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The waiting game

Do I have to refer a patient for homeopathy?

Three experts advise a GP who is in two minds about referring a cancer patient for complementary medicine

A patient with disseminated malignancy has asked for referral to a hospital for integrated care with a view to homeopathy. I don’t believe homeopathy is an effective treatment or in her best interest. How should I respond?

Dr Simon Parton: Agree if the patient fully understands their condition

My first priority would be to establish the patient’s understanding of the diagnosis. What information has she received about conventional management options, prognosis and potential side-effects?

I would discuss my concerns with the patient about the risk of deviation from recognised and evidenced therapy while maintaining a relationship of trust and support. I would offer to share with her any published NICE guidance for her cancer, and review any literature she has on her proposed homeopathic treatment. I would offer to meet again in a few days to allow further discussion.

I would also direct her to charities such as Macmillan Support, Cancer Research UK and Breast Cancer Care who have information about supportive and complementary therapies that are safe and appropriate.

Having established that she fully understands her condition and her request is based on choice rather than a lack of understanding or capacity I would agree to her request and maintain regular reviews of progress. I would also suggest consultation with conventional oncology services so that there is an opportunity to discuss standard therapies with specialists and maintain an ongoing dialogue with conventional therapy teams so she could consider treatment at a later date. Because of the likely palliative nature of any therapy for disseminated disease, early information and referral to community palliative care services might be appropriate.

Whether she is reviewed in a traditional oncology service or an integrated homeopathic service she will need the ongoing support of her GP and it’s essential to maintain that relationship, especially when she approaches the end of life.

Dr Simon Parton is a GP in Lewisham and chair of Lewisham LMC 

Dr Pipin Singh: Make sure the patient knows the lack of evidence

It will be important to have a full understanding of the patient’s condition and prognosis. A curable metastatic condition may alter the advice that you give.

Establish what the patient already understands about her condition and prognosis. If she has capacity to make a decision, you have to respect her wishes. If she doesn’t understand her condition and you feel she lacks capacity, you may wish to offer further discussion with her next of kin or close relative. If there is no one else to discuss with, you may wish to consider a patient advocate.

Knowledge of homeopathy will vary from doctor to doctor, however as GPs it is important we respect patients’ health beliefs. Explore why the patient is requesting homeopathy. Does she have a fear of conventional treatments? Find out what the patient already knows about homeopathy. Is this something she or a family member or friend has used before with good outcome?

You should explain that homeopathy is not recommended by NICE or the NHS and does not have a robust evidence base. It is not routinely available on the NHS although a few doctors do offer homeopathic options for certain conditions. There is also no regulation of homeopathic practitioners.

Agreeing to a referral is acceptable as long as the patient has capacity and is fully informed of the pros and cons.

Dr Pipin Singh is a GP in Wallsend, Tyne and Wear

Dr Zaid al-Najjar: You needn’t refer but you must explore why she has asked

Whether you believe homeopathy is effective or not, it has a significant following and many GPs encounter situations like this.

In the first instance, it would be helpful to discuss your concerns with the patient, exploring why she feels conventional treatment might not satisfy her needs.

You do not have to make a referral if you do not believe it would be of clinical benefit or in the patient’s best interests, but it is important to consider Section 5d of the GMC’s consent guidance on patient treatment:

‘The doctor should discuss the issues with the patient and explore the reasons for their request. If, after discussion, the doctor still considers that the treatment would not be of overall benefit to the patient they do not have to provide it. But they should explain any other options that are available, including the option to seek a second opinion.’

Together, you may like to explore the possibility for mainstream therapies to be carried out alongside homeopathy, subject to the availability of funding and willingness of the specialists involved.

Ensure you record all discussions you have with the patient.

If you have concerns about the patient’s capacity to make an informed decision about her care, given the disseminated malignancy, you should contact your defence organisation.

Dr Zaid al-Najjar is a medicolegal adviser at the Medical Protection Society and a sessional GP in London

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Readers' comments (40)

  • http://www.bmj.com/content/345/bmj.e6184/rr/604264 and this one as well. Just for purpose of discussion.

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  • You know natural treatments are also studied in thousands of peer reviewed research papers! Some of these treatments also really work, but some are still too unwilling to look. It is a pity really as conventional 'quacks' do not have a monopoly on health care.

    There are many conditions which conventional medicine has no 'cure' for so it is said that these conditions are untreatable. This is really not the case as many of these cases can be treated using different methods.

    I think many medical doctors are just threatened by this and it is a pity as each form of medicine has its strengths and weaknesses.

    As a medical doctor but practicing naturopath these things are pretty obvious. I only started exploring other treatments when I discovered conventional medicine did not have the answers for many different conditions and only concentrated on suppressing symtoms rather than looking and fixing the cause of the problem.

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  • An article by Dr Helen Beaumont

    http://www.dailymail.co.uk/health/article-3502616/Don-t-hate-homeopaths-ve-unfairly-vilified-quacks-actually-help-save-NHS-doctor-argues.html#ixzz43ZqosD5V

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  • Homeopathy does not work beyond placebo effect. That has been demonstrated to the nth degree. However, if a patient wishes to follow that route and is willing to pay, having been made aware of the alternatives and their relative efficacy and adverse effect profile, then that is their choice. I don't advocate homeopathy for major or minor illness but if a "competent" adult wishes to pursue that course so be it. I do however object to NHS funding of homeopathic treatments (as indeed I also do of some "conventional" medicines which do little if any good)

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  • What exactly is "homeopathy". Is it just giving a potion of infinite dilution or does it also include the extended consultation preceeding the dose. This consultation, often at least 30 minutes, is given in the context of a non-judgemental, caring environment. This may be the real value rather than the associated solution.

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  • I always find it interesting when homeopathy supporters accuse skeptics of being "ignorant" of homeopathy. It is a superb irony that actually we understand it and they don't!

    Science has a complete and coherent explanation for all the observations in homeopathy, which is also fully consistent with other science. Homeopaths prefer an explanation which is incomplete, incoherent, and inconsistent with other science.

    Science forms its view of homeopathy by examining all the evidence, good, bad or indifferent. Homeopaths discount contradictory evidence, despite it being of generally substantially greater methodological rigour than the evidence they cheerfully accept.

    Yet it is science advocates who are supposedly "ignorant" and "dogmatic". Odd, that.

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  • Guy Chapman is correct in his resume, Stewart Block also hits the nail on the head. The NHS cannot afford such time-consuming and expensive 'placebo' [= 'I will please'] 'treatments'.

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  • Agree with Andrew Sokorski .

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  • Doctor Dog

    I'd encourage self- referral myself.

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  • Have the Indian Government got it wrong?

    http://www.chironhealthchoices.co.uk/a-message-from-india/

    I don't think so!

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