", the TCM Registration Act is largely based on the same framework the Medical Registration Act and the Dentists Act, and TCM practitioners are subject to penalties if they are "found guilty of misconduct or improper behaviour".

But those points do not change the fundamental fact that TCM is a pseudoscience the theory and practice of which are not based on evidence, and that no amount of legislation or regulation is going to make it so. To want to "regulate" TCM before we can even demonstrate the existence of 'qi' is as ridiculous a notion as that of having a medium registry before we can proof that spirits or deities exist.

Lipstick on a Pig

(Posted on the Singapore MD blog)

My Foot!

(Posted on the Singapore MD blog)

Sense and Sensitivities

(Posted on the Singapore MD blog)

"Caveat Emptor"

(Posted on the Singapore MD blog)

Loss 4

(Posted on the Singapore MD blog)

A Taste for Your Own Medicine

(Posted on the Singapore MD blog)

Trust

(Posted on the Singapore MD blog)

Quote of the week

In Singapore, TCM complements western medicine and this mixed
system is best for consumers. The two operates on very different philosophy and
it is hard and unfair to assess one using the other's benchmark.

For patients, whether it is east or west, so long as it works,
it is the best!

- Mr Khaw Boon Wan, Minister for Health, on TCM

Dr Tan, I presume?

Google is a wonderful thing.

This letter on the ST Forum today did not come as a surprise to angry doc:


Dispel concerns about complications after vaccinating kids

I REFER to Tuesday's report, 'Immunise infants early, specialists urge'.

I would like to ask child specialists how much adjuvants are given to children in the form of aluminium and mercury salts in vaccines, besides preservatives, over a two-year period, under the Ministry of Health (MOH) childhood immunisation programme.

Scientists have shown that aluminium and mercury are foreign to our biological system and do more harm than good. Does MOH have a register of all complications related to childhood vaccines given in Singapore? According to vaccine package inserts, these complications range from mild fever to severe convulsions and delayed eczema.

In a 2007 clinical study of 300 babies aged between nine and 12 months at five SingHealth polyclinics, what was the adverse complication rate and the severity, in terms of morbidity and mortality? Are these babies followed up long-term and for how long?

Mothers' concerns about autism and vaccination are real. The incidence of autism is reported to be rising in Singapore. This issue has not been thoroughly addressed as to its causation.

Tan Soon Kiam


Sounds familiar?

On a whim angry doc decided to google Mr Tan's name, and it turns out that 'Mr' Tan may in fact be 'Dr' Tan.

In fact, judging from the topic of his 'concern', he may be the same Dr Tan we encountered on this blog more than two years ago.

Dr Tan, as we can see from his letters, is no heavy metal fan. Readers may wish to google his name to find out for themselves why this is so.

Medium Register

An interesting piece of news here:

Mediums to be regulated
Taoist Federation aims to weed out unskilled tang ki
By Yen Feng

THE Taoist Federation is taking steps to regulate spirit mediums here.

As early as next month, it will issue registration forms to the roughly 300 temples affiliated to it, so a register of mediums, or tang ki in Hokkien, can be set up.

Federation president Tan Thiam Lye told The Straits Times last week that this was the first in a series of steps to set apart those trained in channelling Chinese deities.

Registration is, however, voluntary for now. Down the road, licences may be issued.

More immediately, the federation will also produce a free manual to help devotees discern between skilled and unskilled mediums.

Saying the federation will take things 'one step at a time', he added: 'It is time for us to regulate them. We must not let the actions of a few bad apples lead to a misunderstanding of mediums and Taoism.'

angry doc will be very interested in finding our how to "discern between skilled and unskilled mediums". Maybe they can give a copy of the manual to Father Simon so he doesn't hold a "prayer session" for the wrong person in the future...

Letter to the Editor, SMA News

Dear Editor,

I write in response to the article "Traditional Chinese Medicine - Friend or Foe?" by Dr Jeremy Lim in the March 2009 issue of SMA News.

While I understand that Dr Lim was writing in his personal capacity, and that his views do not represent those of the editorial board or SMA, I am nevertheless disappointed by his uncritical support for Traditional Chinese Medicine (TCM).

Dr Lim began his defence of TCM with the 'science was wrong before' argument. While he is correct in pointing out that Jenner and Semmelweis' views were rejected by their colleagues in their days, they were eventually vindicated via the scientific method - their findings were accepted to be true because they explained observed phenomena, and not because the medical community decided to adopt a different standard of assessing a scientific claim. Dr Lim could well have included Dr Barry Marshall as a recent example of a 'misunderstood innovator', but we should remember that in trying to gain acceptance for his theory he did not appeal for a different 'metric' to be applied to it, but sought to provide evidence by drinking H. pylori. Why should TCM be held to a different standard?

Dr Lim then went on to state that "Western medicine has no monopoly on knowledge and we must actively and aggressively seek ways to compare Western methods and TCM, finding metrics that can be applied equally to both." I would like to contend that this is a misrepresentation of Western medicine today. Western medicine"does not claim to have a monopoly on knowledge; what it does claim to have is a valid tool for assessing claims in the form of the scientific method. The scientific method make us test each claim by demanding observable evidence, and to abandon a claim or a theory if it did not fit observed phenomena - it contains within itself the mechanism to correct previous assumptions, and is in fact the method that vindicated Jenner, Semmelweis, and Marshall. In contrast, TCM is based on a pre-scientific theory of unobservable qi and meridiens. Neither of these entities have been demonstrated objectively, while at the same time efficacy from modalities of treatment used in TCM have been shown to be due to processes that can adequately be explained by modern science (pharmacological properties of active compounds in herbs, endorphins-production in acupuncture), yet both continue to be taught and used as if they were true - it is not Western medicine that is claiming monopoly in knowledge here. The "metric" that should and must be applied equally to TCM and Western medicine, and for that matter all forms of alternative medicine, is the scientific method - it has been an objective and reliable method for evaluating claims, and proponents of different "metrics" have yet to come up with anything as effective as it.

Dr Lim then quotes Dr Lee Tat-Leang on the difficulty in performing randomised controlled trials for TCM treatment modalities because they involve "individualized and prolonged treatment", and mentioned in particular the difficulty of finding an appropriate placebo for acupuncture. This argument is a poor defence for the lack of quality evidence for TCM since a randomised controlled trial is not the only acceptable form of evidence, nor does the design of a randomised controlled trial necessarily forbid "individualized and prolonged treatment". With regards to placebo for acupuncture, I would like to point out that that sham acupuncture in the form of blunt or retractable needles which do not penetrate the skin or needling at points which are not identified to be acupoints have been widely used and accepted as forms of placebo in acupuncture studies. A recent meta-analysis of 13 studies on analgesic effect of acupuncture and placebo acupuncture [1] showed no significant difference between the two, which supports the view that the theory of qi and meridiens upon which acupuncture is based is not an adequate explanation of observed phenomena.

While I agree with Dr Lim's next point that it is possible to study the use of TCM in clinical trials that look at objective parameters, I believe that the important distinction between the treatment modalities used traditionally in TCM and the theories behind it must be made. We must not commit the logical error of accepting the that the theories behind TCM are true simply because a certain modality (be it herbal remedy, acupuncture, or traditional massage) has shown efficacy, but continue to test each claim. More importantly, we must not be lulled into thinking that "patient satisfaction" is more important than scientific rigor, and that the "philosophy" behind the treatment is not important as long as our patients are satisfied. Such an attitude promotes complacency, and will allow other forms of unproven therapy or pseudoscientific "alternative" medicine to claim legitimacy.

Dr Lim ends his article with a commentary on how "Singapore's Unique Position" means we are well-placed to "critically appraise the different elements of TCM viz-a-viz Western medicine" because of our "greater understanding and respect" for TCM. I would argue that any presumption of "understanding" and any unwarranted "respect" for TCM may in fact be detrimental to scientific study as it would prejudice the investigators' minds. As for Dr Lim's question of whether we will "seize the opportunity" in "blending" TCM and Western medicine, I would like to point out that Germany and the USA have already been studying TCM for many years, with the US National Institute of Health having set up a National Center for Complementary and Alternative Medicine (NCCAM) to conduct research on TCM and other forms of alternative medicine. The German social insurance had a few years ago withdrawn reimbursement for acupuncture for treatment of certain conditions based on studies that showed no difference between acupuncture and standard treatment for these conditions (while inexplicably continuing to pay for those conditions where no difference was found between treatment with acupuncture and sham acupuncture), while NCCAM had spent more than US$800 million on research since 1991 but have not managed to demonstrate the efficacy of any alternative medicine - the "opportunity" had already been seized by other people, and I am not sure that was a loss to us.

Sincerely,
angry doc

1. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ 2009 Jan 27;338:a3115.

Loss 3

The Straits Times, which angry doc is given to understand is "waging a vociferous campaign against alternative therapies for autism", reported this piece of news off Associate Press yesterday. Curiously, the editor had decided to leave out two paragraphs from the AP report, which angry doc had highlighted in blue.


Controversial autism study 'off'

CHICAGO - A US government agency has dropped plans for a study of a controversial treatment for autism that critics had called an unethical experiment on children.

The National Institute of Mental Health said in a statement Wednesday that the study of the treatment - called chelation - has been abandoned.

The agency decided the money would be better used testing other potential therapies for autism and related disorders, the statement said.

'There will be parents who are disappointed,' said Dr Richard Nakamura, the scientific director of NIMH. 'We recognize that for children there is a fine line for the risk-benefit ratio. You have to be pretty certain of the overall safety of the procedure.'

The agency wasn't confident enough in the procedure's safety, Dr Nakamura said.

The study had been on hold because of safety concerns after another study published last year linked a drug used in the treatment to lasting brain problems in rats.

Chelation removes heavy metals from the body and is used to treat lead poisoning.

Its use as an autism treatment is based on the fringe theory that mercury in vaccines triggers autism - a theory never proved and rejected by mainstream science.

Mercury hasn't been in childhood vaccines since 2001, except for certain flu shots.

But many parents of autistic children are believers in the treatment, and NIMH agreed to test it.

The researchers had proposed recruiting 120 autistic children ages 4 to 10 and giving half a chelation drug and the other half a dummy pill.

The 12-week test would measure before-and-after blood mercury levels and autism symptoms.

The study outline said that failing to find a difference between the two groups would counteract 'anecdotal reports and widespread belief' that chelation works.

Autism is a spectrum of disorders that hamper a person's ability to communicate and interact with others.

Most doctors believe there is no cure.

In cancelling the study, the agency noted it would take another year to review the study and three years to do it.

In the meantime, the agency said, it was likely that other research would 'provide deeper understanding of the causes of autism and more refined avenues for developing treatments.'

NIMH should reconsider its decision to cancel the chelation study, said Rebecca Estepp, national manager of Talk About Curing Autism, a support group for families with autistic children.

"By discontinuing this study, the NIMH will not prove the effectiveness of chelation therapy one way or another. Instead, they have merely left parents with more unanswered questions," Estepp said in a statement.

Several scientists praised the decision, including the lead author of the rat study, which found lingering problems in animals that did not have elevated lead levels.

'I think they're making the right decision not to go forward with the study,' said Prof Barbara Strupp, a professor of psychology and nutritional sciences at Cornell University.

'Our data raise concerns about administering (the chelation compound) to children who do not have elevated levels of heavy metals,' Prof Strupp said.

Dr Paul Offit, chief of infectious diseases at the Children's Hospital of Philadelphia, agreed with the decision to cancel.

'Suppose that a child suffers a severe side effect from chelation,' said Dr Offit, author of Autism's False Prophets, a new book on autism research.

'Without any evidence it's helpful, I think it's unethical.' The chelation drug proposed for the study, DMSA, can cause side effects including rashes and low white blood cell count.

'This was a wise and careful decision,' said Professor Ellen Silbergeld of Johns Hopkins University's Bloomberg School of Public Health, who had been invited to comment on the study during an earlier review, in an e-mail. -- AP


angry doc is unsure whether if the decision is a win or a loss in the "campaign against alternative therapies". On the one hand funding for a study which carries a potential risk towards children but has little biological basis for a cure had been discontinued, but on the other hand such a decision allows proponents of "alternative therapies" to continue to promote their business - since it has not been "disproven" - and even to portray this as a part of a conspiracy by the government and the medical and scientific communities to deny children with autism a chance at a cure.

In fact, they already have.

angry doc wonders when our local proponents and practitioners of "alternative therapies" will chime in.

angry doc also wonders if, had the study not been discontinued and the result had shown that chelation did not cure autism, proponents of chelation for treatment of autism will accept the evidence and renounce their claims. Past experience does not allow angry doc to be optimistic, so perhaps it is a good thing that the study had been stopped after all.

Loss 2

angry doc is still in pain. More pain than before, in fact.

Nevertheless, a blogger's got to do what a blogger's got to do.

angry doc would thank fellow Clearthought-bloggers Leng Hiong and Edgar and blogger Han Solo for looking at the "evidence" behind "alternative therapies for autism" in the recent discussion on The Online Citizen.

angry doc hasn't got anything to add to the dicussion, but he would like to draw his readers' attention to this parliamentary Q&A on the issue, which he reproduces below:


Autistic Spectrum Disorder
27 Aug 2008

Question No: 578
Question By: Ms Denise Phua Lay Peng

To ask the Minister for Health what measures are being taken to protect the interests of patients with special needs/disabilities from practitioners offering non-evidence-based medical or alternate treatments.

Reply from MOH

1. There are two main levels of protection against such unethical exploitation of patients.

2. First, the Medical Registration Act requires the doctors to practice [sic] ethically. They will be subject to disciplinary action if they use treatments which are not in the interest of their patients.

3. Second, patients and their care-givers must exercise due diligence and consult the right practitioners. When in doubt, they should first check it out with their trusted family physician. Alternatively they could seek a second opinion from the practitioners in the public clinics for patients with special needs, before accepting any unconventional or unusual treatment.

4. Helping patients with special needs is often a long journey. It is understandable why some families become anxious, embarking on remedies that promise them hope of a rapid “cure”. The Internet has further promoted the dissemination of theories and practices, many of which are questionable and without scientific basis. For instance, the use of controversial Complementary and Alternative Medicine (CAM) treatment for children with Autistic Spectrum Disorder (ASD) is popular in the West, despite an absence of scientific support. My Ministry will work with MCYS and its VWOs concerned to educate the families on how to evaluate such information and not be taken in by pseudoscience and unsubstantiated theories. Meanwhile, my Ministry is also collaborating with the Academy of Medicine to formulate Clinical Practice Guidelines to assist doctors in Singapore in diagnosing and managing children with autistic spectrum disorders. The efforts will include compiling the evidence for the various treatments and to disseminate a layman’s version to patients and their caregivers.


While MOH Clinical Practice Guidelines (CPGs) have their limitations, they do provide a handy compilation of references on the subject being discussed, together with glossaries on levels of evidence and grades of recommendations. While they can be a little technical, they are actually available for download from the MOH website by medical professionals and laymen alike.

angry doc is looking forward to receiving a copy of the CPG on autism treatment later this year, and he hopes to be providing a link to the CPG on this blog then.

Cow Dung 8

More news from Ye Olde Country:

(emphasis mine)


$2.2m for brain injury after detox diet

THE family of a British woman who suffered brain damage following a “detox” diet warned on Tuesday of the dangers of such regimes.

Ms Dawn Page received more than £800,000 ($2.2 million) in an out-of-court settlement after a diet in which she increased her water intake and decreased the amount of salt she consumed.

The 52-year-old mother of two, from Faringdon, southern England, began vomiting severely soon after starting the “hydration diet” in 2001. She was left with epilepsy and a brain injury affecting her memory, concentration and ability to speak normally.

She gave up her job as conference organiser and her family says she will not work again.

Ms Barbara Nash, the nutritional therapist she consulted, allegedly assured her that the vomiting was part of the detoxification process. Ms Nash, who calls herself a “nutritional therapist and life coach”, denies liability in the case and insists she was not guilty of substandard practice.

But Ms Page’s husband, Geoff, 54, yesterday warned of the dangers of “fad-type” diets. He said his wife was not obese but had just wanted to lose some weight.

“Just days after she started the hydration diet, she began to feel unwell ... Things went from bad to worse ... Her life has been seriously affected, perhaps ruined,” he said.

Geoff said his wife was advised to drink at least four pints of water a day. The therapy was known as the Amazing Hydration Diet. He added: “It’s important people understand how dangerous diets like these are.”

Ms Nash has a diploma from the College of Natural Nutrition, based in Tiverton, Devon.

Plexus Law, the firm that represented her in court, said all allegations of substandard practice made in the litigation would continue to be “firmly denied” and the settlement agreed was less than half the total claimed.

THE GUARDIAN


Dr Crippen blogged about this earlier this month.

angry doc is surprised that Ms Page's husband was not 'gagged' as part of the legal settlement. He is not, however, surprised by the fact that he took the settlement - £800,000 is a considerable sum of money, and there was no guarantee that he would have won the case had it gone to trial.

As angry doc understands it, in medical malpractice law, a doctor is "not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art". If the same principle applies to practitioners of alternative medicine, then it may not matter how little evidence of efficacy or safety there is behind a mode of therapy - as long as most other practitioners are doing the same thing, it's OK.

This legal principle, known as the Bolam Test, has traditionally relied on the opinion of the 'professional body'. It is therefore important for us to look at the body of knowledge and evidence on which each professional body builds it opinion on.

Are there any good reasons or evidence to suggest that drinking four pints of water a day while restricting salt intake is a safe and effective way to lose weight? Or that "[w]ater and natural salt, when combined together, give you everything your body and mind need"? Or that homeopathy works? For that matter, how do you know if the treatment your 'western' doctor is giving you is evidence-based?

angry doc thinks all 'consumers' of healthcare need become more critical and discerning, and develop the habit of requiring evidence from their healthcare providers. It's not only about making sure that your money is well-spent - it is also about safety.

"The History of Creationist Thought"