Integrated medicine
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7279.119 (Published 20 January 2001) Cite this as: BMJ 2001;322:119
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Sir,
"In the case of homeopathy, in particular, it's really impossible to
understand the subject in any depth unless you view it from a historical
perspective." [1]
It is difficult to understand exactly what Dr Campbell means by this
remark. For example, many would say that any would-be practitioner would
chiefly want to ensure that it works. That would be a top priority. Once
satisfied that it does work, then the next priority for a busy
practitioner, would be to buy one of Dr Andrew Lockie's excellent books
and set about learning all about the remedies and their medical uses.
Initially using specifics like Drosera for Whooping cough and Kreosotum
for vaginal thrush, for example, the beginner can soon progress to the
deeper and subtler aspects of practice.
In this scenario, any understanding of the history of homeopathy
seems to be of negligible consequence. Why does he say ‘impossible to
understand the subject in any depth’? It just sounds a very strange thing
to say. The vast bulk of homeopaths in the world practice it very
successfully while being blithely ignorant of the history of the subject.
Perhaps Dr Campbell is referring entirely to his own website, which
gives the main outlines of the history of homeopathy as it has developed,
but which does not give much information about the mission that Hahnemann
inherited from Medieval medicine, or the social context in which he
worked. Or how, single-handedly, Hahnemann ingeniously solved all the
problems with Medieval medicine and in so doing stands out as the greatest
physician who ever lived.
Perhaps Dr Campbell means that the history of homeopathy reveals much
about unorthodox medicine in general?
Maybe I could tempt Dr Campbell to explain more clearly, what he
means by the above remark? If, after a suitable space of time has elapsed,
it is apparent that Dr Campbell does not wish to address these questions,
then I shall assume that he will not mind if I have a stab at the task
myself.
Sources
[1] BMJ letter, Re: Integrated medicine - a short road to betrayal,
21 January 2001, Dr Anthony Campbell
Competing interests: No competing interests
I am sure that you will receive many adverse critiques of this pseudo
-editorial article. Whether you call it 'integrated medicine' ;
Complimentary medicine' or Alternative medicine', much of this form of
therapy is mostly unproven and unsubstantiated by scientific research.
When it is given alongside / simultaneously with proven scientifically
evidence based medicine, the final results are often confounded.
Your editorial authors (and the Prince of Wales!) bemoan the paucity of
funding for research into ‘alternative medicine’. Unfortunately there is a
general paucity of funding for research that is based on sound scientific
methodology. So it is not surprising that there is a shortage of money for
research into complimentary or alternative 'medicine'. It has been
established by surveys that these therapies are successful because they
are based on public demand for a non-threatening modality of treatment
when faced with the increasingly ‘cold and impersonal’ scientific approach
to medicine. However, a high demand and expenditure by members of the
public does not necessarily mean that alternative medicine works, just
that some companies and persons are making a good living from promoting
it.
The article by MacLellan et al, of the Department of Obstetrics and
Gynaecology, University of Adelaide, South Australia 5000, Australia,
published in the Lancet, 1996 Mar 2;347(9001):569-73, and quoted by your
editorial authors to substantiate their argument, puts the counter
argument very well.
" Extrapolation of the costs to the Australian population gives a natural
expenditure in 1993, for alternative medicines, of $621 million
(Australian dollars) and for alternative therapists of $AU309 million per
annum. This compares to the $AU360 million of patient contributions for
all classes of pharmaceutical drugs purchased in Australia in 1992/93. The
public health and economic ramifications of these huge costs are
questioned in view of the paucity of sound safety and efficacy data for
many of the therapies and products of the alternative medicine industry.”
I rest my case.
Sincerely
Roger Clarke
Competing interests: No competing interests
I am currently doing a systematic review about the effectiveness of
Chinese medicine for psoriasis. I have some thoughts to share.
1.Western medicine has already established comprehensive and rigorous
models from animal experiments, biological experiments and clinical
trials. However, Alternative medicine is more philosophical and
metaphysical approached. That’s the main problem, I believe.
2.If we do believe “only” criteria used in clinical trials such as
randomisation, double blinded, etc, is the best approach to assess the
effectiveness of alternative medicine, then alternative medicine has a
long way to go. The lack of common language to communicate both sides
would prevent alternative medicine to integrate into “conventional”
medicine. A common language means the same or at least similar diagnosis
method, outcome measure, and the definitions of diseases, etc. In that
situation, how can we talk to each other sensibly?
3.I believe it is because we have different ways of looking at the world.
Nowadays many health professional use health-related quality of life
instruments to “integrate” the discrepancies between self-report outcomes
and clinical outcomes. “Maybe” alternative medicine has more effects in
those self-report scales than traditional therapy. I mean, if we rely on
HRQOL scales to judge the effectiveness of a treatment. What will it be?
At least I don’t believe patients are all stupid to spend lots of money on
something useless.
4.I believe if we really want to understand more about alternative
medicine, in a way we need to get rid of a bit the idea of FDA or Cochrane
library. They made and definitely make mistakes. It is the same as in
other disciplines. Challenging an old physics theory, claiming there is
something smaller than atoms, etc. The ironic is we call it “big
discovery”.
5.To integrate both, building the relationship between HRQOL research and
clinical indicators may be promising. However, in my study I have not
found any Chinese clinical trials used HRQOL scales to discuss the
“holistic” effects. I believe it is because HRQOL is rather new. The
criteria in those Chinese clinical trials used different criteria from the
western ones.
6.multi-ingredients Chinese medicine PG2 (Hwuan Chi) has passed the phase
II clinical trial.
7.Padma 28, which was found accidentally by an Israel physician Sallon
while she was in India for sanitary promotion campaign, has been used in
Swiss. In Israel this drug has also been applied to treat alcoholics,
intermittent claudication.
8.Genic have been proved to totally inhibit the duplication of HIV within
4-day treatment with less side effects than traditional triple therapy.
This study has passed animal test and in vitro human lymph test in Germany
HIV centre.
9. I totally agree "with no specific funding for research into
complementary medicine, evidence will not be forthcoming." The U.S. put
lots of money on it is because there is a huge market on it.
Finally, a real story to share with you.
I am a pharmacist (Taiwan) with western medical education and I spent
two years for my MSc in medicinal chemistry. I did not believe Chinese
medicine until I was “forced” by my mother to use it (with an open mind?).
Until now, I still don’t understand how that practitioner (healer) used
“Qi Gong” to cure my ankle problem, which was badly injured in Britain. My
G.P. in Britain repeatedly said it takes more than six weeks to heal…. The
GPs only asked me to rest, to rest, to rest. I rested for over three
months and I still could not play badminton. Finally I was fed up with it and
flew back to Taiwan. After two visits the pain and discomfort was gone!
The treatment cost me £12. I also had another injury on my waist. I
suffered from it for over two years. Again, after three visits it’s
gone. I am not saying my experiences PROVE the effectiveness of Qi Gong
because my single case does not mean anything. I am saying an open mind is
extremely important to accept another possibility which we is out of our
beliefs, education, experiences, or whatever.
However, I did not feel any effect after three treatments of acupuncture
for my spinal injury. The injury cured itself.
Competing interests: No competing interests
Clearly there is a growing perception that a narrowly focussed
biological approach to patients is inadequate. There is a need to address
the psychological aspects of patients presentations and to provide
appropriate interventions in these areas. This seems to be the argument
offered for embracing complementary and alternative medicine. There is
another way.
There is a science of psychology and its practical application in
clinical psychology and psychiatry. The problem is not that a science of
the 'art of medicine' doesn't exist, but that it has become divorced from
general medical practice. Liaison psychiatrists and psychologists have
been addressing these isues for many years. There is a substantial
evidence base of randomized trials on which to base practice (1). Some
have been published in the BMJ. It is amazing to me that liaison
psychiatry/ psychology was not mentioned in this special issue of the BMJ.
Medicine can integrate psychological aspects of care without having
to 'go alternative'.
(1) Royal Colleges of Physicians and Royal College of Psychiatrists.
Joint working party report: the psychological care of medical patients;
recognition of need and service provision. London, Royal College of
Physicians, 1995.
Competing interests: No competing interests
Inasmuch as medicine is defined as "the art of preventing or curing
disease", all successful preventative or curative techniques are that art.
The source of a treatment can't matter. Consider, for instance, the
medicinal value of mould.
It follows that any new or old medical technique can only be measured
by its successfulness, according to the same rigorous standards in all
cases. In fact, throughout history, medicine (and disease) have always
evolved. It has not changed that each treatment, regardless of its
source, eventually stands or falls on its own apparent merit. What has
changed is our ability to apply rigorous standards when determining such
merits. This suggests, therefore, that the NIH is doing a wonderful thing
in embracing opportunities to define and refine medicine.
The tragedy is not that science is soon going to elucidate the merits
and demerits of so many therapies yet untested. The tragedy is the
drawing of a line in the sand of society, a line separating people
educated in universities from people educated elsewhere.
People want to be "masters of their own destiny". We make choices,
act independently, try things out. We have self-help books, the Internet,
distance education, and a growing trend of "choose your own health care
methods". Feeding this basic human drive for independence and self-
control are opportunities to choose amongst multifarious accessible and
ostensibly "proven" (e.g., by testimonials) treatments. In contrast,
feelings of utter dependence are fueled by prescriptions backed up by
realistic but unamazing statistical likelihoods of their effectiveness.
Unless the world at large can be trained in biochemistry, physiology,
statistics, etc., the more formally trained medical community will have to
work fast to erase a line. It is a line undoubtedly darkened by self-
serving financial interests that ironically but so effectively separates
"biomedicine" from "I'm a living human" medicine in the eyes of so many
people. The point has to be made to the alienated public that the
university-trained medical community does not consider itself an elite,
know-it-all race. Perhaps the biggest tragedy of all is that it seems it
all boils down not to verifiable knowledge, integrity, and respect but to
the biggest sell.
Competing interests: No competing interests
It is common to talk about integrating complementary and conventional
therapies. The assumptions being that the practitioners are keen to be
part of the NHS, and that limited availability within the NHS produces
inequity in healthcare provision. The questions then are which therapies
should be integrated and how should they be integrated? Complementary
therapies are currently delivered within the NHS through a variety of
models including primary care, hospitals, and by conventional healthcare
staff who have completed additional training and extended their skills
(Fulder 1996, Coates and Jobst 1998). The extent to which different models
have been compared and contrasted, however, is somewhat limited and the
most appropriate mechanisms for delivering complementary therapies within
the NHS have not yet been established.
Furthermore, there are diverse definitions of 'integration'. For
example one definition might be to place the patient at the centre of a
package of care that combines different but appropriate therapeutic
modalities, delivered within the context of their own theoretical
perspectives. Another definition is that 'integration' is simply about
taking the best bits of complementary and alternative medicine and placing
them in the NHS. But if we have limited research evidence about the
effectiveness of the 'best bits', and have not fully explored the
fundamental underpinnings, similarities and differences of conceptually
diverse therapies, how can we 'integrate' appropriately? There are no
simple answers to this. What may be missing from the debate about
complementary therapy and its integration into orthodox healthcare is
dialogue about the fundamental principles of complementary therapies. What
do the common principles within complementary therapies have to offer?'
How different and diverse are they? How do they contrast with conventional
Western medicine? But also can they provide a deeper understanding of
human nature, health and illness? And can they enhance our ability to
provide a therapeutic context for our conventional health care?
Two issues need to be explicit. The first is that any attempt to
integrate a complementary therapy should be clear about the therapeutic
approach, parameters, context, strengths and weakness of the initiative
when reporting the outcomes. The second is to continue to facilitate
dialogue about the fundamental principles of complementary therapies.
So how can we consider these issues when planning the education of
healthcare practitioners? The 'familiarisation' courses suggested by the
Select Committee may quickly become a feature of all pre-registration
medical and nursing training. However there is a danger that such courses
will only skim the surface and fail to do justice to some of the
therapies. Yet perhaps at this level, the best we can do is to present an
overview of a range of complementary therapies, raise awareness about
safety, regulation and evidence, and talk of the challenges the different
philosophical perspectives present. In contrast, at the post-registration
level, different professional disciplines can come together to learn new
therapeutic techniques, whilst exploring and debating the contribution of
different philosophical perspectives.
The integration of complementary and alternative approaches within
conventional healthcare, and the development of multi-disciplinary
education that incorporates such therapeutic approaches will require
careful planning. The context and cultural development of complementary
and alternative approaches, requires further dialogue and debate. If these
issues are neglected as we hurry to incorporate different 'techniques'
into our conventional practice, we may simply be left with additional
tools that we are ill equipped to use.
References
Coates J.R. & Jobst K.A. (eds) (1998) Integrated Healthcare: A
Way Forward for the Next Five Years? The Journal of Alternative and
Complementary Medicine 4(2), 209-247.
Fulder S. (1996) The Handbook of Alternative and Complementary
Medicine. Oxford University Press.
Dr Janet Richardson
Chairman of the Research Council for Complementary Medicine
And Director of Integrated Health Development, Oxford Brookes University
janet.richardson@brookes.ac.uk
Competing interests: No competing interests
Sir,
I quote from your recent correspondence:
"I am, however, appalled: if we get into bed with alternative
medicine we are not only betraying our scientific heritage but we are
also a short step away from betraying our patients. It has taken hundreds
of years to pull medicine away from the quagmire of superstition,
witchcraft, mumbo-jumbo and sheer quackery and turn it into something
resembling a scientific pursuit."
It is true that many of those (and I include myself) who practice and
research into alternative medicine are not medical doctors. It is also
true that many of us not only adhere to the principles of true scientific
enquiry but also are familiar with the history of the development of
medical science.
There are a number of examples of good science, conducted by both
scientists and medical doctors, peer-reviewed and published in respected
medical and scientific journals which should also be included under the
umbrella heading of alternative medicine, and I offer just three examples:
1] Dr Harold Saxton Burr (PhD), a neuro-anatomist at Yale University
School of Medicine for over 40 years, developed a practical, safe and
consistently reliable (over 95%) electro-metric test for cervical cancer
in the 1940's.
2] Dr Robert Becker (MD), an american orthopaedic surgeon,
artificially induced limb regeneration in frogs and demonstrated de-
differentiation of cancer cells all the way back to primitive cells in the
1970's.
3] Dr Bjorn Nordenstrom (MD), Professor of Diagnostic Radiology at
the Karolinska Institute in Stockholm, and pioneer of the percutaneous x-
ray guided needle biopsy technique, has been reversing otherwise
intractable terminal lung cancer in his patients for over 30 years.
These are important, validated and practical scientific breakthroughs
which should, by now, be taught as part of orthodox medicine and be
routinely employed to save lives.
If orthodox medicine shuns the brightest and best innovators from
within its own ranks it is little wonder that so little progress has been
made in the treatment of the major causes of death amongst its unwitting
patients.
It should therefore come as no surprise that the tired, sick,
bereaved, frightened and gullible public - our mutual patients - , are
increasingly turning to " superstition, witchcraft, mumbo-jumbo and sheer
quackery ".
Yours sincerely,
Rory Orr-Sabard
CAM Practitioner
Competing interests: No competing interests
I just read the article, "Integrated medicine - a short road to
betrayal". I was really shocked to read the article. It is always advised
to have a complete idea about the field before making any comments. I have
done my Doctor of Medicine (M.D) in Herbal Pharmacology. I have
three years Research experience in Experimental Pharmacology. I have
fully evaluated a new Herbal and a Metal drug using Scientific parameters.
I have done all the tests extensively ( Bio-chemical, Pharmacological,
Microbiological, Phyto-chemical,Toxicological and Clinical studies. I am
ready to show all the necessary documents). A lot of research is being
done on the alternative drugs and the results prove to be highly effective
and encouraging without any side-effects. Alternative medical systems
have got the solution for the dreaded diseases like AIDS etc.
Alternative
Medical Systems are fully scientific and no one can charge it as baseless
etc. We are not going to discover anything new. It is only going to be
the rediscoveries of what is said in the Traditional literatures perhaps
in the modern/scientific terminologies. Our ultimate aim is going to be
one. i.e. providing a healthier life for all. We(the People of Alternative
Medical Systems) only opt for a peaceful, understanding and co-operative
working atmosphere. If such an atmosphere prevails wonders can be explored
from the Alternative Medical Systems. Then we will find a
Wonderful,Natural,innovative and a Eco-friendly Road.
Competing interests: No competing interests
Dear Editor,
I am dismayed at the responses of so many medical practitioners still
apparently unable to see that those engaged in serious and professional
research/practice into various complementary therapies do so with the very
best of motives. We surely all want to see our patients receive the best
possible care to ensure the best possible outcomes? There seems to be
reference only to 'complementary therapy as though it were a single
discipline rather than a wide array of practices of which many are rapidly
establishing credence among not just the public and whole time
complementary therapists, but also an increasing number of doctors who do
recognise that conventional medicine cannot always provide the best
outcomes.
For goodness sake, wake up and realise that CAM is not something to be
dismissed as quackery like so much black magic; it is here to stay, and
the sooner it receives the complete backing of the medical fraternity and
appropriate regard in the race for research funding the sooner we can all
work in harmony - for the ultimate good of those we profess to care
for.Let well conducted research provide the evidence for or against
the variety of CAM treatments on offer; let there be a genuine attempt to
combine allopathic and complementary medicine to achieve the greatest
synergistic effect.
Competing interests: No competing interests
no such thing as complementary or alternative medicine
There is no such thing as alternative, complementary or orthodox
medicine. The current divisions are arbitrary. There are treatments,
therapies and interventions that have an evidence base and those that do
not. Although I think the BMJ has been drawn into giving credence to
snake oil salesmen, the theme issue did illustrate several points [1].
Firstly, there are side effects for practitioners who claim to practise
alternative/complementary medicine. They are at high risk of suffering
from pomposity, self importance and delusions of grandeur. There was an
Orwellian ‘four legs good, two legs bad’ tone to much of the writing [2].
Traditional healing good, modern medicine bad; oriental medicine good,
western medicine bad; complimentary practitioners caring and holistic,
orthodox doctors (apart from those who had been enlightened [3]) uncaring
and not holistic. Essex’s first inverse law says that the more someone
talks about being holistic, the less they are likely to be so. I can’t
remember the last time one of my colleagues used the phrase ‘holistic’ but
I know from doing joint clinics with them and seeing them practise that
they are holistic, caring and conscientious. They don’t talk about it,
they just do it. Perhaps those who are so ready to criticise and claim
the moral high ground should arrange clinical attachments for themselves
or their students with my colleagues.
Secondly, why is there grievance by some authors that ‘orthodox’ medicine
uses things that they believe are the preserve of
‘alternative/complementary’ medicine? The latter groups do not have a
monopoly on viewing the person as a whole or on certain treatments. For
example, extracts of hypericum perforatum from St John’s wort – which by
the current artificial division is called a herbal remedy – has been found
to help in depression [4]. Ideally the active ingredient will be
elucidated (and toxic impurities removed); licensing trials will be done;
the dosage(s) established; side effects, interactions and long term
effects will be reported; and evidence based guidelines will be produced
for its use. Then the NHS should fund it. There must be accountability
and responsibility by those prescribing it. Currently there appears to be
very little of either by those advocating ‘alternative/complementary’
therapies.
Millions of pounds are wasted annually both within and without the NHS on
interventions which have no proven value and whose effectiveness,
interactions, long term effects, and side effects are not known. The
challenge for purchasers is to ignore the orthodox -
alternative/complementary division, and ask, “Where is the evidence? Show
us the evidence and we’ll fund it; no evidence, no funding.”
Yours sincerely,
Dr Charles Essex
Consultant Neurodevelopmental Paediatrician
Child Development Unit,
Gulson Hospital,
Coventry CV1 2HR.
c.essex@ntlworld.com
no conflict of interest
References
1. Integrated medicine : orthodox meets alternative [theme issue]. BMJ
2000;322: [20 January]
2. Orwell G. Animal Farm. London : Penguin, 1964.
3. Essex C. Patch Adams. BMJ 1999;318:817.
4. Woelk H. Comparison of St John’s wort and imipramine for treating
depression : randomised controlled trial. BMJ 2000;321:536-9.
Competing interests: No competing interests