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Evidence-Based Medicine and Prejudice-Based Medicine: the Case of Homeopathy

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Evidence-Based Medicine and Prejudice-Based Medicine: the Case of Homeopathy 2368 ARTIGO ARTICLE Evidence-based medicine and prejudice-based medicine: the case of homeopathy 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 Alternative Medicine (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 doctor 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% Cad. Saúde Pública, Rio de Janeiro, 30(11):2368-2376, nov, 2014 2370 Barros NF, Fiuza AR 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.
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