The General Medical Council: nice bedside manner with quacks

I have for some time been critical of the GMC’s acquiescence over doctors who practise quackery, but I’m concerned now at how it seems to be getting into bed with them. I just came across an `oncologist and professor of Chinese medicine‘ and phoned the GMC for advice as to whether they would regulate such a person – who is not apparently registered to practise in the UK. It was an odd conversation, which I have followed up with this email to the GMC:

The other day I spoke to one of your advisers, who used the term `allopathic medicine’. I was horrified to hear this. She then said that this is widely used in GMC documents, so I had a look. She was right. It seems that this word is being used as a label for what most people would consider to be real medicine, as opposed to `treatments’ based on imaginary ideas about how the body works. Perhaps you don’t know the provenance of the word.

It was coined by the inventor of homeopathy, Samuel Hahnemann, to distinguish his `system of medicine’ from the convention at the time. In the 1790s doctors killed more patients than they cured, by such practices as purging and bloodletting. Hahnemann’s treatments of course did nothing at all, so at least his patients had the chance of letting nature take its course. His dictum of `like cures like’ was an error, as he thought that the fever he suffered from taking cinchona was the usual reaction, and mimicked the symptoms of malaria. In reality most people don’t get this reaction so Hahnemann was probably allergic to cinchona. He then extrapolated this one observation to every disease he could find. If you read his `Organon of the Healing Art’ you will find that it’s a collage of allegories and anecdotes which might well illustrate his thinking, but provide no scientific basis for his `system’. There is an excellent critique of that work here, dating from 1842 so it has been known to be worthless for a very long time.

Hahnemann’s ex cathedra `law of similars’ was based on the false assumption that all diseases could be cured by giving a `remedy’ that produced similar symptoms to those of the disease. He then invalidated this idea by insisting that remedies must be diluted until there was virtually nothing of the starting substance left, and hence no symptoms. So he was not treating `like with like’ at all, he was treating like with nothing. He then decided that this new approach had to be demarcated from conventional medicine, which he said used treatments which produced symptoms opposite to those of the disease. This wasn’t really the case then and it certainly isn’t now. So his system was `homeopathy’ and its opposite was `allopathy’.

From this, it’s obvious that to call modern medicine allopathy is entirely wrong. It’s wrong because it was originally applied to everything that wasn’t homeopathy, it’s wrong because modern medicine does not treat only on the basis of symptoms, and it’s wrong because modern medicine doesn’t treat by opposing symptoms. Not only is it conceptually and etymologically wrong, it is also harmful because it gives comfort to those who oppose modern medicine and mostly make money by misleading vulnerable patients. `Allopathy’ is widely used by opponents of evidence based medicine as a derogatory term, and we should not encourage this by using their lexicon.

The conversation which triggered the foregoing was about a doctor who claims to be able to cure cancer with a mixture of herbs. I was asking about how this sort of activity is regulated by the GMC. I learned that some curious rules apply. If the doctor claims to cure cancer, and only uses herbs, then the GMC says this is `out of remit’. A wide range of evidence-free practices fall into this category, such as homeopathy. However if the doctor claims a specialism, in this case oncology, then it is within remit. What concerns me is that the obvious harm of misleading patients with false claims of efficacy, and in this case breaching The Cancer Act 1939, are of no concern to the GMC.

All of this seems to reinforce my impression that the GMC is excessively tolerant of doctors who mislead patients with false claims. This tolerance extends to taking on their terminology. I will be very interested in your response to this – in particular to correct anything I have misunderstood.

I don’t expect a reply for a few days, and will certainly post it here when it arrives. I did get a read receipt. The GMC of course says that replies are private but I shall as ever use the public interest defence. I also asked during that phone call, if they declined to regulate a doctor using herbs, who would? The adviser referred me to The Register of Chinese Herbal Medicine. I asked if this was a statutory regulator. The adviser said yes – but of course it isn’t, it’s totally voluntary and doesn’t require evidence based practice from its members. Like all quack regulators, it’s useless.

Watch this space.

Updated 5.11.2017

Yes I did get a reply, and it was surprisingly extensive. I was expecting to be dismissed, but the writer clearly understood my argument:

In fact, we use the term ‘allopathic’ only with reference to the criteria that we apply to determining whether an overseas medical qualification is acceptable for GMC registration. If you try searching our website for the word again, you will find that all of the documents returned by such a search relate to those criteria – which are published online, here. Criterion 2(a) begins with the words ‘it must be a primary qualification in allopathic medicine’, the aim being to make it clear to prospective applicants that qualifications in any form of complementary or alternative medicine (CAM) won’t be acceptable.

You make a valid point about the origin of the word, and its use by homeopaths and those who support homeopathy as a form of treatment. But, at the same time, it’s not uncommonly used by others as a convenient shorthand for conventional, evidence-based medicine, in contrast not just to homeopathy but to all forms of CAM, including (for instance) traditional Chinese and Ayurvedic medicine. We expressly define it in those terms in the glossary we’ve published for the purposes of interpreting the criteria. That’s available online here.

I don’t think our approach is particularly unusual or controversial. You may be interested to know, for instance, that the World Health Organisation has adopted a similar usage, for similar reasons, in a number of its publications – for example, in Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review, in Traditional Medicine Growing Needs and Potential – WHO Policy Perspectives on Medicines, No. 002 (2002), and in Traditional Medicine Strategy 2002–2005.

Turning to the matter that led you to contact us in the first place, I’m sorry if the advice you were given wasn’t helpful. The key point is that, by law, our disciplinary jurisdiction extends only to doctors who are registered with us. We would have no locus to take action against an alternative medicine practitioner making claims of the sort to which you refer, unless (perhaps) he or she was also making false claims to be GMC-registered or licensed. Both of those are criminal offences under the Medical Act 1983 – which sets out our functions and purpose – and it would be open to us to refer any evidence of such an offence to the police.

I understand that offences under the Cancer Act that relate to advertising cures are matters for the Advertising Standards Authority (ASA) and local Trading Standards, with the latter being responsible for prosecutions. You may therefore wish to get in touch with the ASA for further advice. I’m afraid it’s not something we can take further ourselves. Although protecting the safety of patients and the public is the GMC’s main objective under the Medical Act, we have to recognise that our statutory role in that connection is focused quite tightly on regulating the medical profession, and that authority to deal with issues that fall outside that role has been assigned by law to others.

I have this clarifies matters a little but, if you have any questions, please do let me know.

Of course, I did have more questions:

Many thanks for your thoughtful reply. As you might imagine, I have some comments.

The GMC’s definition of allopathic medicine avoids the elephant in the room, which is that the two main categories are separated as to evidence. Essentially modern medicine, which the GMC now calls allopathic, is evidence based. This has not always been the case, and even today not all of it is. But in general modern medicine is defined as:

1. Having a plausible mechanism of action.

2. Having been tested in patients and robust evidence supports its use.

CAM immediately fails the first of these tests. Traditional explanations for the huge range of CAMs out there are largely inventions, eg acupuncture meridians, ayurvedic humours, and chiropractic subluxations. It fails the second because what evidence there is, is mostly from unstructured and observational studies, and anecdotes. Even acupuncture, which has become firmly embedded in main stream medicine in some areas, is increasingly being exposed as a theatrical placebo, as the rigour of RCTs improves. Notwithstanding the debates around the evidence for much of conventional medicine (eg reproducibility of studies, false positive results), it clearly is working towards fully evidence based practice. CAM rejects this and clings to imaginary explanations of how the body works. Why is it so hard for the GMC to define medicine on the basis of evidence?

Just because others use the term `allopathic’ does not justify its use by the GMC. I can’t find in the WHO documents any mention of evidence in relation to their use of the word. In any case the WHO has for years been sympathetic to traditional systems of health care.

With regard to the case which underlies this exchange, presumably it’s up to me to report the doctor to the police for practising medicine without GMC registration?

This brought the following reply from the GMC:

I don’t take issue with you about the difference between conventional medicine on the one hand and complementary and alternative medicine (CAM) on the other. And as I indicated in my last email, I take your point about the origin of the word ‘allopathic’. But I don’t think etymology takes precedence over usage, and it’s not just the GMC and the World Health Organisation who use the term as shorthand for conventional medicine.

For instance, if you conduct a search of the BMJ’s website, you’ll see that it’s been used in that sense in research papers the Journal has published, some of them quite recent – for instance in Physician age and outcomes in elderly patients in hospital in the US: observational study (May 2017). I think this perhaps reflects the fact that, in medical and academic circles, the word has been reclaimed from homeopathy.

Perhaps more importantly, it’s worth bearing in mind that we need our acceptability criteria to be readily understood by international medical graduates from across the world. And our experience is that the word ‘allopathic’ is readily understood by doctors as a neutral catchall term for conventional medicine (although that’s partly because we’ve defined it as such in our glossary, this is essentially a belt and braces measure – not all prospective applicants for registration read around our guidance as much as they really should).

I believe that’s common usage in India, for example. In fact, it’s used by the Medical Council of India, not least in its Code of Ethics Regulations. And doctors who graduated in India form the second biggest group of GMC registrants after doctors who qualified in the UK.

All that said, we review our acceptability criteria from time to time and I’d be happy to look at whether there is a better word we can use next time we undertake such a review.

Turning to your final question, practising medicine without GMC registration isn’t necessarily a criminal offence (although it might in some circumstances involve the commission of another type of offence – wounding, for instance, if it involved surgery). That has to be the case because there is no general definition of medical practice anywhere in UK law – rather, the approach that the law takes is to reserve particular activities to registered medical practitioners in the particular legislation that covers those activities.

However, there are quite a lot of things that would generally be regarded as medical practice but which aren’t reserved. For example, a lawful entitlement to conduct a physical examination isn’t exclusive to registered doctors, and couldn’t be. If it were, CAM practitioners – and, indeed, mainstream healthcare professionals, such as ambulance staff and paramedics – would find themselves perpetually in breach of the law.

In the circumstances, the offences defined in the Medical Act 1983 are, very specifically, pretending to be GMC-registered and pretending to be licensed. If you have evidence of such an offence, we’d be happy to liaise with the police ourselves. Otherwise, your main option would seem to be to contact the Advertising Standards Authority, as I suggested in my last email.

I hope this clarifies the position a little further.

So I’m leaving it there. I did point out that the Indian government actively supports CAM, including homeopathy, so it’s hardly surprising to see it using the word ​allopathy’. This is not something to be lauded or emulated. I’m also intrigued by the legal black hole that unregistered medical practitioners hide in. We don’t have the equivalent of legislation that most US states have, which is practising medicine without a license. The dangerous `alkaline diet’ quack Robert O Young was jailed under that law recently. It hardly seems reasonable to expect Trading Standards to take on regulation of unregistered medical doctors, with their resources having been decimated over the last decade.

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2 Responses

  1. With all the news about Oxfam and the Charity Commission probably time to consider Cancer Active charitable status in view of funds channeled through a BVI company directly to its founder

    • Indeed. As it happens I was looking at CancerActive again only yesterday. This will take a bit of work – shall we collaborate?

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