Tuesday, 30 June 2020

Remote working and Homeopathy

Even before the COVID-19 pandemic, it was increasingly common for UK homeopaths to offer consultations via platforms like Skype, Facetime and so on. Problems with this have been touched on before in conjunction with CEASE therapy.

This post will look in more detail at some of these problems as well as discussing how homeopathic consultations differ from other forms of consultation and its suitedness to remote working. 

The homeopathic consultation differs from, say, a GP appointment in a number of key ways. The homeopathic consultation may appear to resemble a psychotherapeutic encounter but in reality, there are profound differences in both practitioners and goals (this will be discussed in a future post).

Homeopathic consultations are predominantly verbal. Homeopaths vary a lot in terms of the approach they take. Whilst there has been some academic study, it is limited and tends to be partisan but indicate that a less structured approach than other types of medical consultation. This could be a function of length - it is difficult to maintain a structured approach for an hour or more.

Physical examination
Western trained lay homeopaths tend not to physically examine patients. Some do use bizarre machines though. Some use applied kinesiology. Obviously, they can not use these devices but some may claim that their devices are capable of remote diagnosis. It is better not to ask about broadcast radionics. Homeopathic Facial Analysis (HFA) may be out as well.

Medically trained homeopaths may be more inclined to examine patients. DHMS/BHMS qualified practitioners from the Indian sub-continent may also be more inclined to examine patients - some of them pose in white lab coats with a stethoscope round their neck, others make a great deal out of medical tests, which they are not considered qualified to perform in the UK (they do not have a recognised medical qualification). A similar situation may apply for certain laboratory tests or referral for specialist tests.

Digital photography can be useful in remote examination. Video tends to be less useful because of its lower resultion but sometimes it is useful to see a patient moving. Technological advances have resulted in better and cheaper medical sensors. One good example would be blood glucose meters for diabetics and their results can be uploaded. Smart watches and other devices now offer routine monitoring of various vital signs such as pulse rate and blood pressure. Some of these devices are not as accurate as those used by clinicians. Partly because of inferior sensors and partly because they need to used in a certain way and consumers don't always do that. Overuse and incorrect use of certain devices can result in increased levels of anxiety.

Of course, this isn't relevant to lay homeopaths because they are not qualified to diagnose in the flesh, let alone remotely.

Non verbal communication
Non verbal communication (NVC) is a two way street. Whilst it is important in evaluating a patient, a practitioner's NVC can affect how a patient percieves the practitioner. There is research that shows a link between practitioner and patient satisfactory. In psychological therapies, NVC is an important part of active listeningMore generally, there has been an increased focus on teaching medical practitioners communication skills, especially those who encounters many patients face to face (it is less of a concern for, say, pathologist).

On the other hand, some of the claims about reading body language are overstated. Certain emotional states can manifest themselves physically but they can arise from a physical condition as well.

Tone of voice is tricky. Telephone/internet call quality can be poor and then there is the matter of having a base line to compare to. It can be difficult to pick up emotional queues from speech from someone you've never spoken to before. Some people find telephone/internet calls much more stressful than face to face interaction. Video calls may allow for picking up on facial expressions but again, there are issues of quality and not having a base line. For example, some people's neutral expression may look angry to others.

What communication skills lay homeopaths are currently taught is unknown. Research suggests that in the past there was no formal training. As far as can be told, none of the usual providers of training for homeopaths offer any additional courses in NVC or active listening, but that would not prevent a homeopath going elsewhere.

There is a tendency among some to think that lay homeopaths are naturally more empathic people and have good listening skills. Some of that tendency may be due to lay homeopathy being predominantly female and assumptions about women having better communications skills. In reality, most people of whatever sex have far worse listening skills than they think. There are plenty of homeopaths who display very little empathy. 

Language and cultural barriers
Increasing use of communications technology has meant that some UK lay homeopaths are now targeting foreign clients and not just British ex-pats. Brits tend not to be very good with languages, so some of those clients will be speaking in their second or possibly even third language. Fluency and vocabulary are obvious stumbling blocks. However, there are also cultural differences in how patients think about symptoms and conditions. There has been researching into different expressions of depression and anxiety. This US article is helpful.

In certain NHS contexts, an interpreter may be provided. Because of the multi-cultural nature of the NHS, it is possible that the NHS could find a native speaking clinician for the patient. This is particularly important when informed consent for treatment is required.

The business of informed consent and homeopathy is a tricky issue at the best of times. How can someone consent to a treatment that is fictive? Yes, they can consent to taking an inert sugar pill that contains no active substance that has not been demonstrated to have an effect greater than that consistent with placebo, but can they consent to a form of sympathetic magic? Doing that in a foreign language?

Cultural barriers can also extend to NVC. Gestures have different meanings in different cultures for one thing, even some facial expressions. 

Privacy, Confidentiality and Safety
Some homeopaths were working from home already to one degree or another. Telephone consultation has been around for a long time so in theory these issues should be understood.

As many are currently finding, working from home can have difficulties in terms of setting boundaries for other family members, particularly if they don't have a dedicated space. Distraction is an obvious problem but privacy and confidentiality need to be considered too. A child or spouse inadvertently overhearing initimare or medical information, for example.

For clients, many of the same problems apply but there is the additional issue of safety. There are signs that  lockdown has lead to increased domestic abuse. It might seem unlikely that a victim of domestic abuse would seek out a homeopath but it does happen. Abuse can be more subtle than most think, especially certain controlling behaviours. Being overheard saying forbidden things can lead to unpleasant consequences. Although not directly related, there have been court cases involving divorced parents arguing about treatment of a child - in particularly vaccination. Differences in option on treatment of children can lead to conflict. By extension, a partner who disapproves of homeopathic treatment could be hostile if it were going on in their own home.

The consultation space is supposed to be a safe place. A place where the client can be themselves. A place free from environmental stressors. If the client doesn't feel that they are in a safe place, they may not feel to disclosure. If their immediate stressors are present, they will be stressed.

Zoom has become very popular but it isn't terribly secure and some organisations have banned its use. 

International legal issues
Some jurisdictions take the view that the jurisdiction in which the patient is based has precedence. Often in such jurisdictions a medical practitioner would need to be registered in the patient's jurisdiction. This is the situation in Canada and the US - MDs need to registered with the State/Provincial board relevant to the patient. It's a recognised problem in the roll out of telemedicine.

Other jurisdictions take the view that where the practitioner is located takes precedence. The UK is like this as are some other European countries, although there can be complications when it comes to prescribing.

As has been been discussed before, in civil law jursidictions such as France, only registered medical professionals can practice homeopathy. In common law jurisdictions, anyone can.

Where things get really complicated is UK lay homeopaths dealing with clients resident in jurisdictions that require practitioners to be registered in that country and that country is a civil law jurisdiction, a lay homeopath would be acting illegally. It is likely that insurance would not cover them.

Insurance might not cover remote working with clients in (certain) other countries.

As far as can be told, none of the UK homeopathy associations have any policy or guidance on telemedicine (it's possibly hidden anyway as "members only" content). Other healthcare associations do and some even go far to see it as a particular competency that requires specific training.

It is possible that the COVID-19 pandemic represents a blip and levels of remote working will return to normal once all restrictions are lifted. Pandemics aren't predictable and restrictions may be in place for a long time. It is not possible to predict when the next one will come along. Hopefully the UK will be better prepared next time - and that would include the UK homeopathy associations.

The Society of Homeopaths will in particular have to do develop guidance because of it being a Professional Standards Authority Accredited register.

Thursday, 25 June 2020

Society of Homeopaths - update on Accreditation with Conditions

The situation with the Society of Homeopaths (SoH) and their Accreditation by the Professional Standards Authority (PSA) is somewhat unclear. That Accreditation had a Condition placed on it and there was a three month deadline for parts of that Condition to be met.

The following Condition of Accreditation was issued to be implemented by the timeframe as specified, or by the following annual review of accreditation:  
1. The Society of Homeopaths must:  
a. make its position statements clear that registrants must not practise or advertise adjunctive therapies that are incompatible with Society registration. Specific reference must be made to the Society’s position forbidding the practice of CEASE, and dietary/nutritional supplements. This must be submitted to the Authority for review and published within three months. (paragraph 2.13)  
b. make its position statements clear that registrants’ scope of practice does not allow registrants, whether acting in a professional or public capacity, to provide advice on vaccination or offer or provide homeopathy as an alternative to vaccination for the prevention of serious infectious diseases. Registrants should direct service users to NHS and other public health sources, for example, their GP or public health departments. Revised statements must be submitted to the Authority for review and published within three months. (paragraph 2.19)  
c. provide quarterly reports of its monitoring to ensure that within the following 12 months all registrant websites comply with its updated position statements (as referred to in part a above) (paragraph 5.10) 
d. complete and make available to the public its guidance on adjunctive/supplementary therapies and inform the Authority how it will promote compliance with that guidance. (paragraph 2.24)
Slightly later that might have been expected, the PSA made an anouncement.  
The Authority renewed accreditation for the Society of Homeopaths in February 2020, with conditions attached. Two of the conditions were required to have been met by May 2020. 
These conditions have been met. For more information, please refer to the panel decision and to the Society’s website.
So parts a) and b) have been satisfied? 

Position Statement
It is relatively short so is reproduced in full.
The Society of Homeopaths is committed to choice in healthcare, enabling the public to make informed decisions to achieve and maintain good health. Our registered homeopaths work holistically, offering support to each individual, guided by their specific symptom picture. 
As Homeopaths do not claim prevention or complete cure of any named disease, the Society does not permit RSHoms to practise or promote protocols such as CEASE therapy which are dedicated to specific named conditions. 
The Society expects professionalism in every aspect of homeopathy practice with clarity for the public regarding the expertise of its registered homeopaths. RSHoms will expect patients to maintain a relationship with their GP and other healthcare professionals involved in their care. 
Our Registered Homeopaths will work within their individual Scope of Practice and act appropriately as healthcare professionals in all aspects of their work, adhering to the Society’s Code of Ethics and Scope of Practice. This applies within the consultation as well as professional communications. 
RSHoms may only claim expertise in a specialist area or offer an adjunctive therapy if they can provide evidence that they are suitably qualified and insured to do so. RSHoms may give general health advice, such as for nutritional supplements, providing the advice complies with relevant official guidelines.
Members with qualifications in additional therapies will ensure that the patient is always informed about the treatment modality being offered and consent has been obtained. 
The Society does not permit RSHoms to offer homeoprophylaxis, provide advice on, or participate in a patient’s decisions regarding vaccination. RSHoms should direct patients to their GP or public health departments.
Advice for the Public on vaccination 
Homeopaths are not able to offer advice on vaccination. The Society recommends that members of the public seek the advice of their GP and/or relevant Department of Health guidelines concerning vaccination and protection against disease. 
May 2020
So, yes, it has made public the prohibition on CEASE therapy but it was prohibited because the PSA would not have accredited the SoH if members were permitted to carry on offering it than because of claims of cure or prevention. If the PSA had, the Good Thinking Society would have carried on with their Judicial Review which they would have won. It would be a blatent breach of its Public Sector Equality Duty.  

The wording of the prohibition "practice or promote protocols... ...which are dedicated to specific named conditions" is odd. This is different from "must not practise or advertise adjunctive therapies that are incompatible with Society registration". So any distinct protocol for a named condition is prohibited but others are not?

Consider the case of Homeopathic Detox Therapy (HDT) which is basically the same thing as CEASE therapy and the Accreditation report makes note of this. This interview with its supposed inventor Ton Jansen reveals that much broader claims are made than just "vaccines cause autism" and homeopathic remedies made from vaccines can "cure" autism. To quote -
Well, there are many cases I have successfully cured, including children with diabetes and autism, cancer patients, Crohn disease, glaucoma, multiple sclerosis, etc. As I mentioned, when you know what to do, there are no incurable diseases. My experience is that well indicated homeopathic remedies work well, but not long lasting. After a proper course of HDT they work perfectly. So I am very happy that I discovered this workaround path.
Some SoH members who formerly openly offered CEASE therapy now offer HDT instead. Question is whether HDT is also prohibited by the SoH? If it isn't, what is the reasoning for this given that CEASE therapy is? The risks are very much the same.

What happened to the prohibition on dietary/nutritional supplements? Rather than a prohibition, the SoH indicate that as long as "relevant official guidelines" are stuck to, there isn't a problem. That the PSA say part a) of the Condition has been met suggests that some sort of discussion went on. This blog has always maintained that the big problem with CEASE therapy is that it advocates neglect of autistic children. Media reporting has had a stronger focus on the high doses of vitamins and minerals. Looking back at what both the SoH and PSA have said over time, they have responded more to that than the issue of neglect. It's something tangible. The Position Statement effectively prohibits doses higher than recommended daily intake. So no more advising vitamin c megadoses and so on. A total prohibition would be difficult and would not make much sense (although there are questions about multi-level marketing and commission-based sales made by some members).

Part a) is probably satisified but the wording is clumsy, likely subject to misintrepration by members and may have some unintended conseqences. HDT is a problem though and it possible that more prohibited therapies will emerge over time.

The SoH did manage to make it clear that homeoprophylaxis and offering "advice" on vaccination is prohibited. But there is still plenty of directing the public to sources of misinformation on vaccination on members' own websites, let alone social media.

Part b) again, is probably satisfied. Member compliance is not part of part b).

The SoH probably do not understand the consequences of some of the other things that the Position Statement says. "General health advice" is, well, very general. "Relevant official guidelines" means what exactly? This could be read as prohibiting members from making any health related statement that contradicts NHS guidance. One practical implication is that it prohibits conspiracy theory type misinformation from members' websites.

"Specialist area" is a difficulty as well, particularly determining what is a "suitable qualification". The SoH is only concerned about the courses (and their providers) that allow entry to membership. It doesn't recognise any other courses. The general effect of this is that members can not refer to themselves as "specialists" or having "specialisms". Over time the use of the phrase "special interest in" has become more prevalent. It is likely that "expert" is also a problem.

The issue of recognition of courses is also an issue for "adjunctive therapies". Part d) has a deadline that for practical purposes is end of 2020 - beginning of 2021.

The unclear wording of the Position Statement has implications for Part c) that will play out over time.

Scope of Practice
The Position Statement links to a Scope of Practice document. The Accreditation report says re part d) of the Condition -
2.23 The Society advised that it ratified a formal Scope of Practice in September 2019. The Scope sets out what all registered members of the Society of Homeopaths can do, and what registrants may be able to offer as a result of achieving qualifications in other areas. Where they are outside of the main scope of homeopathy, registrants must make clear to the public they are separate practices and provide relevant evidence of qualifications held for those practices. The Scope of Practice would be formally issued to registrants and published online in January 2020. The Authority will follow this up with the Society in due course to ensure it has been done.  
2.24 The Society advised that its newly revised Scope of Practice will be supported by guidance on Professional Homeopathy Promotion ‘which will outline how members of the Society can communicate their adjunctive therapies alongside their homeopathic practice and what evidence of certification they are required to demonstrate. This piece of work will take place in the first half of 2020 following the review and update of the Society risk register.’ 
2.25 As part of the Condition issued the Authority required the Society to complete and make available to the public its guidance on adjunctive/supplementary therapies and advise the Authority how it will promote compliance with that guidance. (Condition 1d)
The Scope of Practice document is dated February 2020 (and apparently formulated by September 2019) and there were some communications but whether or not all members would have read it is another batter. The delay between its communication to members and communication to the public should have give members sufficient time to comply with it.

It doesn't start very well. 
This statement paper aims to define the Scope of Practice for homeopaths registered with the Society by setting out:  
§ General parameters applicable to all registered members.§ An outline for each member to develop their individual Scope of Practice. 
It has been compiled through a process of collaboration between a working group consisting of the Society’s Professional Standards Manager, two Directors and four registered members and incorporating feedback from the Society’s Board and Professional Standards Committee.
To be blunt, it fails to define much at all. Possibly earlier drafts did, otherwise it looks as if the SoH put a lot of effort into creating very little. It might be the case that it was impossible to agree anything more clearly worded.

A point-by-point dissection of it would make for tedious reading but one strong criticism is that the Position Statement clearly places restrictions on practice (even if they are unclear, certainly don't go far enough and there are probably more to come) but the Scope of Practice makes no mention of those restrictions. There is a clear arc of increasing restrictions on practice over time as the SoH is forced to react to external forces judging that some members' practices are way outside of any putative Scope of Practice or any notion of the limits of competence.

Of course, there is something to be said for maintaining a list of therapies that are incompatible with Society registration separate to but referenced by the Scope of Practice. Same could be be said for qualifications for adjunctive therapies deemed acceptable by the SoH. There would be no need to update the Scope of Practice document itself every five minutes.

Professionalism and prescription
The Reluctant Profession - Homoeopathy and the search for legitimacy (Cant and Sharma, 1995) is a fascinating paper but is behind a paywall. The abstract says -
This paper examines a group of lay homoeopaths, represented by the Society of Homoeopathy, and traces the changes that have been made to their organisation, training and knowledge as they attempt to enhance their legitimacy in the eyes of the public, government and orthodox medical profession. The group has acquired a number of `professional' properties, but in so doing have reduced levels of freedom, marginalised factions within the group and failed to gain greater authority in the healthcare market. The homoeopaths themselves thus recognise that there are costs as well as benefits associated with their professional project and so they have undertaken many of the changes reluctantly.
More than 20 years later, the SoH are in roughly the same position.

The Scope of Practice document resembles to some extent Scope of Practice for regulated professions such as physiotherapy and occupational therapy. There are fundamental differences between these professions and homeopathy. Perhaps the most important is that they went through the professionalisation process a long time ago whereas lay homeopathy has at most taken a few tiny steps. Although private practice does exist, many physios and OTs are employed, their first roles are in the NHS and they may well benefit from structured development.

Many SoH members seem to have language comprehension problems. It is clear that some struggle with understanding the de facto limits of homeopathy and their own competence.

If the SoH wishes to retain SoH Accreditation and carry on down the road to greater professionalism, it will need to become more prescriptive. It is going to end up prohibiting members from more and more types of activity. It needs to consolidate Scope of Practice, not loosen it to the point of being meaningless.

Saturday, 6 June 2020

"Mr Homeopathy" and his magic COVID-19 remedy

"Mr Homeopathy" is Dana Ullman, a California based lay homeopath.
DANA ULLMAN, MPH, CCH, is one of America’s leading advocates for homeopathy. He has authored 10 books, including The Homeopathic Revolution: Why Famous People and Cultural Heroes Choose HomeopathyHomeopathy A-ZHomeopathic Medicines for Children and InfantsDiscovering Homeopathy, and (the best-selling) Everybody’s Guide to Homeopathic Medicines (with Stephen Cummings, MD). Dana also created an e-course How to Use a Homeopathic Medicine Kit which integrates 80 short videos (averaging 15 minutes) with his famous ebook that is a continually growing resource to 300+ clinical studies published in peer-review medical journals testing homeopathic medicines. This ebook combines the descriptions of these studies with practical clinical information on how to use homeopathic medicines for 100+ common ailments. This ebook is entitled Evidence Based Homeopathic Family Medicine, and it is an invaluable resource. Dana has been certified in classical homeopathy by the leading organization in the U.S. for professional homeopaths.He is the founder of Homeopathic Educational Services, America’s leading resource center for homeopathic books, tapes, medicines, software, and correspondence courses. Homeopathic Educational Services has co-published over 35 books on homeopathy with North Atlantic Books. 
Dana writes a regular column for the wildly popular website, www.huffingtonpost.com(to access these articles, click HERE!)
But clicking "HERE!" doesn't take you to his column. It was removed from HuffPost a long time ago.

It's not clear where the "Mr Homeopathy" epithet came from. But it's not of any real interest. It's diificult to determine how important and influential is in the US and globally. Probably much less than he and his supporters would like to believe.

It is not intended to delve into Ullman's past. The focus here is COVID-19 and his understanding of US regulations/legislation.

The Problem
Ullman's website sells a China nosode 200C. Ullman tells us -
To clarify, the source of this medicine is from a respected homeopathic pharmacy that sells only to professional homeopaths.  They obtained the original source material from the sputum of 13 Chinese patients.
and -
Manufactured by a respected American homeopathic pharmacy who has received third party authentication. 
We are not allowed to provide “indications for use,” though a homeoprophylaxis protocol will be provided with each order.

Some have called COVID-19 "China flu". It is a coronavirus, not an influenza virus and WHO guidance suggests that geographic naming of diseases is not best practice. 

The US Food and Drug Administration (FDA) is cracking down on bogus treatments for COVID-19. There have been a number of warning letters sent to homeopathy vendors including Kari Kindem. An archived version of the offending website tells us -

The current circulating Coronavirus Nosode is a homeopathic nosode that is made from the current circulating strain that started in late 2019 , now named “COVID-19”. 
All homeopathic remedies are highly diluted and are non-toxic. 
When a homeopathic remedy is so highly diluted and succussed, they do not contain a single molecule of the original material. Instead they contain an energetic signature. 
The Coronavirus 2019 nosode  is 100% safe and non-toxic and is made according to strict pharmacopeia guidelines at a highly reputable, licensed USA lab.
The homeoprophylaxis dosing method recommended and used for the Coronavirus 2019 is a similar type of method that used for short term homeoprophylaxis programs for many other infections diseases in HP programs for all ages, including for infants and children, college and medical students, mission workers, business travelers and tourists. 
The HP method will help to stimulate the body to recognize the current circulating COVID-19 strain and help to increase a person’s natural immunity to it.
Coronavirus Nosode: For those living in the USA, we offer the use of the homeopathic nosode for homeoprophylaxis  purposes. This remedy can be used for general immune boosting for those living in areas with actual diagnosed Coronavirus cases or those living in larger cities with the potential of higher levels of exposure to such cases.

Family Purchase With Our Supervision: The cost for HP supervision for short term (6 months) Coronavirus homeoprophylaxis is $49 per family and includes: 
A 1 dram vial with about 140 #30 size pills of the Coronavirus 2019 (COVID-19) homeopathic nosode in a 200C potency. 
You have access to a one (1) time download of detailed written dosing instructions and other information about the main homeopathic remedies and suggested dosing for Coronavirus. 
Purchase includes 7 days of email access for dosing questions NOT COVERED IN THE DOSING INSTRUCTIONS PROVIDED from the date of receipt of the product. Additional questions after this period are charged per day. 
You will receive information about how to purchase after your information is reviewed.  Please be patient as we have many requests.
It's not clear if this is the same product as Ullman is selling. Ullman does not make the claims that Kindem does but the intention is clear. Whether the FDA would act against Ullman is unknown.

Ullman knows something of regulation. His article The End of Homeopathy is NOT Near! talks about the misinformation put about by some parties such as Americans for Homeopathy Choice (mentioned in this previous post).

Possibly Ullman is ignorant of other elements of regulation or perhaps he doesn't think they apply to him? This blog has looked at US regulation several times in the past (here and here) and the status of nosodes was discussed here. In short, most nosodes are not considered OTC. They are de facto prescription only. The supply to/by lay homeopaths is illegal. Lay homeopaths are not recognised in any State. They have no prescribing rights.

Oh dear
It doesn't look good. Ullman is suggesting that inert sugar pills can prevent COVID-19. The supply of them to the public by him is legally questionable. It is the kind of thing his critics would have a field day with and might even attract the attention of the media. The legal/regulatory outcomes for Ullman are likely minor but he would be well advised to stop selling the product. 

The identity of the "respected homeopathic pharmacy" isn't known but is of greater concern. The legal/regulatory outcomes could be a lot worse for them.

UPDATE: 18/06/2020
Not long after this post was published the China 200C nosode disappeared from Ullman's online store. This could be coincidence. Whether Ullman would still sell it to a member of the public is unknown. "Mystery shopping" isn't a tactic used by this blog - others are better at that kind of thing.