Evidence-Based Medicine,Clinical Practice Guidelines,and Common Sense in the Management of Osteoporosis

ObjectiveTo evaluate the benefits and limitations of randomized controlled trials (RCTs), clinical practice guidelines (CPGs), and clinical judgment in the management of osteoporosis.MethodsA review was conducted of the English-language literature on the origins and applications of RCTs, CPGs, evidence-based medicine, and clinical judgment in the management of osteoporosis.ResultsEvidence-based medicine is use of the currently available best evidence in making clinical decisions for individual patients. CPGs are recommendations for making clinical decisions based on research evidence, sometimes with consideration of expert opinion, health care policy, and costs of care. The highest levels of medical evidence are usually thought to be RCTs and meta-analyses of high-quality RCTs. Although it is desirable and appropriate for clinicians to consider research evidence from RCTs and recommendations presented in CPGs in making clinical decisions, other factors—such as patient preference, comorbidities, affordability, and availability of care—are important for the actual implementation of evidence-based medicine.ConclusionDecisions about who to treat, which drug to use, how best to monitor, and how long to treat require clinical skills in addition to knowledge of medical research. The necessity of integrating common sense and clinical judgment is highlighted by the fact that many patients treated for osteoporosis in clinical practice would not qualify for participation in the pivotal clinical trials that demonstrated efficacy and safety of the drugs used to treat them. (Endocr Pract. 2009;15:573-579)     

Rural Doctors’ Views on and Experiences with Evidence-Based Medicine: The FrEEDoM Qualitative Study

Background

Evidence-based medicine is the integration of individual clinical expertise, best external evidence and patient values which was introduced more than two decades ago. Yet, primary care physicians in Malaysia face unique barriers in accessing scientific literature and applying it to their clinical practice.

Aim

This study aimed to explore the views and experiences of rural doctors’ about evidence-based medicine in their daily clinical practice in a rural primary care setting.

Methods

Qualitative methodology was used. The interviews were conducted in June 2013 in two rural health clinics in Malaysia. The participants were recruited using purposive sampling. Four focus group discussions with 15 medical officers and three individual in-depth interviews with family medicine specialists were carried out. All interviews were conducted using a topic guide and were audio-recorded, transcribed verbatim, checked and analyzed using a thematic approach.

Results

Key themes identified were: (1) doctors viewed evidence-based medicine mainly as statistics, research and guidelines, (2) reactions to evidence-based medicine were largely negative, (3) doctors relied on specialists, peers, guidelines and non-evidence based internet sources for information, (4) information sources were accessed using novel methods such as mobile applications and (5) there are several barriers to evidence-based practice, including doctor-, evidence-based medicine-, patient- and system-related factors. These included inadequacies in knowledge, attitude, management support, time and access to evidence-based information sources. Participants recommended the use of online services to support evidence-based practice in the rural settings.

Conclusion

The level of evidence-based practice is low in the rural setting due to poor awareness, knowledge, attitude and resources. Doctors use non-evidence based sources and access them through new methods such as messaging applications. Further research is recommended to develop and evaluate interventions to overcome the identified barriers.     

The Spatialisation of Disease: Foucualt and Evidence-based Medicine (EBM)

In this paper I draw on the French philosopher Michel Foucault for a viewpoint on aspects of EBM. This means that I develop his idea of the spaces occupied by disease. I give much of the paper to only one of these spaces, the space of perception of disease, in order to major on the medical gaze, one of Foucault’s best-known contributions to the philosophy of medicine. As I explain what I mean by each of the spaces of disease, I configure EBM into this space. The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Evidence-based clinical practice requires integration of individual clinical expertise and patient preferences with the best available external clinical evidence from systematic research and consideration of available resources. EBM can be considered a subcategory of evidence-based healthcare, which also includes other branches of health-care practice such as evidence-based nursing or evidence-based physiotherapy. EBM subcategories include evidence-based surgery and evidence-based cardiology (Guyatt et al. 2008, 783).     

Transforming scientific evidence into better consumer choices

Translational research using evidence-based and comparative effectiveness research continues to evolve, becoming a useful tool in improving informed consent and decision-making in the clinical setting. While in development, emerging technologies, including cellular and molecular biology, are leading to establishing evidence-based dental practices. One emerging technology, which conjoins bench proteomic findings to clinical decision-making for treatment intervention, is the Translational Evidence Mechanism. This mechanism was developed to be a foundation for a compact between researcher, translational researcher, clinician, and patient. The output of such a mechanism is the clinical practice guideline (CPG), an interactive tool for dentists and patients to game evidence in reaching optimum clinical decisions that correspond to individual patient preferences and values. As such, the clinical practice guideline requires the vesting of decision, utility, and cost best evidence. Evidence-based research provides decision data, a first attempt at supporting decision-making by providing best outcome data. Since then comparative effectiveness research has emerged, using systematic review analysis to compare similar treatments or procedures in maximizing the choice of the most effective cost/benefit option within the context of best evidence. With innovation in the clinical practice guideline for optimizing efficacy and comparative effectiveness research, evidence-based practices will shape a new approach to health-based systems that adhere to shared decision-making between bench scientists, healthcare providers and patients.     

Transforming scientific evidence into better consumer choices

Translational research using evidence-based and comparative effectiveness research continues to evolve, becoming a useful tool in improving informed consent and decision-making in the clinical setting. While in development, emerging technologies, including cellular and molecular biology, are leading to establishing evidence-based dental practices. One emerging technology, which conjoins bench proteomic findings to clinical decision-making for treatment intervention, is the Translational Evidence Mechanism. This mechanism was developed to be a foundation for a compact between researcher, translational researcher, clinician, and patient. The output of such a mechanism is the clinical practice guideline (CPG), an interactive tool for dentists and patients to game evidence in reaching optimum clinical decisions that correspond to individual patient preferences and values. As such, the clinical practice guideline requires the vesting of decision, utility, and cost best evidence. Evidence-based research provides decision data, a first attempt at supporting decision-making by providing best outcome data. Since then comparative effectiveness research has emerged, using systematic review analysis to compare similar treatments or procedures in maximizing the choice of the most effective cost/benefit option within the context of best evidence. With innovation in the clinical practice guideline for optimizing efficacy and comparative effectiveness research, evidence-based practices will shape a new approach to health-based systems that adhere to shared decision-making between bench scientists, healthcare providers and patients.     

抑郁症治疗的循证医学研究进展

循证医学是近年来国际上临床医学领域迅速发展起来的新学科,已成为当前国际医学研究中的热点之一,是指对病人的诊 断、治疗、预防、康复和其他决策应建立在当前最佳临床研究证据,是遵循证据的临床医学,强调收集最佳证据。其理念的科学性 和有效性迅速渗透到医学领域的众多学科,循证精神卫生也相继提出并发展。抑郁症是由各种原因引起的以抑郁为主要症状的 一组心境障碍或情感性障碍,近几年能够有效运用循证医学方法为治疗抑郁症寻找最佳临床证据,制定循证诊疗指南成为了临 床医生的迫切要求。本文就抑郁症治疗方面的循证医学研究进展做一综述。     

From evidence-based medicine to genomic medicine

The concept of ‘evidence-based medicine’ dates back to mid-19th century or even earlier. It remains pivotal in planning, funding and in delivering the health care. Clinicians, public health practitioners, health commissioners/purchasers, health planners, politicians and public seek formal ‘evidence’ in approving any form of health care provision. Essentially ‘evidence-based medicine’ aims at the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients. It is in fact the ‘personalised medicine’ in practice. Since the completion of the human genome project and the rapid accumulation of huge amount of data, scientists and physicians alike are excited on the prospect of ‘personalised health care’ based on individual’s genotype and phenotype. The first decade of the new millennium now witnesses the transition from ‘evidence-based medicine’ to the ‘genomic medicine’. The practice of medicine, including health promotion and prevention of disease, stands now at a wide-open road as the scientific and medical community embraces itself with the rapidly expanding and revolutionising field of genomic medicine. This article reviews the rapid transformation of modern medicine from the ‘evidence-based medicine’ to ‘genomic medicine’.     

Integrate personalized medicine into clinical practice to improve patient safety

Medical practice is based on the experience of practitioners and on learned medical knowledge. This knowledge is based on studies of patient's population. Modern medicine is facing a variety of clinical forms and also variable patients’ responses to treatment. Pharmacogenomics has brought insights to this variability and has led to the development of personalized medicine. The adoption of personalized medicine is slowed down by a number of technical and methodology barriers. The concept of personalized medicine should not be only limited to genetics but must reuse all patient information to get the most suitable patient profile. In this paper we present a methodology for the integration of personalized medicine into clinical practice.     

Evidence-based medicine: watching out for its friends

An old joke states that one need not worry about one's enemies, but may be in danger from one's friends. We review a number of "enemies" and "friends" of evidence-based medicine (EBM). To understand where these enemies and friends have come from, it is important to see how the rise of EBM has created shifts in power, especially within academic medicine. Attacks from "enemies"-especially the criticism that EBM amounts to overturning a medicine of the individual in favor of an undesirable population medicine-tend to reflect misunderstandings of EBM, or of the degrees of uncertainty inherent in medicine itself, rather than substantive criticisms. The activities of three categories of so-called friends might well give EBM an undesirable reputation. These "friends" are the practitioners of a crude version of EBM (uncritical acceptance of randomized controlled trials while rejecting all other forms of evidence), commercial sponsors of clinical trials whose biases distort the available evidentiary base, and bureaucrats who employ EBM practices in the service of inequitable rationing of health resources.     

The promise of protein glycosylation for personalised medicine

BackgroundComplex diseases such as cancer are a consequence of numerous causes. State of the art personalised medicine approaches are mostly based on evaluating patients' individual genetic background. Despite the advances of genomics it fails to take individual dynamic influences into account that contribute to the individual and unique glycomic and glycoproteomic “configurations” of every living being.Scope of reviewGlycomic and glycoproteomic-based personalised medicine diagnostics are still in their infancies, however some initial success stories indicate that these fields are highly promising to mediate novel early diagnosis and disease stratification markers, subsequently resulting in improved patient well-being and reduced treatment costs. In this review we not only summarise current protein glycosylation based examples that substantially improve or possess great potential for personalised medicine, but also describe current limitations as well as future perspectives and challenges associated with establishing protein glycosylation aspects for this purpose.Major conclusionsMany protein biomarkers currently in clinical use are glycoproteins, however, their glycosylation status is seldom evaluated in a clinical context. To date just few examples have already been successfully translated into clinical practice, making protein glycosylation a highly promising diagnostic target with humongous potential for personalised medicine.General significanceThere is an urgent need for markers that enable the establishment of an individualised and optimised patient treatment at the earliest disease stage possible. The glycosylation status of a patient and/or specific marker proteins can provide important clues that result in improved patient management. This article is part of a Special Issue entitled “Glycans in personalised medicine” Guest Editor: Professor Gordan Lauc.     

In the patient's best interest--a call to action,a call to balance

Nurses, physicians, and other healthcare professionals often complain that a loss of freedom or other obstacles hinder their ability to act in the best interest of the patient. These barriers cause professional burnout and moral outrage, and may contribute to a migration away from medicine or, more broadly, healthcare. Understanding the historical underpinnings of the phrase "in the patient's best interest," and realizing that healthcare, which is fundamentally a moral enterprise must be built on sound business principles can help healthcare professionals reframe the issue, and reclaim their original commitment to a difficult path.     

Use of macrolides in pregnancy and lactation according to evidence-based medicine: pro et contra

The use of macrolides in the treatment of chlamydial infection during pregnancy and breast feeding is reviewed from the viewpoint of evidence-based medicine. The clinical experience and research data suggest azithromycin to be safe and effective in the obstetric practice.     

Prospects for translational regenerative medicine

Translational medicine is an evolutional concept that encompasses the rapid translation of basic research for use in clinical disease diagnosis, prevention and treatment. It follows the idea "from bench to bedside and back", and hence relies on cooperation between laboratory research and clinical care. In the past decade, translational medicine has received unprecedented attention from scientists and clinicians and its fundamental principles have penetrated throughout biomedicine, offering a sign post that guides modern medical research toward a patient-centered focus. Translational regenerative medicine is still in its infancy, and significant basic research investment has not yet achieved satisfactory clinical outcomes for patients. In particular, there are many challenges associated with the use of cell- and tissue-based products for clinical therapies. This review summarizes the transformation and global progress in translational medicine over the past decade. The current obstacles and opportunities in translational regenerative medicine are outlined in the context of stem cell therapy and tissue engineering for the safe and effective regeneration of functional tissue. This review highlights the requirement for multi-disciplinary and inter-disciplinary cooperation to ensure the development of the best possible regenerative therapies within the shortest timeframe possible for the greatest patient benefit.     

From hierarchy to network: a richer view of evidence for evidence-based medicine

Evidence-based medicine (EBM) advocates the improvement of patient care through the use of current best research evidence in medical decision making. In practice, "best evidence" generally refers to where a study fits on a hierarchy of evidence, which places randomized controlled trials (RCTs) and other population-level research above laboratory research. Because population research is concerned primarily with average results obtained from large groups of people, ranking evidence on the basis of its place in the hierarchy is shortsighted and ultimately limits the ability of research results to inform the care of individual patients. The history and methodology of epidemiology reveals a close relationship between population-level and laboratory research; both types of research are necessary if we are to understand the causes of a disease. What EBM does not take into account in its hierarchy of evidence is that the same thing is true for research on the safety and efficacy of medical interventions. To maximize the information that clinical research can provide for clinical care, RCTs should be designed to elucidate within-group variability. This can only be done if the hierarchy of evidence is replaced by a network that takes into account the relationship between epidemiological and laboratory research.     

The clinical psychologist; his role in private medical practice

The independent diagnosis and treatment of mental and nervous disorders according to California law constitutes practicing medicine. By this yardstick, an increasing number of clinical psychologists are entering the private practice of medicine. The medical profession has not provided through its leadership the opportunity for clinical psychologists to utilize their skills in a legitimate and supervised way in the treatment of private patients, nor has the medical profession taken sufficient interest in modern methods of treating patients with psychogenic disorders. If the psychiatric team is a feasible and practical approach to spreading the base of psychiatric treatment in hospitals and clinics, it should be applicable to private practice settings too. In the team setting, the psychologist can render great assistance to the physician in the diagnosis and treatment of patients with psychogenic disorders without compromising the principle that the primary responsibility for the patient is the physician's. By virtue of his training and experience, it is the psychiatrist who is best qualified to supervise the work of the psychologist; and until such time as the medical profession is better acquainted with psychotherapeutic techniques, the employment of psychologist assistants should be (according to good medical practice) left to the psychiatrist. The need for some regulation of the use of the title "psychologist" is increasing in order to protect the public from quacks who pose as psychologists. However, any law which is directed toward elimination of the quack should specifically define psychotherapy and contain provisions for its use under adequate medical supervision. The medical profession is obligated to take its traditional role in providing the best possible treatment for patients who are in need of it, and psychotherapy is an inherent part of treatment.     

Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association

ObjectiveHypothyroidism has multiple etiologies and manifestations. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions. This paper describes evidence-based clinical guidelines for the clinical management of hypothyroidism in ambulatory patients.MethodsThe development of these guidelines was commissioned by the American Association of Clinical Endocrinologists (AACE) in association with American Thyroid Association (ATA). AACE and the ATA assem bled a task force of expert clinicians who authored this article. The authors examined relevant literature and took an evidence-based medicine approach that incor porated their knowledge and experience to develop a series of specific recommendations and the rationale for these recommendations. The strength of the recommen dations and the quality of evidence supporting each was rated according to the approach outlined in the American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Guidelines—2010 update.ResultsTopics addressed include the etiology, epide miology, clinical and laboratory evaluation, management, and consequences of hypothyroidism. Screening, treatment of subclinical hypothyroidism, pregnancy, and areas for future research are also covered.ConclusionsFifty-two evidence-based recommenda tions and subrecommendations were developed to aid in the care of patients with hypothyroidism and to share what the authors believe is current, rational, and optimal medi cal practice for the diagnosis and care of hypothyroidism. A serum thyrotropin is the single best screening test for primary thyroid dysfunction for the vast majority of outpa tient clinical situations. The standard treatment is replace ment with L-thyroxine. The decision to treat subclinical hypothyroidism when the serum thyrotropin is less than 10 mIU/L should be tailored to the individual patient.     

Medicinal mushrooms and cancer therapy: translating a traditional practice into Western medicine

Modern medical practice relies heavily on the use of highly purified pharmaceutical compounds whose purity can be easily assessed and whose pharmaceutical activity and toxicity show clear structure-function relationships. In contrast, many herbal medicines contain mixtures of natural compounds that have not undergone detailed chemical analyses and whose mechanism of action is not known. Traditional folk medicine and ethno-pharmacology coupled to bioprospecting have been an important source of many anticancer agents as well as other medicines. With the current decline in the number of new molecular entities from the pharmaceutical industry, novel anticancer agents are being sought from traditional medicine. As the example of medicinal mushrooms demonstrates, however, translating traditional Eastern practices into acceptable evidence-based Western therapies is difficult. Different manufacturing standards, criteria of purity, and under-powered clinical trials make assessment of efficacy and toxicity by Western standards of clinical evidence difficult. Purified bioactive compounds derived from medicinal mushrooms are a potentially important new source of anticancer agents; their assimilation into Western drug discovery programs and clinical trials also provides a framework for the study and use of other traditional medicines.     

Predictive diagnostics and personalized medicine for the prevention of chronic degenerative diseases

Progressive increase of mean age and life expectancy in both industrialized and emerging societies parallels an increment of chronic degenerative diseases (CDD) such as cancer, cardiovascular, autoimmune or neurodegenerative diseases among the elderly. CDD are of complex diagnosis, difficult to treat and absorbing an increasing proportion in the health care budgets worldwide. However, recent development in modern medicine especially in genetics, proteomics, and informatics is leading to the discovery of biomarkers associated with different CDD that can be used as indicator of disease's risk in healthy subjects. Therefore, predictive medicine is merging and medical doctors may for the first time anticipate the deleterious effect of CDD and use markers to identify persons with high risk of developing a given CDD before the clinical manifestation of the diseases. This innovative approach may offer substantial advantages, since the promise of personalized medicine is to preserve individual health in people with high risk by starting early treatment or prevention protocols. The pathway is now open, however the road to an effective personalized medicine is still long, several (diagnostic) predictive instruments for different CDD are under development, some ethical issues have to be solved. Operative proposals for the heath care systems are now needed to verify potential benefits of predictive medicine in the clinical practice. In fact, predictive diagnostics, personalized medicine and personalized therapy have the potential of changing classical approaches of modern medicine to CDD.     

Thirteen follies and fallacies about alternative medicine

Thirteen common misunderstandings about alternative medicine and the consequences for health.The use of alternative medicine (AM)—treatments such as herbs or massage therapy—has long been a part of healthcare in many regions of the world “to complement mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine” [1]. What AM cannot do is replace conventional treatment, particularly when it comes to serious or even life-threatening conditions. Nevertheless, many AM apologists insist that it can do so, that it is an alternative rather than a complement. This assumption can confuse patients and even endanger their lives. In this Opinion article, I explore some of the most common fallacies used to support, justify or promote AM.1. Since many people believe in or practise AM, it is tempting to assume that it is useful. According to this argumentum ad populum, millions cannot all be wrong. However, belief can be wrong, practice can be misguided, and popularity is not a reliable indicator for effectiveness; after all, medicine is no popularity contest. The history of medicine is littered with examples that demonstrate how misleading this fallacy can be. Bloodletting was believed to be effective, was widely practised and highly popular, yet it certainly killed more patients than it ever helped.2. The classic post hoc, ergo propter hoc fallacy—‘it worked for me (my aunt, my cat etc)''—is firmly engrained into the human mind. If a patient receives a treatment and then gets better, what could be more logical than to assume that the treatment was the cause of the improvement? This conclusion seems as obvious to patients—and many clinicians—as it is fallacious. Proponents of AM employ this fallacy incessantly to convince us that ineffective treatments are, in fact, effective.Apart from the treatment per se, a whole range of phenomena exists that can cause or contribute to improvement: the placebo effect, the natural history of the illness, the regression towards the mean and so on. It means that patients can get better after administering useless or even mildly harmful remedies; subsequently is not the same as consequently. Causal inferences based on anecdotes are therefore highly problematic and certainly no sound basis for robust conclusions about the efficacy of therapeutic interventions.Most apologists for AM argue that it is of secondary importance how a given type of AM works. Even if it were a pure placebo, they say, it would still help suffering patients through a placebo response, and surely that must be a good thing. In other words, the mechanism of the effect is of little practical relevance and what counts most is to help the patient.This fallacy ignores several important issues. The administration of placebos in clinical routine can be unethical and dangerous, but is also not necessary to produce a placebo response. If a clinician administers an effective therapy with empathy and compassion, he or she generates a placebo effect in addition to the specific therapeutic effect. Exclusively relying on placebos therefore deprives the patient of the latter.3. Apologists for AM like to cite statistics that show how a sizeable percentage of all conventional treatments is not supported by sound evidence. Thus, they argue, it is unfair to insist on AM being solidly evidence-based. Unquestionably, many conventional therapies are currently not evidence-based. Yet, this is hardly a reasonable justification for using unproven or disproven forms of AM. Unreliable railways do not get more acceptable because thousands of people get stuck in traffic jams on the roads.4. The adverse effects of conventional medicine are argued to be so serious and frequent that those of AM are negligible. While it is true that the risks of some conventional treatments are greater than those of some forms of AM, this is beside the point. The real value of a treatment is not determined by its absolute risk but by the balance between risk and benefit. If a treatment is potentially life-saving, substantial risks can be tolerated. If a therapy has no benefit, even a small risk would weigh heavily and the risk–benefit balance would not be positive.5. Whenever scientific investigations fail to show what they had hoped for, apologists for AM claim that science cannot be meaningfully applied to their field. Their type of AM, they insist, is holistic, individualized, complex, relies on subtle, unquantifiable energies and so on, and these circumstances prevent it from being squeezed into the straight jacket of reductionist science. After all, there are many things “between heaven and earth” that science will never be able to capture.Science certainly has its limits. Yet, when it comes to testing therapeutic claims, it provides us with fairly adequate tools to assess them. Even if the claim is that a particular holistic, individualised and complex form of energy healing makes you feel better, live longer or experience life more wholesomely, the hypothesis is scientifically testable. Even if no validated outcome measure exists for a particular claim, scientists should be able to develop one. The notion that “a therapy defies scientific testing” merely discloses a lack of understanding of what science can achieve.6. Most people would probably agree that many AM practitioners are well intentioned. There is also evidence that they are capable of building up a good therapeutic relationship with their patients [3]. To extrapolate from such data that AM is useful would, however, be erroneous. Compassion, empathy and good interactions with patients are certainly important, but they are not a monopoly of AM. In fact, these qualities are among the hallmarks of any good healthcare. To imply that only AM practitioners possess them is wrong and an insult to the many clinicians who are doing their best to implement patient-centred care, often under difficult circumstances.7. Many forms of AM are said to have long histories that must surely count for something; any treatment that has stood the test of time must be useful. Some practitioners of AM even insist that the “test of time” is more relevant than that of science. A long tradition of use can, of course, be an indicator of the safety and efficacy of a treatment, but it can never be proof. On the contrary, a long history might just indicate that the origins of that therapy reach back to a time when anatomy and physiology, among other things, were not well understood. This, in turn, might lessen the chances that any such intervention is plausible or effective. Treatments such as bloodletting or purging again provide apt examples.8. Enthusiasts of AM tend to appeal to authority in various ways. They may state that a government organization endorses particular modalities, that respectable pharmacies sell AM preparations, that the royal family uses them, that Nobel-prize winners support them and so on. These claims may well be true, but to infer that such endorsements render AM valuable would be fallacious. Endorsements of this kind might merely show that even well-educated, authoritative people or institutions can sometimes commit silly mistakes.9. An entire industry has developed around the notion that AM is natural and therefore cannot do any harm. The implication is that conventional treatments are based on unnatural chemicals, which are potentially harmful. Nature, by contrast, is benign and natural remedies are to be preferred. This argument is as effective for marketing purposes as it is fallacious. Firstly, by no means are all forms of AM natural. For instance, there is nothing natural in sticking needles into a patient''s body (as in acupuncture) or endlessly diluting and shaking a medicine (as in homeopathy). Secondly, Nature is not necessarily benign. Even herbal extracts from natural sources are not necessarily safe [2]—think of hemlock.10. Many AM enthusiasts seem to believe that powerful intrigues aim at suppressing the knowledge of AM about how to heal the sick. The pharmaceutical industry is often cited in this context. The underlying assumption is that the pharmaceutical sector would lose substantial amounts of revenue if the true value of this or that form of AM became general knowledge. I have never seen any evidence to suggest that this notion is true or that those who make such claims can produce good evidence for it. In my experience, the pharmaceutical industry is barely aware of AM or, when it is, it has found ways of profiting from it by marketing ‘natural'' supplements.11. If ‘big pharma'' is not in the frame, other institutions or professionals might be. Oncologists, for instance, are said to disregard and suppress alternative methods claimed to be cancer cures. Yet I have never met a single oncologist who would not be delighted to see an effective cancer cure emerge or who would care one iota whether it originates from the field of AM or from any other source.12. Absence of evidence is not evidence of absence of effect. If, for a given form of AM, we have no or no good evidence for its effectiveness, we cannot assume that it is ineffective. The principle is, of course, entirely correct. We have not identified life on other planets, for instance, but we cannot be sure that no extraterrestrial life exists. However, the conclusion some AM apologists draw from this principle is grossly misleading. They argue that it is reasonable to use the treatment in question until evidence emerges that proves it to be ineffective. In healthcare, it is unwise and arguably unethical to give the benefit of the doubt to under-researched therapies. In the interest of our patients, we should use treatments that are supported by sound evidence for effectiveness, while those that do not fall into this category should be avoided.13. AM is dominated by strong beliefs rather than sound evidence. Thus, it is perhaps unsurprising that some believers resort to ad hominem attacks, particularly when they have run out of rational arguments against their critics. During the past 20 years of researching AM, I have received my fair share of such personal attacks that attempt to undermine my authority and integrity. For instance, it has been claimed that I am not qualified to do the work that I do, that I am guilty of scientific misconduct, that I am on the payroll of ‘big pharma'', or that I have personal reasons to be biased. The aim of ad hominem attacks is to discredit an opponent and, for some fanatic believers, this aim seems to justify even the most drastic means.AM is plagued by fallacies that confuse or mislead the public and thus prevent many patients from making the right therapeutic decisions. A good example is the attitude of many AM apologists regarding immunization [2]. They tend to combine several of the above-listed fallacies into a series of grossly misleading arguments: vaccinations are not as effective as they are made out to be, and infection rates actually declined because of better hygiene; vaccinations frequently cause serious problems, such as autism; famous and intelligent people have refused to vaccinate their children; vaccinations are unnatural, while the alternative options are natural and safe; vaccinations are pushed by ‘big pharma'' to enrich their shareholders; just because there is no evidence for the alternatives, this does not mean they are not effective; and the experts who speak out in favour of vaccinations are corrupt.This example highlights the fact that much harm can be done by falling for the plethora of fallacies that dominate the field of AM. It is therefore important to discuss these arguments openly and disclose them for what they truly are: often seemingly plausible notions that are actually misleading to the point of endangering public health.