2368 ARTIGO ARTICLE

Evidence-based and prejudice-based medicine: the case of

Medicina baseada em evidência e medicina baseada em preconceito: o caso da homeopatia

Medicina basada en la evidencia y medicina basada en el prejuicio: el caso de la homeopatía

Nelson Filice de Barros 1 Alessandra Rodrigues Fiuza 1

Abstract Resumen

1 Faculdade de Ciências In recent decades an important social movement Durante as últimas décadas, um importante movi- Médicas, Universidade Estadual de Campinas, related to Complementary and Alternative Med- mento social relacionado à Medicina Alternativa e Campinas, Brasil. icine has been identified worldwide. In Brazil, Complementar foi identificado em todo o mundo. although homeopathy was recognized as a spe- No Brasil, apesar de a homeopatia ser reconhecida Correspondence N. F. Barros cialist medical area in 1980, few medical schools como especialidade médica desde 1980, poucas es- Departamento de Saúde offer courses related to it. In a previous study, 176 colas médicas oferecem cursos relacionados a ela. Coletiva, Faculdade resident doctors at the University of Campinas Em um estudo prévio, 176 médicos residentes da de Ciências Médicas, Universidade Estadual de Medical School were interviewed and 86 (49%) Faculdade de Medicina da Universidade Estadual Campinas. rejected homeopathy as a subject in the core de Campinas foram entrevistados e 86 (49%) re- Rua Tessália Vieira de medical curriculum. Thus, this qualitative study cusaram a disciplina de homeopatia no currícu- Camargo 126, Campinas, SP 13087-887, Brasil. was conducted to understand their reasons for lo médico. Portanto, este estudo qualitativo foi [email protected] refusing. 20 residents from 15 different specialist conduzido para entender as razões desta recusa. areas were interviewed. Very few of them admit- Vinte residentes de 15 especialidades diferentes ted to a lack of knowledge for making a judg- foram entrevistados. Poucos declararam falta de ment about homeopathy; none of them made a conhecimento para julgar a homeopatia; nenhum conscientious objection to it; and the majority deles fez uma objeção consciente a ela; e a maio- demonstrated prejudice, affirming that there is ria demonstrou preconceito, afirmando que não not enough scientific evidence to support ho- há evidência científica suficiente para sustentá-la, meopathy, defending their position based on defendendo suas posições baseados em opinião personal opinion, limited clinical practice and pessoal, prática clínica limitada e em informações on information circulated in the mass media. Fi- de meios de comunicação de massa. Finalmente, nally, resident doctors’ prejudices against home- este preconceito em relação à homeopatia pode ser opathy can be extended to practices other than estendido a outras práticas diferentes da medicina allopathic medicine. alopática.

Evidence-Based Medicine; Complementary Medicina Baseada em Evidências; Terapias Therapies; Homeopathy; Prejudice Complementares; Homeopatia; Preconceito

Cad. Saúde Pública, Rio de Janeiro, 30(11):2368-2376, nov, 2014 http://dx.doi.org/10.1590/0102-311X00183513 EVIDENCE-BASED MEDICINE AND PREJUDICE-BASED MEDICINE 2369

Introduction did not know about its “inclusion in the curricu- lum of some Brazilian Medical Schools” 8(p. 16). The indexed literature on Complementary and According to Soledad et al. 9, only 40% (99) of 247 (CAM) has had around two medical students, from the University of Campi- hundred new clinical studies per annum added nas, correctly answered the questions about ho- to it, leading to a considerable increase in the meopathy principles and 25% of them were com- availability of evidence about its use 1. Never- pletely incorrect in their answers. theless, different biases related to the process of With regard to resident doctors, Brotherton et disseminating this knowledge have also been ob- al. 10 found that a quarter of the medical residence served, such as the so called bias of localization 2, programs in the United States develop subjects which shows that the greater part of positive and practices associated with CAM. It was also evidences on the use of CAM are published in pointed out by Lebensohn et al. 11 and Maizes et no- or low-impact-factor journals. In addition al. 12 that the offer of these subjects in family med- there is the geographic bias 3, which shows high icine programs have overcome the lack of inter- impact North American journals tend to publish est of young professionals in this area, leading to more negative evidence, while European jour- an increase in demand. This fact was considered nals, which also have a high impact factor, tend absolutely pertinent by Frenkel et al. 13 due to the to publish a greater number of studies with posi- proximity of the type and manner of work of the tive evidence. family health and CAM. These biases certainly matter a great deal Other studies with resident doctors investi- as regards the introduction of CAM in national gated specific knowledge and attitudes. The find- health systems, as professionals, health policy ings of Ashar et al. 14 showed that residents from managers and constructors tend to keep up to 15 different internal medicine programs in the date by seeking journals of greater impact, ex- United States had little knowledge about the use, actly those in which the majority of negative efficacy, safety and drug interaction of vitamin evidences are published 4. This is one way of ex- supplements. Very similar results were obtained plaining the perpetuation of the cycle of rejection by Xu & Levine 15 as regards the use of phyto- and social nonexistence of CAM, which can be therapeutic medications, especially with respect identified within a system of maintaining the sta- to the knowledge necessary for prescribing and tus quo composed of the pressures of the mono- referring patients to other professionals. Another culture of knowledge, linear time, naturalization interesting finding described by Lie & Boker 16 of differences, logic of the dominant and logic was that in comparison with professors and of productivity 5. undergraduate students, the group of resident To gain a better understanding of the struc- doctors at the Irvine School of Medicine of the ture of this complex, Polich et al. 6 interviewed re- University of California is the group that makes searchers of outstanding importance to identify least use of practices such as: meditation, tai chi, how they perceive and negotiate the challenges herbs, vitamins and homeopathy. of research with CAM in the area of health. After The issue at stake is the reconfiguration of analyzing the history of personal engagement of the frontiers of biomedicine and what are seen as these researchers, their reactions to the strategies important actions of advancement and retroces- for disseminating their studies in peer reviewed sion that extrapolate the dominions of scientific journals, they concluded that these investigators knowledge. This movement confirms the theory are exposed to constant pressures to appear and of Marcuse 17 and Denzin 18 that against an ac- act in a more “scientific” way. tion of counterculture, there is a cultural back- Different studies have been conducted with lash, so that people with new ideas are some- medical students and resident doctors includ- times rejected outright, whether or not there is ing on issues such as their perceptions and use evidence to support their point of view. of CAM. According to Teixeira et al. 7, over 85% Based on this set of information, a qualita- of the medical students at the University of São tive project was conducted with resident doctors Paulo considered that homeopathy and acupunc- from one of the most important Medical Schools ture should be included in curricula, as options in Brazil, about their perceptions related to learn- (72%) or compulsorily (19%); while 56% showed a ing homeopathy as part of medical undergradu- great interest in learning about them. In another ate studies. study conducted during a medical students’ con- ference, Teixeira 8 found that 43% of students did not recognize homeopathy as a “medical special- ty”, they were all unaware that it was “available through public health services” 8 (p. 16) and 64%

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Methodology Results

In a previous quantitative cross-sectional study None of the interviews refused homeopathy developed in 2008, 86 (48.9%) of the total of based on conscientious objection, since no argu- 176 resident doctors were unfavorable to the ment presented was of an informed nature on the inclusion of homeopathy in the undergraduate principles of homeopathy, and the justifications curriculum 19. In 2010 we developed a qualita- were based on general concepts and common tive study 20,21,22 in which 20 resident doctors sense. Thus, the interviewees made objections to were interviewed using semi-structured inter- homeopathy without knowledge of it and with- view techniques, out of the 23 who were still out producing an epistemological rupture, which in medical residence programs at the School goes beyond the spontaneous perspective of the of Medical Sciences, University of Campinas production of knowledge. (FCM/UNICAMP). In the 20 interviews held, there were few The participating residents were from 15 dif- expressions of a lack of knowledge and it is not ferent residence programs, namely: Gynecology possible to affirm that this is the most relevant and Obstetrics; Nephrology; Dermatology; Car- factor in their justifications. Moreover, a strong diology; Radiology and Imaging Diagnosis; Oph- relationship was observed between a lack of thalmology; Otorhinolaryngology; Infectology; knowledge and negative social value relative to Orthopedics and Traumatology; Plastic Surgery; homeopathy practices. The first association can Pediatrics (Pediatric Nephrology); Anesthesiol- be observed in the following extract, in which ogy; Urology; Psychiatry; and Radiotherapy. the interviewee affirms not having a great deal of Their demographic characteristics were: knowledge about homeopathy, and even so, does 47.37% female and 52.63% male; age-range not give it any credit. 26 to 31 years and conclusion of medical “In truth I do not know a great deal in order to course between 2002 and 2007. The major- have something to say. It’s as I told you, one has no ity concluded their undergraduate studies at the basis. One has the idea that homeopathy is a lot FCM/UNICAMP. of little drops, natural things or not, but in truth, The participants were invited to respond vol- one is not in the habit of giving a lot of credit to the untarily to the research, after being informed of pharmacological part of the stuff, you see?” (R1). its objectives. Each resident was contacted per- The lack of knowledge and negative value is sonally, and signed the Informed Consent Form. no different in the extract below, however in it The interviews were of a short duration, in spite one observes an aspect associated with hardly of the interviewers’ strategy of posing direct ques- reflexive social reproduction and a biased basis. tions in an endeavor to encourage participants to Thus, even among those who sought to be co- talk 22. In some interviews, irritability was per- herent, affirming they do not know homeopathy, ceived when the participant’s position was be- their arguments allowed them to see the negative ing questioned. However other resident doctors social value. changed their opinions as regards the inclusion “In truth, I don’t think I have a great deal of of homeopathy in undergraduate courses, per- argument to talk about this, because I have never haps as a result of the effect of the research, while studied it in depth. Homeopathy is a course we do demonstrated an interest in talking more about not have in undergraduation, so, after all, I don’t the subject after the interviews, both to clear up have sufficient knowledge to be saying this. What I doubts and to find out the interviewer’s opinion, know about homeopathy, I sincerely do not believe. or even to expand on their own interviews. The From what I know, I really don’t believe” (R2). interviews were recorded, transcribed and ana- In the material analyzed here, prejudice was lyzed by the second author and checked by the expressed in different forms, delimiting a set of first. Data analysis was thematic, fulfilling the sub-themes related to gender, ethnicity, social stages of classification by theme and deductive class and other forms. In the following extract categorization. when the resident doctor was invited to explain The study was conducted in accordance with his point of view, he justified it on the basis of the Helsinki Declaration, Resolution n. 196/1996 evidence-based practice, but when he was asked and Resolution n. 466/2012 (Brazilian National to discuss his evidence, then it was characterized Health Council), and was approved by the Eth- as prejudice, as can be observed. ics Research Committee of UNICAMP (report n. (I): “In the research last year, you said that ho- 136/2010). meopathy should not be introduced in the under- graduate course, why? ”. (P): “Because I think there is not a lot of scien- tific evidence, therefore it should not be taught”.

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(I): “Based on what evidence did you identify warning the interviewee gives the researcher on this negative point of homeopathy? ”. dealing with a practice that could lead to “being (P): “It is because what I know about home- put in jail!”, as can be observed as follows. opathy it does not have.... It is that I... homeopathy (I): “In the research last year, you said that ho- starts from this principle of dividing something in meopathy should not be introduced in the under- several, several a several times, dilution, is it not graduate course, why? ”. so?? Now, I confess, I never studied it properly to (P): “Because I think it is an alternative thera- know” (R4). py, not so? There are no studies as yet proving the Another subtheme used to justify the posi- efficacy of homeopathy, there are still many ques- tion against homeopathy was associated to clini- tions about homeopathy that does not make it a cal experience. It is well known that this is one therapy that is applied to all patients”. of the pillars of medical education, however the (I): “Do you base this on some evidence? ”. defense based on clinical practice is a little pre- (P): “On what one sees, in reports, on television mature in this case, since it concerns recently about homeopathy, there was even that report graduated resident doctors. that came out on “Fantástico”, that homeopathy (I): “In the research last year, you said that ho- was not effective” (R18). meopathy should not be introduced in the under- (I): “In the research last year, you said that ho- graduate course, why? ”. meopathy should not be introduced in the under- (P) “Because I don’t believe in the theory of ho- graduate course, why? ”. meopathy”. (P): “Because it has no scientific basis, or scien- (I): “Based on what evidence?”. tific proof that it works”. (P): “Based on clinical practice. (...) I have nev- (I): “Based on what evidence did you identify er sat down to read a study... I have heard com- this negative point of homeopathy? ”. ments about studies that have been made and (P): “Recently there was the child of a homeo- they have never managed to prove the efficacy of pathic doctor in Australia, who died because he homeopathic medication. I have never taken a was a homeopath and refused to treat the child study to read and have never even been interested with conventional treatment. He was condemned, in looking for one” (R3). put in jail! For not having treated his child ad- Of the same order as the justification in which equately. (...) I don’t believe it forms part of the clinical experience is given, there is personal ex- scope of medical sciences” (R7). perience. This justification is also poorly based The last theme is associated with the social and in the citation below, it is less clear than ever, invisibility of this medicine in comparison with since one is unable to identify whether the expe- hegemonic practice. This is a strong expression rience is of personal use of homeopathy or that of of the “monoculture of knowledge” which pro- patients that are treated. duces insignificance, promoting non existence. (I): “In the research last year, you said that ho- So that those who opt to treat or to be treated meopathy should not be introduced in the under- with homeopathy do not exist and it is not even graduate course, why? ”. necessary to have any evidence to prove this (P): “Because I think it doesn’t have a very “secondary subarea”, as is observed in the follow- broad scientific basis”. ing segment. (I): “Are you basing this on some evidence to (I): “In the research last year, you said that ho- identify this point? ”. meopathy should not be introduced in the under- (P): “Personal experience only, no scientific graduate course, why? ”. evidence, nothing like that. Personal experience, (P): “And I think that in the face of the neces- of my patients” (R12). sity, amount of knowledge, I would see this sub- Another theme that characterizes prejudice is area as secondary in comparison with the others”. associated with the reproduction of information (I): “And to you, which is the most negative circulated by the mass media, whose validation aspect of homeopathy? ”. criteria are not exactly based on scientific evi- (P): “I think the lack of evident and clear bases dence. The first extract, justifying on the basis of a of its results”. television program, presents homeopathy firstly (I): “Do you base this on some evidence? ”. as an “alternative therapy”, something that was (P): “No” (R1). very common in academic debates in the 1970s Thus, it is showed that prejudice appears to and 80s. The second segment of the interview re- be the basis for medical residents’ refusal of ho- produces information that a large British journal meopathy. A fact that prevents them from seek- published and which was circulated on the In- ing greater knowledge and studying it, based ternet, also with poor criterial details. However, on their denial essentially of the mistaken non- what draws most attention in this speech is the existence of scientific evidences, proof on the

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bases of personal experience, reproduction of on medical ethics, relative to abortion and scarcely accurate information circulated in the euthanasia 25,26. mass media and the invisibility of this practice For Gampel 27, there are five factors that jus- in comparison with the hegemonic model. Cer- tify conscientious objection in medicine: (1) the tainly, the result is the maintenance of the cycle centrality for the doctor’s essential ethical values; of prejudice in which doctors, by denying it, do (2) the basic rules of the profession and relevance not know it, and because they do not recognize to the moral integrity of the professional doctor; it, they deny it. (3) the instruction of the concept of the doctor as a medical ethic, rather than a personal eth- ic; (4) the impact on the rights and interests of Discussion patients; and (5) recognition of the competent rights and interests by law and by the rules of It should be pointed out that there were some medical ethics. difficulties in performing the work of data collec- It was considered a lack of knowledge when tion, such as: (a) finding the interviewees, who perceptions related to the following factors could frequently change training section within the be observed in the discourses: ignorance result- Medical School Hospital complex; (b) little avail- ing from not reading, lack of knowledge, infor- ability of the resident doctors due to the great de- mation, or education about homeopathy; lack of mand for them; (c) resident doctors’ low level of experience and the knowledge/understanding interest in this subject. Nevertheless, we inferred derived from self experience and other experi- that two points helped in promoting receptive- ence with homeopathy; lack of understanding, ness to participation in the research: (a) recogni- unfamiliarity with, innocence of, unconsciousness tion of the interviewer due to having conducted of homeopathy bases 28. Prejudice is understood the previous study; and (b) appreciation of the as generalizations expressed from personal expe- importance of scientific research to the academic rience or by imposition from the social medium, life of the interviewees 19. showing one to be against the practice, fact, or This study has the limitation of being devel- person, before even getting to know it. As in other oped in only one medical school; however it is expressions of prejudice, in this analysis one can one of the most important schools of medicine in also observe justifications that are inadequate Brazil. Also, the multi-method perspective adds from the point of view of knowledge, not very credibility to the study 22. accurate and expressions of resistance on a non Homeopathic medicine was introduced to rational basis. Brazil in the XIX century and is currently ranked The majority of the professionals interviewed the 16th medical specialty with the largest con- are recently qualified doctors with little prac- tingent of professionals among 61 specialties tice and knowledge about homeopathy and in analyzed in the survey conducted in 1996 7,8,23. their school experiences they take on prejudices Nevertheless, only 17 schools of medicine among without realizing they are reproducing it. In fact, 115 analyzed in Brazil have been teaching ho- they carry out an action that has already become meopathic principles, and among these not all well known, and which only varies in relation to respect the minimum curriculum of 45 minutes the object, because prejudice is not something per lesson as suggested by the Brazilian Homeo- that experience accumulates and that guides the pathic Medical Association 24. action without blocking reflection. Prejudice is In this article, the idea that CAM should be constructed and involves generalization to all used by all and for all health problems is not de- elements that form part of a set of characteris- fended, but that professionals should know its tics that do not necessarily belong to the object. principles and discuss their decision based on Thus, prejudice is not a cognitive process, but it is well founded evidence and conscientious ap- its negation; and it is not even the exercise of free proval or objection, and not on a lack of knowl- imagination, because the petrified subjectivity in edge or prejudice. prejudice prevents freedom 29. Conscientious objection was considered the The resident doctors interviewed refused ho- argument that lets one see that the individual meopathy based on the movement of Evidence refuses to practice or act on the basis of moral Based Medicine (EBM). This finding is recurrent judgment, in accordance with philosophical, among allopathic doctors and coherent with religious or political beliefs. It is a concept of the analyses presented in other articles 4,30. The the same order as that of “civil disobedience”, adoption of EBM makes it possible to see that it whereby some soldiers refused to take part in deals with an action that precedes “prejudice”, the war. Later, this concept was brought to the supported by stereotyped thinking. For Jahoda medical field, mainly associated with debates & Ackerman 31 it concerns an attitude of hostility

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in interpersonal relationship, directed against an The actions of the WHO and its affiliates pro- entire group or against individuals belonging to it mote social inclusion and limit prejudice. In this and which is an irrational purpose. way, one does not seek to exonerate the agent Prejudice as it has been identified does not from responsibility for his acts, but understand point towards a process of conception, or to the genesis of his action in a culture that privi- singularization of the type of evidence lacking, leges force and in which the prejudiced individ- but rather to the production of social invisibility. ual prepares the action of exclusion of those who Indeed, more knowledge about homeopathy is are weaker by those who cannot live with their necessary, however a meta-analysis was devel- own fragility 39. Therefore, inclusion of CAM in oped at the beginning of the 1990s, constructed undergraduate courses in the field of health is with 105 controlled clinical studies, among which fundamental so that students have information 81 pointed to the positive effects of homeopathy and education and can operate as agents of social and 24 to negative effects 32. transformation 40. Thus, an exercise of visibility is necessary, on From this general panorama it is possible the one hand to reflect on the biases of studies to see the marginalization of homeopathy and about CAM published in conventional medical the challenges of connivance with differences in journals, and on the other hand, broaden the teaching and medical assistance; as well as the perspective of science in the field of health, with construction of social environments that allow a process of observation, identification, descrip- the coexistence of traditions, founded on differ- tion, experimental investigation and theoretical ent principles or visions which may help in the discussion, not restricted to a single tradition processes of prevention and health promotion 10. of thought. It is possible to identify the smaller On the other hand, it points to the need for the number of publications about CAM in journals development of the sociology of CAM, based on with a high impact factor owing to: (a) low in- therapeutic pluralism 41. clusion of professionals practicing CAM in the academic environment, which may lead to less scientific training; (b) lack of adequate financing, Final considerations due not only to distancing from academia, but mainly to a lack of interest on the part of sup- In this article a critical perspective has been porting institutions; and (c) a lack of cooperation adopted to analyze the evidence in the field of between biomedical researchers and CAM 33. health as a fact that expresses domination, preju- The invisibility of CAM is prejudicial not only dice, and the mistaken use of a tool. Neverthe- to scientific knowledge, but also to patients, who less, the epistemic guidance adopted is the same frequently do not reveal the other forms of care that Foucault 42 (p. XVI) announced in the in- and cure they use, assuming the risks with the troduction of the Birth of the Clinic: “This book purpose of not exposing themselves to further is not written by one medicine against another, social humiliation. Solely accepting the onus for or against medicine, by an absence of medicine. the non conventional therapeutic option can Here, as in other places, it deals with a study that also be understood as resistance against the rei- tries to extract from the thickness of the discourse, fication or even genesis of its pathogenesis; or the conditions of its history. What counts in the surrender to a fixed enunciation, “reified” and things said by men is not so much what they have transformed into a fetish 34. thought short of or beyond them, but what has sys- This is why the World Health Organization 35 tematized them from the beginning, making them, has created proposals for social inclusion of non throughout time, infinitely accessible to new and conventional practices that guarantee access to open discourses to the task of transforming them”. other forms of understanding the health-disease- Therefore, there is no pretension to affirm care process; to help the dialogue between bio- that one practice has greater relevance than an- medical professionals and practitioners of CAM; other, or to follow with alternative guidance of to regulate the practice of CAM and promote its the counterculture of the 1960s and 1970s, but to implementation in health systems with safe and give visibility to a clash within the field of health. rational use. In the United States, different ap- However, it is concluded that prejudice is still one proaches have been taken to implement CAM of the main constraints to the inclusion of alter- in health services 36 and to teach in the field of native and complementary in aca- health 37. In Brazil the pathways are different, be- demic undergraduate courses in medicine. This cause homeopathy has been a medical specialty involves the creation of a vicious cycle of refusal, for more than 30 years, and it is being included in based on biases that produce invisibility, exclu- the Brazilian Unified National Health System and sion and social humiliation for those who use it, some Brazilian medical schools 24,38. in the condition of professional or patient.

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Based on the reproduction of irrational con- so much diagnostic and predictive capacity in cepts and backed by the discourse of evidence- western medicine, however, there has also never based medicine, the resident doctors interviewed before been a record of such quest for practices of have shared prejudices against homeopathy. other types of medicines. Thus, they demand scientific evidence for recog- Nevertheless, it is necessary to observe quali- nition, but not for refusing, which shows a clear tative changes within this contradiction over the contradiction between an evidence-based dis- last few decades, as CAM have moved from the course and a practice based on prejudice. In the marginality of the field of health to its periphery face of this scenario, the need for the inclusion 43. This movement must be appreciated and rec- of non conventional care and cure practices in ognized, for example, in the fact that 51% (90) undergraduate courses is preeminent, in order to of resident doctors interviewed accepted and guarantee, based on the thinking of social condi- supported the teaching of homeopathy in the tions that promote inclusion and help to combat medical course. Undoubtedly this is a signifi- subjective conditions related to prejudice. cant advance of non conventional practices in Finally, it is concluded that in the last few the field of health, demonstrating that although decades an important social movement has oc- there is hegemony in the biomedical model in curred related to the non biomedical care prac- this field, its structure is not entirely equal or tices in the field of health, starting with a con- homogeneous. tradiction that still persists: never have we had

Resumen Contributors

Durante las últimas décadas, un importante movi- N. F. Barros and A. R. Fiuza were responsible for the pro- miento social relacionado con la medicina alternativa ject and writing the paper. y complementaria ha surgido en todo el mundo. En Brasil, pese a que la homeopatía fue reconocida como especialidad médica desde 1980, pocas escuelas médi- Acknowledgments cas ofrecen cursos. En un estudio previo, 176 médicos residentes de la Universidad de Campinas- Facultad The authors would like to thank the referee for impor- de Medicina fueron entrevistados y 86 (49%) rechaza- tant suggestions. ron el curso de homeopatía en el plan de estudios mé- dicos. Este estudio cualitativo se propone entender las razones del rechazo. Se entrevistaron a veinte residentes de 15 especialidades diferentes. Pocos declararon falta de conocimientos para juzgar la homeopatía; ninguno hizo una objeción consciente a la misma; y la mayoria demostró prejuicios, afirmando que no hay evidencia científica que apoye la homeopatía, defendiendo sus posiciones con opinión personal, práctica clínica limi- tada e informaciones de medios de comunicación de masas. Finalmente, el prejuicio de los médicos residen- tes sobre la homeopatía se puede extender a otras prác- ticas diferentes de la medicina alopática.

Medicina Basada em Evidencia; Terapias Complementarias; Homeopatía; Prejuicio

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