ethics

The importance of a fluffy pen

Many years ago, in my pre-reg year, I was pulled into an office by my tutor and told that I needed to sober up. She didn't mean that in an alcohol sense, but instead that I needed to start being more serious, dour, and less quirky. She told me that my personality, as it was, wasn't right to be a professional.

At the time, I believed her. She told me that I would never make a good pharmacist if I carried on the way I was. I was terrified, as all I wanted to do with my life was to be a pharmacist. If I couldn't be a good one, then I would really need to change my personality.

All of this started because I had a Christmas pen. It played tinny music for an alarmingly long time when pressed, and it became a bit of a joke in the dispensary to sneak up behind me when I was working and set it off, making everyone dissolve into giggles. A dispensing assistant, who was wearing a Christmas tie, was also told off, and strongly advised to not wear it again.

But nowadays, I disagree heartily that you have to be serious to be professional. I think a little bit of well-placed silliness and a lot of humour can add to our professionalism.

We need to be approachable to patients. And what makes a person more approachable than a little bit of personality? Nothing, except perhaps a novelty pen. On a couple of occasions, women who have come to see me about the emergency hormonal contraception pill, and who have been very nervous, have ended up giggling at a ridiculously fluffy pink flamingo pen I used to have. It broke the ice, and they could see that I was a person just like them, and I wasn't going to sit there all business-suited and high and mighty at the other side of the table and judge them. They felt a lot more comfortable because of that pen, and I think I was able to help them a lot more as a result.

At the moment, I have a Special Pen in my desk drawer. It is comedically large, pink, and slightly phallic, with some floppy rubber spikes on the end. I like to take it out of my desk drawer and offer it up, straight-faced, when people ask to borrow a pen. 

my special comedy pen, with a banana for scale

my special comedy pen, with a banana for scale

We health care professionals deal with a lot of dark stuff on a daily basis: sickness, death, disability, anger, frustration etc. We need to balance that darkness out with something lighter. Whether its doing something daft in the dispensary to make your staff laugh for a few seconds when times are stressful, or donning a fox mask and writing silly things on the internet, it all counts. 

As long as we put the patient first, we treat others with respect, and we work within our limits, true professionalism doesn't have to mean that we all walk about with serious faces.


Hxxx  

Homeopathic Harms 3.1 Addendum: C's Story

Imagine you're twelve years old.

You're on the cusp of adolescence, a time where you start to move away from the comfort and protection of your family and begin to forge your own way in life. Friendships become increasingly important, and you're in a constant process of trying to make new ones, maintaining old ones, and falling out with others. The world seems confusing, terrifying, and wonderful in varying measures, and you spend a lot of your time watching those around you and drinking in how they act, what works and what doesn't, deciding how to act yourself to fit in and be accepted. This is the time when, though the ground is constantly shifting beneath your feet. you start to put down little social foundations and try to make sense of the world. 


There is a wealth of evidence that suggests many benefits of connecting with people of your own age during adolescence. At such a crucial, tumultuous time of life, being socially isolated from your peers can have long lasting and harmful effects. 


What's this got to do with homeopathy?

I've written before about how poor advice from homeopaths can potentially cause a lot of damage, and through our Homeopathic Harms series of blog posts, Nancy (of the Evidence Based Skepticism blog) and I have hopefully managed to convey to you an idea of how it can sometimes be the seemingly innocuous and difficult to quantify harms that can be most worrying.

I received an e-mail the other day that I have since been thinking a lot about and which I wanted to share with you. Its a real-life example of just how much harm poor advice from a homeopath can cause. The chap who sent me the email has very kindly allowed me to share his story with you, but of course I am going to respect his anonymity and refer to him as C.

C's story

C. had delayed puberty. Now this is something that is fairly common, happening in about 3% of cases, and which can be caused by a number of factors, but the most common type is Constitutional delay in growth and puberty (CDGP). This is basically a technical way of saying 'Just one of those things, which might be caused a whole load of stuff or possibly just chance.'

Conventional medicine would manage CDGP by... well, usually just by waiting, really. Monitoring, and reassurance are often all that is required. Otherwise, short courses of sex hormones should be enough to do the trick. If the delay in puberty is caused by something, then ideally the underlying cause would be appropriately treated. You can see some good, reliable guidance on management here

Note, by the way, that the definition of delayed puberty according to patient.co.uk specifies '...in boys beyond 14 years old'.  Now, I have no way of saying what the definition of delayed puberty was at the time that we join C's story, but his experiences began when he was 12- well below the point where we would diagnose delayed puberty nowadays.

C's mother consulted a homeopath. He was given some homeopathic pills, which on account of just being made out of sugar, had no beneficial effects, but also no harmful effects. However, the homeopath also appears to have given C's mum some advice, the goal of which seems to have been isolating him from his peers between the ages 

C was:

  • not allowed to stay at school for lunchtime, but instead had to go home.

  • not allowed to stay at school after the school day had finished.

  • not allowed to cross the local footbridge over the motorway, which cut him off from the majority of his peers.

  • not allowed to go down the street of the one classmate who lived on his side of the motorway.

  • allowed and encouraged to socialise with one boy who was two years his junior.

The first question is why. Why on earth would a homeopath give such advice? We can only speculate that the homeopath in question thought- apropos of nothing- that since C was a late developer he should be kept away from people his own age and instead only socialise with younger children. I've had a look around some homeopathic websites on the internet, and found nothing that looks similar to this sort of advice. [I did, however, find this website, which amused me no end due to its impressive reference list. No, really, go and look at the link and scroll to the bottom, if you want a good laugh]. In fact, I couldn't find anything at all suggesting that enforced social isolation is good for anyone or for treating anything, really. 

C's case would appear to be one of a homeopath acting outside of their competence and providing bizarre and very harmful advice. In C's case, homeopathic treatment was certainly not safe, although this had nothing to do with the sugar pills themselves.

The result of this set of rules on C were, in his own words:

"a boy who was immature, shy and lacking in self-confidence. When it came to puberty I had significant mental health problems (starting with OCD due to high levels of anxiety) which have had an impact throughout my life....I didn't regain a sense of normality (in terms of socialising properly) until the age of 25-26."

Limitations

C's story is, of course, merely one anecdote, and as good skeptics we of course have to realise the limitations of it. There's nothing to say that, if C hadn't have followed these rules, he wouldn't have gone on to develop any mental health problems, and indeed delayed puberty itself is not without an increased risk of psychological problems.

Given our very human need to fit in, it may be the case that children with delayed puberty have a preference for younger friends, as they stand out less. This is entirely understandable, but in C's case it is clear that his situation was enforced upon him.

 But given the established link between social isolation in adolescence with mental health issues, I think we can pretty safely say that this is a case where at the very least homeopathy worsened his situation. His quality of life was undoubtedly affected when he had to obey the rules.


Thankyou to C
 

Many, many thanks to C for sharing his story with me. I think its so important to hear these stories, as they might help to raise awareness of the less obvious, nebulous harms that can arise from treatment by unregulated, alternative practitioners. Unfortunately, its really difficult to quantify these sorts of harms into cold hard evidence, and that's why I, and many others like me, keep banging on as loudly as we can about them. If you have any examples of potential harm caused by homeopathy, it goes without saying that I would love to hear from you. 


H xxx

Pills, Thrills & Methadone Spills 2: Book review

Community pharmacy can be a pretty lonely career at times. It can be a horrendously stressful and pressured environment to work in. It can also be hysterically funny, and those times often make the rest of it worthwhile. In a workplace that is ultimately centred around illness, the pinpricks of hilarity become all the more important.

Its good, then, that someone decided to make a book of all those funny moments that happen in the average pharmacy day. Its even better when they decide to do so twice. Enter the second instalment of Pills, Thrills and Methadone Spills by fellow anonymous pharmacist Mr Dispenser.


Those of us pharmacy types who use (for which read obsessively depend on) Twitter or who read any pharmacy magazines will no doubt be aware of Mr Dispenser, who is a regular day-brightener with his wit and humour. 

Partly constructed of tweets, part blog-anthology, this is a warm and good natured collection of anecdotes. All but the most curmudgeonly of pharmacists will find themselves laughing out loud, and there will certainly be many moments of recognition in there too. You find yourself thinking 'oh I've got one of those stories too'.

Its a nicely inclusive format, which I think in its own little way helps to address the isolation of the job.  If you look closely enough, you'll even find a couple of pearls of wisdom from yours truly, which is nice. Its like sitting in a pub with a big group of other pharmacists and having a good old chortle about the daft things you encounter everyday. You're left feeling much cheerier about your lot, and with a nice sociable glow. to a non-pharmacy eye, some parts may be slightly close to the bone, but I think that from within the profession its clear that it is meant affectionately.

There is, however, a bit of a disappointing #everydaysexism moment later on in the book in 'Gender Bender'. Given that I write this whilst an unfinished blog post about how harmful portrayals of women can be sits in my blogger account, this is me courteously reminding Mr Dispenser that all women do not merely discuss hair and nails and read Hello magazine, nor do they all coo over babies whilst men leer at sports cars and read Top Gear magazine (Which, by the way, I used to have a wardrobe full of. despite having no driving license). So less of the stereotyping, please, and we will all get along fine at this year's Pharmacy Show

Now lets address the font. Very attentive readers of this blog will know that there is one font that I consider to be an abomination against mankind. Comic sans  is not big, its not clever, and its certainly not jaunty. It doesn't make me think "ooh, a light-hearted and humourous piece of writing!", but rather makes me stabby. There's is nothing wrong with good old arial, and the writing in this book is funny and clever enough on its own without having to resort to comic bloody sans.

Hxxx

DISCLAIMER: This book isn't actually due out yet for 8 weeks or so and may be subject to font changes and editing. If this occurs, I'm going to leave this post as it is, as a testament and reminder of how I can occasionally have some influence. Also possibly because I will be too lazy to amend it.   

You can also find this post- and a whole variety of mine and many other lovely people's book reviews over at Backlight, my collaborative book review blog for busy people.

Prescription exemptions and the bloody Mail on Sunday.

Today, I feel ranty. So ranty, in fact, that I can't even think of a clever title for this post.

Why? because the Mail on Sunday has riled me up with this story about how pharmacies are failing to check exemption statuses of patients. I have been weak, dear readers, and I have allowed the Mail to affect my emotions.

As a pharmacist, my job is to make sure that patients get the right medicines, can use them safely, and have all the information that they need. My ultimate goal is to make sure that my patients stay as healthy as they can for as long as they can, and to improve their quality of life.

My role is not as a fraud investigator, but as a healthcare professional. Its up to the patient to ensure that their exemption is correct and up to date, and its up to me to ask to see proof of exemption, and to train my staff to do likewise. So that's what I- and many, many other pharmacies- do, day in, day out.

What if a patient says they don't have any proof of exemption? I go right ahead and give them their prescription anyway. What am I supposed to do? Say no, sorry, you can't have this inhaler until you go home and get your exemption certificate and bring it back to me. And then what happens when the patient has an asthma attack on the way back to the pharmacy, and without their medication dies? Funnily enough, I suspect newspapers like the Mail on Sunday would just as gleefully report on my failure as a pharmacist to supply life- saving medicine to a patient, and how I was just being evil and money-grabbing instead of thinking about patient care. So we are literally damned if we do, and damned if we don't.

Of course, we can cross the box on the back of the prescription, which means that a small, random selection of prescriptions may be investigated. But this process is pretty murky, and the details of it are unclear to the majority of patients, pharmacists, and pharmacy staff. We get little to no feedback of any cases which are identified as fraud through this method, so it ends up seeming pretty pointless. You spend years and years of dutifully crossing the box, and you never see it making any difference. Perhaps if this process were clearer, and we could more clearly see some results from it, this would spur pharmacists on to continue with the box ticking exercise.

Ever tried to confront someone about the fact that they may be committing fraud? Ever tried to do so over a counter, when you're working on your own and have a queue of about twenty people behind the person you are accusing? A pharmacy is certainly not the correct place for such things to happen in- the personal security of the staff, the workload, and the potential for a patient to have to go without their medicines all mean that its practically something that we cannot do well, without a massive overhaul of staffing and how pharmacies are designed.

I suspect the reporters at the Mail on Sunday haven't ever had to stand on one side of a pharmacy counter whilst a patient asks which of their medicines is the most important because they can't afford to buy all of them. I have, and its heart breaking. Prescription medicines in the UK are £7.85 right now. We're currently in a time when Atos are merrily declaring- sometimes on very shaky grounds- that people who are crippled by a variety of medical and psychiatric problems are fit for work, and are stopping their benefits. There are people out there who cannot afford to pay £7.85 per prescription item, through no fault of their own, and these are the people who are likely to be taking a variety of different medicines. Do I therefore withhold their prescription, or tell them which is the most important drug for them to take and send them off on their way with a sub-therapeutic drug regime that is going to make them even less able to work and find means of paying for their medicines? I can't imagine the hurt and shame that a patient must have to go through to admit that they can't afford their medicines, but I know I don't want to have to put an already unwell patient through that.

I've had a friend worry how he was going to pay for his prescriptions because of problems with his benefits, problems that he had no control over and were to do with mistakes at Atos. Do you know what I told him? Go to your usual pharmacy, tick the box, and don't say anything. I know that's wrong, but given the options: he becomes very unwell vs a small risk he gets a fine of £100 at a later date when he would hopefully be able to pay it, I'm sorry dear readers, but I'm always going to opt for the former. That may be, as the Mail so charmingly puts it "scandalously careless" of me, but it doesn't feel like it. It feels like I am caring for my friend's health, and that's my job, and my personality. What would feel "scandalously careless" would be to force someone with no income through no fault of their own to choose between food or essential drugs. 

Forgive me if I would rather give patients their drugs and keep them as healthy as I can. Do forgive me if I put the quality of my patients' lives ahead of the fear of prescription fraud, which I can do very little about anyway.

This whole system of exemptions and payment is outdated and needs an overhaul. In the meantime, branding pharmacists as lazy debt collectors and desperate patients as robbing prescription cheats doesn't help. As a healthcare professional, my need to provide vital medicines to my patients transcends petty demonisation by a scaremongering newspaper. 

Here's an extract of the Mail on Sunday's report:

 

"Dr Clare Gerada, chairman of the Royal College of GPs, called for a ‘fundamental review of prescriptions’. But a spokesman for the Royal College of Pharmacists said it was ‘not their job to police the Government’s prescription exemption system’, adding: ‘Guidance is very clear that pharmacists must put the clinical needs of a patient first, and not deny someone access to lifesaving medicines because they haven’t got proof of exemption."

Interesting, really, given that the "Royal College of Pharmacists" doesn't actually exist. This is lazy, crappy reporting, if they don't even bother to get the Royal Pharmaceutical Society's name right. You can read how the RPS have responded to this article here. Its a perfectly reasonable response, and in my opinion reflects what actually happens in daily practice.

Hxxx

Customer walks into a pharmacy...

...and chooses what medicine they want to buy, before taking it to the pharmacy counter. Yes, that's right folks, instead of telling a daft joke, I'm going to witter on yet again about the self-selection of P-meds. This time I want to think about it from a patient's perspective. Some of these considerations may seem small and petty, but i just want to put my thoughts down on virtual paper and you can see what you think.

When I walk into a shop, I can be pretty easily intimidated. I'm shy, and I don't like to bother people. I also hate that uncomfortable feeling when you walk into a shop and you feel like you're being watched by someone and then you feel terrible about not buying something. I can get anxious about the smallest of things, in particular not quite knowing what you're supposed to do in a shop- if I can't find the til, or there's an empty box and i don't know who to ask, or if I can't find something, for example.Of course this is worse when I am feeling a bit poorly and I can be particularly skittish- im likely to go home without buying anything, even if i need it, because i can't be bothered to have to work out what I'm supposed to do. This brings me onto my first point about self selection

1. It could be different everywhere.

 Not all pharmacies will take up the self-selection option, so I'll need to ask at the counter as i am used to. But in some pharmacies, the packs may be out on the shelves, whilst in others, they might be in security packs or might be empty packs that I need to take to the counter, like an early nineties video rental shop. It sounds daft, but this sort of thing could be quite off-putting.
 

2. How the hell am I supposed to know what to buy?

 I tend to acknowledge people who know more than I do about a subject and listen to their opinion. If I go to the hairdressers, for example I tend to ask them what style they think would best suit my hair type and face. After all, they've done some training in cutting hair whilst I am utterly clueless about it. If I walk into a pharmacy, therefore I don't expect to have to do all the hard work of product selection myself. My product selection process for most things usually goes like this:

Its either that, or I stand around reading every single box of every single product. This would take me bloody ages, and would be pretty inconvenient.

3. What If Its The Wrong Thing?

 After I have found the shiniest product, I take it to the counter, where I am then told that I've picked up the wrong thing and I'm not allowed to buy it. This, frankly, pisses me off and adds even more inconvenience o the whole affair. I've chosen the product, and now some jobsworth glorified shop assistant is saying that I've chosen the wrong thing? how dare they! (I've lost count of the number of times I've been called a glorified shop assistant by patients-and on occasion non-pharmacist managers over the years, by the way). You know like when you're in a hurry, and you've picked something up in a shop and you take it to the counter, and they tell you that its on buy one get one free, but there is a huge queue behind and you're going to be late for your train so you just say "oh its fine, I'll just take that one". I suspect that would end up happening quite a bit as well.

4. Advice Isn't Quite So Forthcoming.

 When I ask for a specific product in a pharmacy, the counselling and advice I am given tends to be minimal (if at all), whereas if I ask what they would recommend for a particualr symptom (not that I usually have to bother doing that myself, but you know), I tend to be given fuller, more rounded advice as part of the product selection process- I've written about this before. If I want to know something about a product, I have to ask about it, and I might feel a bit stupid doing that when I'm supposed to have picked the product myself. In addition, I might not actually know that I need to ask for advice unless it is offered. With self-selection, I fear that offering routine advice would become the exception rather than the norm, and instead of being proactive in giving advice, we would instead get into a pattern of waiting to be asked.

5. Medicines Are Commodities And Its My Right To Buy Them.

 I've written before about the paracetamol problem- its so widely available that people think its safe and innocuous, and they can take extra or dismiss it because they've sort of forgotten that its a medicine. I think this may become a wider problem. If medicines are available on the shop floor for me to handle and choose myself, I assume that they're either not very good medicines, or they are so safe that I can use them how *I* like. If I want to take three times the amount of antihistamines that it says on the pack, then I can do, just like how if I want to eat peanut butter out of  a jar with a tablespoon then I should be allowed to, because its my choice to buy it and who is anyone else to judge me and tell me otherwise? this is going to be particularly problematic with codeine-containing medicines and similar.

Anyway, those are a few thoughts for now. I may add to them as time goes on. What do you think?

Hxxx 

Are we selling our souls Over The Counter?

There's something beautifully logical and satisfying about a good Over The Counter consultation.

I know what you're thinking, and yes, I should get out more. But it is true. The way I think of it is in a stepwise approach, using a systematic series of questions to eliminate products leaving you with a limited number of options to recommend. I suspect the way a patient views it may vary somewhat from "hey! I'm really being listened to!" to "oh for goodness sake shut up, I'm going to be late for the bus.".

A good consultation goes like this:
 

Step One: Establish the symptoms and check diagnosis.

Fairly self explanatory: to decide what medicine to select, I need to know what I am trying to treat in the first place. I'm also finding out if the patient has any danger symptoms which might be suggestive of a serious illness, so I can signpost them appropriately to the right services. 
Once I know what the problem is, I think about what products are available to treat it over the counter

Step Two: Find out about the patient's medical history.


I'm looking for anything that means the patient is at high risk of complications of the problem, meaning they need to be referred. I'm also thinking of the cautions and contra-indications of the available products to treat the problem and eliminating any products that these apply to.

Step Three: Find out about the patient's drug history.
 

I'm thinking about what drug interactions each of the available products has, and whether or not they are relevant to what the patient is already taking. I'm also thinking about whether or not any of the patient's medicines contain the same or similar ingredients to any of the OTC products- i don't want to risk an overdose. I then eliminate any products that have relevant drug interactions.

Step Four: Consider the evidence.


At this point, there may be only a couple of products that are suitable for the patient. If there aren't any left, I refer them to their GP or other appropriate healthcare provider.Out of the ones that are left, I think about which ones the evidence says are more effective and safe and I'll steer the patient towards that one. If there's no good evidence for at treatment, I'm always clear with the customer about it. Sometimes they listen, sometimes they don't, but its an obligation that I think needs to be done in order to sell medicines honestly and with integrity.
 

Step Five: Consider the price. 
 

Where two products are equally efficacious, I always recommend the cheapest. Because I don't want to waste a patient's hard earned cash, and I think patients appreciate that.
 

Step Six: Counsel the patient.

This involves giving them all the useful little snippets of information about how to use the product effectively and -crucially- safely. It might be pointing out that the product contains paracetamol, or that it causes drowsiness, or that it works best taken at a particular time of day. 


Hopefully all pharmacists will recognize this process, although everyone does-and should- have their own style to go about it with. These sorts of encounters can be really satisfying for both pharmacist and patient, and its often in these moments that I have the most amount of pride in my role. Here I am, giving the patient trusted, evidence based advice which will hopefully bmake the patient feel better. However, you also need a willing patient, and I'm finding more and more often that patients are unwilling to engage in such exchanges. I've also noticed through personal experience as a customer, that some pharmacies are using what i consider to be a cop-out approach to OTC sales. An offhand "you should read the leaflet" whilst I'm handing over my money does not, in my opinion, constitute provide expert advice on medicines. 

So why am I on about this at the moment? Well, there's the Which? report, which has found a disappointing quality of over-the-counter information being provided in some pharmacies. Others have given a more detailed analysis of this report, so I won't go into it too much, except to say that yes, there are methodological problems with it. However, it may well be indicative that in a world where pharmacists are under massive pressure to deliver services and dispense ever-increasing numbers of prescriptions whilst working longer hours for less pay, some are starting to lose pride in the basics. Its understandable. In the rush to get everything done, its easy to start seeing the patient as an inconvenience, who we need to get in and out of the door  as quickly as possible. I'm not saying this is what is happening in every pharmacy or in every case, but based on how I used to feel when I managed a pharmacy, I suspect it is a factor. 

The other reason I've been thinking about this is the issue of self-selection of pharmacy medicines. In my humble opinion, this is a giant backwards step for the pharmacy profession. Self selection reduces the process I described above down to a bare minimum, and reduces the possibility of introducing quality into it. Sure, we can say there will be information on the packs, but lets be realistic about this. Patients very rarely read the leaflets before purchasing, and if they have to do so in the middle of an aisle in a high street pharmacy or supermarket, i think it becomes even more unlikely. In my experience, if a patient has a preconceived idea of the product they want to buy, its very difficult to persuade them otherwise, even when there is a safety concern with their chosen product.

I remember one customer asking for Sudafed, when she was also taking phenelzine. A combination of these drugs could provoke a potentially fatal hypertensive crisis, but no matter how much I explained this, the customer was adamant that she still wanted it. It turned out her daughter, a medical student, had advised her to use this product, but when I spoke to the daughter it turned out she thought that Sudafed just had paracetamol in it.

Now imagine this situation in a self-selection age. The customer picks up the pack, wanders to the pharmacist, who then has to try to wrangle it from their fingertips in order to ensure their safety. Okay, maybe not that dramatic, but the fact that the customer has the product in their hand, and has been able to "choose" it themselves, reinforces to them that it is their right to buy it. But in pharmacy, the fact of the matter is that the customer isn't always right, and its poor customer service- and downright dangerous- to always allow them to think so. 

Imagine that self-selection scenario is also coupled with a curt "read the information leaflet first" as the only form of counselling. Why would the patient bother reading the leaflet, when she already thinks its safe for her to use? And so, what appeared to be a quick, convenient shop for the customer could so easily turn into a fatal drug interaction.

The shopping experience is becoming more and more depersonalised. With chip and pin and contactless payments, you barely even have to glance at the cashier during a transaction- if you're even in contact with a cashier at all. This may be fine when you're buying groceries, but medicines are not commodities. We're different to other shops in that the wares we sell can have fatal effects if they're not used in accordance with expert knowledge and instruction. We simply cannot safely reduce the over the counter consultation to the bare minimum of words required to take money from people as quickly as possible. 

Of course, its not like we pharmacists, will get that much say in the matter, and we'll carry on regardless if self selection goes ahead. Indeed it seems to be a near certainty, despite support from "very few" pharmacists. And it may even be the case that such scenarios never happen in real life. But all I want to do is make medicines safer for people, and to do so we have to identify areas of risk before they happen, and take action to minimise them. 

When it comes to patient care, just hoping the worst doesn't happen isn't good enough.

Hxxx

Homeopathic Harms Vol 7: Professional Ethics

In February 2013, my friend @EBMScientist and I delivered a Newcastle Skeptics in the Pub talk entitled Homeopathy: Where's The Harm? As a follow up to this, we decided to write a series of blog posts expanding on a number of points we covered in the talk:

"Ethics is the science of morals, or moral philosophy. The principles, written or unwritten, that are accepted in any profession as the basis for proper behaviour are the ethics of the profession" -Dale and Appelbe's Pharmacy Law and Ethics

As you'll know by now, I'm a pharmacist. And as such, I have to be registered with the General Pharmaceutical Council (GPhC) to practice in the UK. I'm therefore governed by the GPhC, and in particular their code of conduct, ethics and performance, which has seven main points:

  1. Make patients your first concern

  2. Use your professional judgement in the interests of patients and the public

  3. Show respect for others

  4. Encourage patients and the public to participate in decisions about their care

  5. Develop your professional knowledge and competence

  6. Be honest and trustworthy

  7. Take responsibility for your working practices.

If I-or any of my colleagues- were to act against this code of ethics, we could be held to account by our regulator and reprimanded accordingly. Other healthcare professionals- Doctors, nurses etc- all have similar codes of conduct produced by their regulatory bodies. They all have one thing in common- that the patient is central to everything you do, and if a member steps outside this code of conduct, there is a clear and organized route through which complaints or concerns can be raised. This is as it should be: healthcare professionals have the lives of patients in their hands, and need to be held to account if anything goes wrong. As I've written before in this series, homeopaths don't have to register with a regulatory body and anyone can set themselves up as a homeopath with no training whatsoever. Whilst some 'professional' bodies exist in the UK, they have no regulatory powers so are unable to reprimand anyone if they receive a complaint.

Health care professionals who also practice homeopathy still have a duty to ensure that they abide by their regulatory body's code of ethics. In my opinion, however, it is very difficult to reconcile some of the clear guidance with homeopathic principles. Let's take a look at what I mean, using some selected points from the  the first two standards of the  GPhC's Code of Ethics July 2012 as a guide. (I'll cover the rest of the points in another post)

1. Make Patients Your First Concern
Under this heading, the GPhC states that we must "Make sure the services you provide are safe and of acceptable quality". Given the lack of high quality information that homeopathy works, we are unable to guarantee that such a service is of acceptable quality. You'll also know if you've read the rest of this series of blog posts that there is a lack of evidence regarding the harms- both direct and indirect- of homeopathy- so how could we guarantee that it is safe?

2. Use Your Professional Judgement In the Interests of Patients and The Public
There are a couple of relevant points here. firstly we are told that we need to make sure that professional judgement is not affected by personal or organizational interests or incentives. If you're going to charge for a homeopathic service on the side of your usual practice, then there is already a clear personal incentive to promote homeopathy.  We can minimize the possibility of such things affecting our professional judgement by making sure that we use evidence to guide treatment decisions wherever we can: evidence-based medicine is not perfect, but its the most objective method we have at the moment. And, as you'll know, there is no good evidence at all that homeopathy works. 

We are also advised to:

 "Be prepared to challenge the judgement of your colleagues and other professionals if you have reason to believe that their decisions could affect the safety or care of others"

I myself-and other pharmacists-have done this: I've spoken out about Tony Pinkus, for example, a pharmacist who endangers patients' lives by promoting unlicensed homeopathic vaccines or sugar pills to prevent malaria. In Nancy's latest blog post, she covered some of this, and I know Adam at Dianthus Med has also been discussing this point on twitter and his blog lately. Its clear-from our own professional guidance-that where patient safety is in danger, we do not protect our own- we need to report, speak out, and denounce those amongst our colleagues who let the profession down.

Homeopaths, on the other hand, seem to have no such obligation. We've been struggling to think of one single example of where homeopaths have spoken out against other homeopaths where patient safety has been endangered. In a conversation on twitter, for example, no homeopath would say that it was inappropriate for a homeopath to have said that a homeopathic remedy could have saved someone who died due to injuries sustained in a horrific gang-rape and disembowelment.  I recently asked some homeopaths on Twitter whether they would speak out against a colleague who put patients in danger. The answer I received from one was shocking:

"When its so easy 2 wink at 1's own sins, seems impossible 2 find judge orjury before whom 2arraign the 1st law breaker. KENT" (sic)- @22VenkateshN

Admittedly this particular homeopath that responded (he was the only one) has a reputation for obfuscation, but this reply seems to suggest that no, he wouldn't report, in case someone did similar to him. I tried to clarify : "so to clarify: you wouldn't speak out in case someone else did the same to you? A yes or no would suffice, thank you". The reply:

"some questions can't be replied with a simple 'yes or no'. for example_ 'are you still mad ?'"- @22VenkateshN


I'm not sure what he is trying to imply by asking about being mad, but we'll give him the benefit of the doubt and ignore any insinuations he might have been trying to make. What is staggering is the reluctance to admit that he would put patient care first and report a fellow homeopath in a situation. As a health care professional-and a good person- the code of ethics  becomes deeply ingrained in your being. Its second nature- and pretty obvious- that you would put the needs of a patient first. I persisted further,  trying to make it easy for him to agree that you would report a colleague: "It's very easy, if you work under clear ethical guidance. homeopaths do have that, right?: patient safety comes first: therefore yes, you would report and denounce a colleague who endangered it." Again, the reply astounds:

"Its not that easy, every one accusing everyone else would result. That's why I tweeted the appropriate observations of Kent"- @22VenkateshN

Wow. So it would seem- on the basis of this sort of conversation and the complete radio silence from any other homeopaths- that no, they wouldn't report or denounce a fellow homeopath because some sort of petty slanging match would ensue. Instead of a clear referral process to deal with complaints, accusations would be flying all over the shop- and one very, very important aspect gets forgotten: patient safety. 

I'd love to be proved wrong here. I'd love to think that medical homeopaths or pharmacists who also practice homeopathy would do otherwise, in accordance with their code of ethics. But I'm currently deafened by their silence. If I were one of the more professional, caring homeopaths who really did want to do the best for their patients, I would be utterly horrified and disgusted by some of the claims and actions of others, and I'd want to-nay I'd feel obliged to- speak out against them for the good of my own practice. I'd be embarrassed to be associated with them.

So here's your chance, homeopaths. Speak up against bad practice and drown out the previous deafening silence. Go right ahead: I'm listening intently. And while you're at it, please do take a few minutes out to respond to Adam's Challenge to the Society of Homeopaths too

 

Homeopathic Harms Vol 3: Poor Advice

And so begins the third installment in our Homeopathic Harms series, a collaboration between myself and @EBMScientist of the Evidence Based Skepticism blog. For this post, I have my lovely, wonderful friend @shandymarbles to thank for the idea and the action.

Indirect harms due to homeopathy can, as we're trying to cover in these posts, come in various different guises. In my opinion, there is none more dangerous than this: poor advice from homeopathic practitioners. 

To set yourself up as a homeopath in the UK, you don't need any medical background. You also don't need to register with any regulatory bodies or undergo any standardized training. Medical homeopaths, i.e. doctors who practice it on the side, are of course regulated by the GMC, but your common or garden variety homeopaths could basically be anyone.

And yet, they claim to practice medicine and give advice on your health. Scary stuff, in my eyes. And I can give you a specific example of how harmful this can be, because one of my good friends contacted a UK homeopath recently. This homeopath is, as is proudly declared on his website, an engineer by trade.

Under the pseudonym Stacey Slater (which apparently didn't appear to ring any alarm bells with the homeopath in question), my friend asked for help in treating bipolar disorder. She said she had stopped taking the medication prescribed for it because she was getting horrible side effects, and asked if there was anyway that homeopathic treatments could help her stay stable and avoid psychosis. There are a few things to note here: the question was very specifically asking if homeopathy could be used instead of conventional medicines, and was asking about avoiding psychosis- we're talking about serious symptoms here, not a vague sort of "could it help with me feeling a bit down" sort of question. The description of "horrible side effects" would immediately ring alarm bells to me- what sort of side effects, and how is she feeling at that time.

Here's the response I would have liked to have seen in a dream world filled with responsible homeopaths (actually, in my dream world there would be no homeopaths at all, but you know what I mean):

"Dear Stacey,
Thank you for your enquiry. I'm sorry that you've stopped talking your medication for bipolar disorder, and would like to advise you in the first place to speak to your GP first of all about the side effects you have been experiencing. You should also discuss with them your decision to discontinue your medicines, as stopping them suddenly may cause your symptoms to worsen.
Homeopathy may be a useful option to help treat some of your symptoms. However, I wouldn't recommend that it is used instead of your usual medicines, unless this is done with the agreement of your medical team. Once you have spoken to them, please do contact me again and I will be happy to discuss any homeopathic treatment with you then."

This response covers all bases. It makes sure that the primary outcome of patient safety is covered by referring them to their own healthcare provider, however its also helpful and leaves open the possibility of some homeopathic treatment as an adjunctive, complementary treatment. It does not suggest that homeopathy can be used instead of her usual medication.

Here, however, is the real-life response:

"To,
Dear Stacey Slater,
Yes I am happy to help you for your Bipolar Disorder and will try to restore your previous health. 
Recently, my grandmother has been treated for her 15 years long Bipolar disorder with only two weeks of homeopathic treatment. Now, my father-in law (Himself Medical Practishner) says she is 100% okay with homeopathic remedy and need not take any other medications. 
To help you, I need some more information, like; your physical, mental and spiritual condition.
1. Any skin diseases are you suffering from?
2. Do you have problem of thyroid dysfunction? hyper or hypo?
3. Diabetes?
4.High or low blood pressure?
5. Since how long are you suffering from Bipolar disorder?
6. Your family history, if any one in your blood relation have tuberculosis, diabetes, cancer or high blood pressure?
7. Your liking and disliking? Food,Drink, time and weather 
8. Your family life, etc..
Your detail will help me to prescribe best remedy.
Looking forward to your reply,"

There are a few things to note here, as I'm sure you can tell. This homeopath claims that they will "try to restore to previous health"- in other words, he is offering a cure to bipolar disorder. We've got some anecdotes in there, in lieu of actual clinical evidence, and an extraordinary claim that longstanding bipolar disorder can be cured with only two weeks of magic woo water therapy. Now, given that bipolar is, by its very nature (and name!) a relapsing-remitting disease of two extremes, there is no way that an anecdote could be used as evidence of successful treatment. Who’s to say his grandmother wasn't just going through a good period that just happened to coincide with taking a couple of week’s worth of homeopathic medicines. How do we know she wasn't using effective conventional medicines at the same time? Who's to say she even exists? I can't help but wonder about his grandmother's right to confidentiality as well- has she given consent to be used as an anecdote in his consultations with other patients?

Who is this father-in-law mentioned? If he is so happy with the treatment, why isn't he happy to be named, and why is he even commenting on the grandmother's treatment? What relevance does this have to this homeopath's practice? The advice given that she "need not take any other medications" is a clear indication that this homeopath thinks that the homeopathy he advises can be used to "cure" bipolar disorder on its own, as an alternative to conventional medicine. By trying to make it seem like the advice has come from an actual medical practitioner, the homeopath is clearly trying to give this advice more credibility.

Lets have a think about the consequences of this advice: Our Stacey Slater is reassured that she doesn't have to continue on with her conventional medicines. She responds to the email above, goes on to have a consultation with the homeopath online (which costs £50 by the way- we're not talking pennies here. £50 for an email exchange!) She slips into psychosis, or mania, or a deep, deep depression. Eventually, she can't take anymore and she commits suicide. This homeopath has directly contributed to her death by not advising that she sees her medical team before discontinuing her medicines, and by claiming that she can be cured by inert sugar pills instead of continuing on with effective, evidence-based medication

The problem is, we can't gather robust evidence on this sort of thing, as it would be too unethical to do good, clinical studies. Maybe Stacey hasn't mentioned to anyone that she stopped taking her medicines and she was under the "care" of a homeopath- how would anyone know that the death was caused by him? And even if they did know, they're probably too upset and shocked at that point in time to think about raising a complaint. Who would write up a case report to publish in the medical literature? Certainly not the homeopath in question, he's not going to incriminate himself, and her medical team have probably had little contact with her since she's been advised not to bother with them anymore. And so homeopaths can continue to claim that their treatment is "safe", because we just don't know the scale of these sorts of cases. 

The only bright side here is that, of course, my friend will most definitely not be taking this shoddy advice. She's well aware that homeopathy is a whole load of nonsense and just contacted this guy to see what the response would be. However, we have to wonder how many other emails he's getting, from people who are genuinely seeking help. And we have to wonder what's happening to them, and whether they are safe.As an interesting, and rather creepy, aside the homeopath started following my friend on Google plus and Twitter a couple of hours after responding to her. This is at best weird and unprofessional, and at worst, really quite frightening. I can't think of any healthcare professionals who would do such a thing, just randomly looking up a patient on social media and then following them after one consultation- what about confidentiality? 

Hxxx

Let's talk about death, baby

Yep, settle in, dear friends, and lets have a think about death. Specifically, assisted suicide. 

This subject has come up quite a bit recently in the field of pharmacy and medicine. The PJ online are asking me to vote on whether or not I would refuse to dispense a prescription as part of an assisted suicide. The GMC is revisiting guidance to Drs. It's time to have a bit of a think about how we as pharmacists feel about playing a part in death.

There's a word which I think should be associated with death, and that word is dignity. People on the brink of death are still people, and I think in such discussions that fact is often forgotten,. We talk about our professional ethics, our religious choices, the impact it would have on us and our consciences, but I think we should talk-and think- more about the thoughts and needs of each dying patient. 

We're all frightened of death of course. I've been lucky enough that I haven't had much experience of it so far, but I've had enough to have experienced the lack of control one feels when faced with the death of a loved one. And all the bizarre rituals, funerals, cremations, all of these things that we do are desperate attempts to claw some control and dignity back from the situation. 

And so it is that I personally don't really need to think that much about this decision. I wouldn't hesitate to dispense medicines for assisted suicide, if it is going to give someone the dignity that they so richly deserve. 

People who believe in a god may think this is a typical example of an immoral atheist wanting to go on a legal murder rampage, playing god and interfering with when someone's "time" is. But in actual fact i think it's more about caring for the person involved, giving them respect for the person they are-and were. We need to remember that they remain a person to the end- and so should be allowed the right to choose, right up until the end.

Hopefully that makes sense. 
Hxxx 

Red Wine as a painkiller... In babies?!

A couple of years ago, I was working a locum shift in a supermarket pharmacy. It was quite late at night, and a man came up to the counter to ask me if I did circumcisions. I assumed I had heard incorrectly, but no. "I thought you would be able to do circumcisions, since you can do healthcare services and you have a private room" he said, pointing at the extremely small and flimsy consulting "room" and the end of the counter. I couldn't help but notice the small boy cowering behind him as I politely explained that no, circumcision certainly wasn't a pharmacy service.

At the time, I remember being amazed that it would occur to someone to take their child to a supermarket for what is a surgical procedure. Whilst it may be considered minor surgery, I'm sure to the young boy himself it didn't seem all that minor, and I'm pretty sure he wouldn't be wanting a pharmacist to do it in the middle of a supermarket with only some thin plastic walls between him and the vegetable aisle.

Anyway, I shall leave aside the ethics of circumcision for now, and consider a tweet I saw this morning by Andy Lewis. One particular Doctor, on his website, is advising pain relief options for babies who are about to be circumcised. He advises loading the child up on red wine as a preferred option. Now hold on here, this is a GMC registered Dr advising on giving babies alcohol. Whilst he doesn't give any information about how much wine to give, i'm assuming it would have to be enough to get the child at least slightly intoxicated to have any painkilling effect. A quick google search suggests the 8th day after birth is a usual time for the circumcision to take place, e.g:

"To give the baby sweet, red wine prior to the procedure. (Kiddush wine is ideal). This is very effective in calming the baby. Ideally it is given about 15 minutes before the circumcision and I will give it on arrival if you wish. You will need to provide the wine." (http://www.mohel-circumcision.co.uk/1298.html)

At this point, let us consult TOXbase.org, the database of the National Poisons Information Service (NPIS). They advise that any children under the age of 10 who are symptomatic due to an alcohol ingestion (i.e. intoxicated) are taken into hospital for medical assessment.

Why is it dangerous to advise wine as a painkiller in a child of this age? Well, alcohol in children can be very nasty. It can cause hypoglycaemia, particularly in children, and a seemingly well child can sometimes suddenly and quickly go downhill fast- that's why NPIS recommend that they are observed in hospital.

Such advice, coming from a trusted Doctor, is very concerning indeed. It appears from the website that he expects the baby to be "prepared" prior to his arrival, so he is expecting the parents to administer and provide the wine (whilst he says he can give it "if they wish", to me this implies that its more usual for the parents to give it). He gives no directions as to how much wine to give, which could be easily misinterpreted by worried parents. 

I  emailled the GMC to ask what their stance on such advice is. They eventually got back to me to tell me that it wasn't a concern as usually only a tiny amount is given. This doesn't seem like a very satisfying answer, given that either a) the child is given so little that they don't have effective pain relief or b) they're given enough to be toxic. 

Homeopathic Vaccines: An impassioned challenge

Its been a hard week for us pharmacists. To be honest, I'm sort of at a loss as to where to start, but the most obvious place is in London, at a pharmacy called Ainsworths, where a man called Tony Pinkus works.

Ainsworths is a real life, registered pharmacy, and Mr Pinkus is a real life, registered pharmacist. The main problem with this story, however, is that Mr Pinkus is not selling real life medicines to his real-life patients, and in doing so he is putting peoples' lives at risk.

In an expose by BBC News, Mr Pinkus has been caught recommending by email that homeopathic whooping cough "vaccines" are used instead of getting a proper, real-life vaccine. In the email exchange, Mr Pinkus is careful to express his recommendations as personal choice, and this will presumably form his defence. However in my eyes this is absolutely no defence at all. For years, the pharmacy profession has been slowly but surely promoting ourselves as the trusted healthcare professionals that we are, therefore we have a responsibility to be aware of the position of high esteem we may be held in by the public. We have a duty to know that any 'personal recommendations' we make will constitute medical advice in the eyes of many patients.

Mr Pinkus also states that the patients' GP "will undoubtedly throw a lot of fear in your direction". Now, I remember having it very firmly drummed into me that we need to be careful in our role as a pharmacist not to break the trust a patient has in their GP. Obviously, this doesn't mean that we should cover up any mistakes or errors from them, but it does mean some quite careful wording as enquiries arise. Mr Pinkus is clearly and flagrantly attempting to reduce the trust this patient would have had in their GP's advice and showing a shocking lack of respect to the GP in question, despite knowing absolutely nothing about their practice. I wonder if he has ever considered the longer term implications of such wording. "oh, the GP has told me I should be worried about this lump in my breast, but of course they'll just throw a lot of fear in my direction", for example.

Mr Pinkus has also been investigated by pharmacy's governing body before. In 2006 he was caught selling homeopathic travel vaccines. In 2009 he was investigated by the PRSGB for selling homeopathic swine flu vaccines. In 2011 he was investigated for marketing homeopathic travel vaccines again and malaria prophylaxis. In each case the regulator has let the public down by not taking decisive action over a pharmacist who is regularly and routinely endangering lives, all in the name of "free choice". I don't think i actually need to point out the serious indirect harms that could happen if a patient were to use a sugar pills to prevent malaria, or yellow fever etc. 

Free patient choice is not a defence when patient's lives are at risk.

I've been asking for a response to the case from the GPhC on twitter for a few days now and have heard nothing. I'm also wondering why the story hasn't appeared in some of the major pharmacy news publications (Chemist and Druggist, I'm looking at you).  

This story has really angered me, and i can pinpoint exactly why. I've written before about the constant fear I and many other pharmacists feel whilst at work- the fear that one little throwaway mistake could have huge implications for a patient's life. And there's an added, secondary fear that, if something goes wrong, a regulator could step in and your whole livelihood and career could be at stake. This is a fear that all good pharmacists carry to some degree, and it  can weigh heavily on your life. And yet here strides Tony Pinkus, who waves away any notion of patient safety, and flagrantly (I know it's the second time I've used this word, but it seems to fit the situation rather well) ignores the standards of the regulatory body without, apparently, a care in the world.

Well, I'm taking to heart the GPhC standards for conduct, ethics and performance, one of which is:

"Be prepared to challenge the judgement of your colleagues and other professionals if you have reason to believe that their decisions could affect the safety or care of others"

So this, Mr Pinkus (and any other homeopathic pharmacists who would recommend a homeopathic vaccine) is me challenging your decision, because I believe it most definitely could affect the safety and care of others.

UPDATE: Chemist and Druggist have now covered the story (registration required). The comments section is interesting, with a couple of folk showing a staggering lack of knowledge about homeopathic products.
The Pharmaceutical Journal have also covered the story (registration required). This includes some interesting tidbits, like the fact the MHRA have been investigating 20, yes TWENTY unlicensed medicines being sold on the Ainsworth's website. And the post script is particularly interesting:

'Some of you have noticed that the pertussin products highlighted in the BBC investigation are still on sale. We've clarified this with the MHRA - a spokeswoman confirmed that the MHRA asction (sic) was against products labelled as vaccines. 
"Substances and products labelled with the names of serious diseases such as pertussis are part of a wider, ongoing investigation," she said. So it's watch this space for the outcome of that branch of the investigation."'

This wider, ongoing investigation sounds very interesting indeed. 
 

A childhood story

I was a fairly robust, risk averse nipper. But, like all kids, I got the odd sniffle and sickness now and then. And, like most parents, my Mum would usually take me to see the doctor when I was poorly.

I have a really vivid memory of going to see the doctor. He was a kindly, soft-spoken chap who, as I recall, had a caring manner. And what I remember more than anything was his large leather case, filled with pastel-coloured vials of what he described as "magic crystals". 

Depending on what was wrong with me, I was able to choose from a selection of colours of "magic crystals", which were then administered to me and which, in my head, made me feel a bit better. I think I only got one dose, when I was there in the surgery. Neither my mother nor I have any recollection of me taking home any "magic crystals" or having repeated doses.
 


Now, here's the thing. At no point did my dear darling mother actually bother to ask what the "magic crystals" were. We now assume (hope!) that they were some sort of homeopathic thing. They definitely looked like coloured sugar crystals and tasted like sugar. Or were they some sort of elaborate placebo designed to soothe children into believing they felt better? Or were they some suspicious hallucinogens? The point is, at no point did my mother think to question the doctor: he was in a position of caring authority and he knew best what would make me better, right? And from my perspective, a nice, caring man who my mother had trust in was letting me pick pink sweet-tasting crystals so YAY GIVE ME THE SUGAR! 

Out of interest, my memory is that yes, magic crystals did make me feel momentarily better. But this is a vague memory, which may well have been clouded by nostalgia and the many years that have since gone by. why could this have been? Well, power of suggestion and placebo. As a child I knew doctors made me better: ergo, I felt better when I was at the surgery seeing the doctor.

We hear a lot about patient choice in debates about homeopathy. I guess my point here is that this doesn't always come into the conversation with patients or their carers, and that's worrying. Admittedly it was longer ago than I care to admit, but I'm pretty sure similar practices go on today. I really do hope that medical homeopathists do allow their patients more informed consent, and I also sincerely hope that all homeopathists do the same. But they can't offer them full informed consent because the data isn't there to back up their claims, or they have misunderstood the data that is there, and most importantly, the science and theories don't make sense. What sort of benefit vs risk decision can happen for a patient when they simply pick up a pack of arnica 30C from the shelves of Boots?  What kind of choice was my mum able to make when it didn't occur to her to ask any questions, and no explanation was forthcoming?


Health care professionals have a duty of care to their patients. A large part of this is about communication. What homeopathists (and herbalists, and traditional chinese herbalists, and halotherapists, and anyone else who purport to change people's health) need to realise is that, in the eyes of the public, they hold the same amount of trust and duty of care. And even if regulatory bodies aren't in place to take you to court if you harm someone, your personal morals should step in before you sell a remedy made merely of hope for monetary gain. 

The air is nice up here on the moral high ground.Of course, it could always be the case that it's actually just the mind-altering effects of whatever mind control agents were in the magic crystals....

H xxx