Research is needed to determine how to integrate complementary medicine into the NHS
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7173.1654 (Published 12 December 1998) Cite this as: BMJ 1998;317:1654
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Sir,
In this article by Ernst, Armstrong, et al, the data they supply is pretty
meaningless. What is the point of asking clinicians why patients wish to
use complementary medicine [CAM]? It is patients who choose CAM, not
clinicians. Their questionnaires should be sent to patients and then some
meaningful patterns and indicators could be delineated.
I imagine the responses to such a survey would confirm what most of
us already think: that some pretty fundamental dissatisfaction with the
programme of treatment patients have received from conventional medical
practitioners forms the single most important reason why they then seek
help from beyond the boundaries of conventional medicine.
Therefore, their conclusion in this article that 80% of respondents
held evidence of their effectiveness, say, to be the main reason, is of no
interest to anyone. It tells us nothing. Such a conclusion is an example
of asking the right question to the wrong group of people. What clinicians
really need to know, as opposed to what they have no interest in at all,
is why do patients consult such therapists.
I would say that it is not evidence of the effectiveness [89%] which
sends patients to queue at the consulting rooms of CAM practitioners; nor
evidence of outcome studies [79%]; nor cost effectiveness [78%]; nor
evidence of the professional status of the therapists [55%]. No, it is a
fundamental dissatisfaction with what is on offer from the GP and a desire
to try something new. Is it really very surprising that patients stranded
on long term treatment strategies which they are unhappy with, and which
they are powerless to control or change, might feel somewhat depressed
about their future health?
Thus their contention in their concluding paragraph:
“ Rigorous research ought to precede integration”
is an utterly meaningless remark, which very probably falls a long
way wide of the mark, and for which there seems little evidence. The
evidence they have produced stems only from the opinions of clinicians.
Integration of CAM into general practice must surely proceed more on the
basis of the patient’s wishes, than upon the opinions of clinicians? Is
medicine really more accountable to science or professors of medicine and
the opinions of clinicians than to the views, instincts and preferences of
patients?
Peter Morrell
Competing interests: No competing interests
Re: Asking the right people
Sir
I tend to agree with Peter Morrell that the people who should be
asked about CAM provision for themselves are patients - it is they who
seek intervention and pay heavily for this through public taxation.
I suspect that the average physician has little understanding of most
CAMs and indeed in the case of several, particularly my own Traditional
Chinese Medicine (TCM) - Acupuncture & Moxibustion, we are talking not
only different types of intervention but different paradigms!
Does one ask the gas industry if their philosophy and provision
should be shared with the electrical industry, or vice versa - for the
benefit of the consumer? If Western Biochemical Medicine (BM) is analogous
to the gas industry, TCM is more akin to the electrical industry.
Patients are let down by a politico-medical system that has allowed
Western BM to dominate through the media, medical quangos and public
funding. Now patients are voting for CAMs with their feet (about 30% of
all consultations in Europe and 60% in the USA), they are finding out for
themselves about the great results from CAM interventions for disorders
they have failed to have resolved by BM. They have often been recommended
by others who have ventured forth into the CAM arena and obtained benefit
from the experience. They have to fund their own CAM treatments; their
taxes are not used to fund the 30 to 60% swing as one would expect when
other publicly supported services are often government-subsidised.
Prof. Ernst and two colleagues did perform and publish a study into
patients' "potential reasons for choosing complementary medicine". However
they failed to ask those patients the most obvious and pertinent question
- "Is it because the CAM treatment was effective?" (Ernst, Willoughby,
Weihmayr; 'Nine possible reasons for choosing complementary medicine':
Perfusion 11/95 8. Jahrgang; Klaus Pia Verlagsgesellschaft mbH,
Nurnberg/Exeter; p356-359).
The nine questions were:-
"Why do you think people seek treatment by alternative methods like
acupuncture, homeopathy or chiropractic, is it
1. Because they are disappointed by orthodox medicine
2. Because it is their last hope
3. Because they are not really ill
4. Because they are inclined to unscientific ideas
5. Because they feel they will be better understood
6. Because they want to use all possible options in healthcare
7. Because they previously had a good experience
8. Because they hope to be cured without side effects
9. Because it usually costs extra
These experienced researchers must have had great difficulty devising
so many questions that avoid asking patients if they believe CAM
treatments are effective! I would have added
10. Because you know or have heard from others that such treatment
works.
Perhaps another good question that would have added greatly to our
understanding of why patients choose CAMs would have been
11. Because their 'orthodox intervention' did not work.
When I read this study I quickly concluded that the team did not
appear to want to know whether patients chose CAMs because such treatment
had been efective or not, or because they had been failed by the BM
system.
The results of this 'loaded' questionnaire have since been used in
publications to support the contention that CAMs are generally sought by
people for one or more of (only) the nine (inevitable) reasons; this would
automatically preclude publication of public opinion of effectiveness of
CAMs and ineffectiveness of BM intervention. Was that the intention of the
researchers or merely their limited vision?
If Prof. Ernst believes that rigorous research is needed to determine
how to integrate CM into the NHS, it is essential that the research asks
the right questions; experience of efficacy and effectiveness, or not, for
CAMs and BM seem to be fundamental to any questionnaire on medical
provision a patient may be asked to respond to.
John H.
Competing interests: No competing interests