Around the end of 2012 I was alerted to the claims which Dr Jessica Middleton was making on her website, which she calls The Natural Doctor. A central issue was that Dr Middleton (now Dr Braid – see below) was clearly trading as a medical doctor, as evidenced by the name of her business, and the use of her medical degrees on the opening page of the site. However she does not practise anything which might be called conventional medicine, preferring to offer a wide range of diagnostics and `treatments’ which mostly lack robust evidence. I don’t intend to provide a detailed critique of what is on offer, as my purpose with this post is to explore how such a doctor is regulated. Meanwhile, I’m sure some of you will have your own views about an apparently intelligent young woman who was extensively educated in medicine, to a large extent at public expense, and now chooses not to utilise any of that training in service to the public.
I normally avoid personal attacks, but I have to identify Dr Middleton in order to illustrate very serious problems with the regulatory environment. So I will explain in some detail what happened when I sent a complaint to the General Medical Council. Dr Middleton’s record on the Medical Register shows that she is indeed registered with the GMC, but not licensed to practise. If anyone can explain why this might be the case, please tell me. My understanding so far is that she is not permitted by the GMC to work as a medical doctor, a point which I made to the GMC. At the same time, I submitted a critique of the claims Dr Middleton was making, such as for acupuncture, homeopathy, natural progesterone, kinesiology, and herbs.
The GMC’s first stage process is to refer a complaint to the case examiners, who decide whether there is a case to answer. Quite quickly their decision was that Dr Middleton was not practising as a medical doctor, and was not misleading anyone by implying that she was. I leave it to my readers to look at her website and consider whether the use of the business name The Natural Doctor, information on her short career in the NHS, and the prominent display of her medical degree, are all entirely irrelevant to her present practice.
With regard to the claims on her website, the GMC acted as little more than a postman, and simply forwarded my critique to Dr Middleton. This of course resulted in a voluminous response from Dr Middleton, which I had to go through in further detail. A particularly contentious set of claims related to natural progesterone. Through my good friends at Sense About Science, I contacted The Endocrine Society, who confirmed that the claims were largely spurious. So off went my second critique to the GMC, this time supported by expert endocrinologists. Here is the final decision of the case examiners:
The Case Examiners agree that there is no evidence that Dr Middleton is conducting medical examinations or engaging in medical practice. Dr Middleton is currently a non medical practitioner of complementary therapies. The Case Examiners agree that a doctor advocating an alternative approach in general terms does not raise an issue of professional misconduct.
Reading between the lines, the GMC appears to be saying that a doctor who chooses to practise health care largely based on irrational thinking and false claims, is not practising medicine so is outside the remit of the GMC’s regulatory process. Convenient eh? Dr Middleton, despite being a registered doctor, is absolved of the obligation to follow the requirements of registration, because she provides misleading information to her patients. Of course, the GMC totally ignored my responses that showed the claims to be false.
But who says the information is misleading? Well I do, The Endocrine Society does, and now the Advertising Standards Authority does. After this GMC brush-off, I submitted complaints to the ASA (using the excellent FishBarrel). At the time I excluded the wild claims Dr Middleton made for homeopathy, as the ASA was carrying out a class action and was not accepting further homeopathy complaints (it is now). Some six months later I received a response from the ASA, saying that the complaints had been informally resolved, and that the false claims were to be removed or amended. The last time I looked, the claims had been modified, but I was astounded to see this statement regarding Therapeutic Energy Kinesiology (TEK):
NB: Since March 2011 due to the restrictions imposed by the Advertising Standards Agency(ASA) and the Committee of Advertising (CAP) I am now not allowed to describe on my website what symptoms kinesiology can help or provide any more information. Please ring Dr Jessica’s practice so that TEK can be explained in more detail as the spoken word is not covered by the restrictions of the ASA and CAP.
If we accept the ASA’s decision that the written claims for kinesiology were misleading, this doctor appears to be saying that she will provide misleading information verbally to anyone who telephones her. I’m sure she doesn’t actually think that, and I’m equally sure that she disagrees with the ASA and believes that she is not misleading anyone. But belief is not evidence, a lesson which Dr Middleton appears not to have learned at medical school. I have asked the GMC for a view on the professional ethics of this statement, as well as on the matter of most of this doctor’s claims having been adjudged misleading.
Could it be that the GMC is terrified of opening this can of worms? Here we have a doctor whom the GMC has said is not practising medicine so is not subject to medical regulation. What about a doctor who practises both evidence-based medicine and evidence-free medicine? There are lots of these, for example medical homeopaths. I am now wondering how these would be viewed by the case examiners. Would they be considered subject to regulation for the bits of their practice that are real medicine, and not for the bits that are make-believe? So far the GMC has shown very little enthusiasm for disciplining medical homeopaths, even though homeopathy has been comprehensively dismissed by the Chief Medical Officer, the government’s Chief Scientist, and now at long last the Secretary of State for Health. Only the most extreme cases are referred for action by the case examiners, for example that of Dr Marisa Viegas who caused a patient’s death by advising her to stop treatment for heart failure and to take homeopathy.
So it seems that the GMC will only take action when the doctor concerned has killed someone – rather too late some would say. It is really very disappointing that, after a great deal of public concern about the effectiveness of the medical profession regulating itself, resulting in the establishment of the independent Medical Practitioners Tribunal Service, the gate keeper is still the GMC – and only the GMC decides whether to refer a case to a Tribunal. So plus ça change….. the doctors still look after themselves.
So I have alerted the GMC to these two developments, the ASA’s ruling about misleading claims, and the doctor’s written offer to provide misleading evidence orally. I am told that the case has been referred to the Rule 12 team. Rule 12 of the Fitness to Practise Rules empowers the Registrar to review decisions that may have been wrong, or where new evidence has arisen. The GMC is at pains to clarify that even if one or both of these tests is positive,
…..a review can only be undertaken if the Registrar is also of the the view that a review is necessary for the protection of the public; necessary for the prevention of injustice to the practitioner; or otherwise necessary in the public interest.
Does the GMC take the view that preventing misleading information being given to sick people is necessary or not necessary? So far we don’t know, and as no time scale can be given for a reply, it’s going to take some time to find out. Meanwhile Dr Middleton will be happily taking phone calls from anyone who wants to be told porkies about how their body works.
The ASA also thought Dr Middleton’s statement about oral advice rather surprising, but technically it would not fall under the Committee of Advertising Practice (CAP) code as it isn’t a claim. The ASA didn’t think anyone would take up the offer, but I am a lot more sceptical about that. Some people are comforted by lies, as long as the lies reinforce their beliefs.
I note that Dr Middleton is now using a new surname, Braid. If that is because of marriage, may I wish her all the happiness of married life. That is a quite separate matter from her job as a purveyor of quackery. Under her new name, she has reacted to the ASA’s action by starting a petition. She objects to being required to back up claims with proper evidence. Interesting that she has addressed it to the wrong minister – Jeremy Hunt is not responsible for consumer affairs. Also she can’t spell complementary. She is of a similar age group to my GP son, who was taught a great deal about the nature of evidence while at Southampton School of Medicine. I assume that Dr Braid’s education at Manchester included much the same material. Yet she seems to have forgotten all that, because she really does not understand what evidence is. Let me summarise for her.
Randomised controlled trials (RCTs) are the bedrock of clinical research. But they are not the last word. In tightly controlled circumstances they can tell us whether a treatment has some intrinsic activity, with reasonable confidence. There is always uncertainty of course, and even when we have good RCT results there is always the question “so what?”. The efficacy we have measured may not matter to most patients seen by clinicians. An example of that is the SSRI anti-depressants, which have very little activity in mildly depressed patients, despite obtaining marketing authorisation on the basis of RCTs. Hence, less rigorous but more realistic research is increasingly being undertaken, to see whether the RCT evidence can be generalised to the population that a practitioner sees.
But what if a drug failed all the RCTs, and the drug company still insisted on marketing it? What if they said “Never mind the RCTs, we have done other less rigorous research and that shows it works. Please give us a licence.” Would any of us accept that? Yet that essentially is what Dr Braid is saying. She wants to skip the RCTs and rely only on anecdotes, testimonials, uncontrolled case series etc. Basically RCTs are an inconvenient truth for the treatments she sells to patients.
I should conclude with a consideration of this matter of truth. Have I accused Dr Braid of lying to patients? It depends on what you mean by a lie. If it means telling somebody something that you know is untrue, then Dr Braid most likely is not lying. If it means telling people something that any person could reasonably be expected to know to be untrue, but you simply ignore the truth and pretend you know differently, then that is pretty close to a lie. My guess is that Dr Braid is not consciously lying, and firmly believes that what she tells patients is true. But by ignoring the actual truth the effect is the same – sick patients are misled, and may suffer damage.