The role of complementary and alternative medicine
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7269.1133 (Published 04 November 2000) Cite this as: BMJ 2000;321:1133
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Sir,
A range of important criticisms can be levelled at this article by
Ernst [1]. One presumes that BMJ readers would wish to reach a sober,
detached and completely balanced view of CAM modalities. This is an
important topic in modern medicine and has been described as posing a
major “challenge to regular medicine” [2]. Ernst’s numerous publications
simply fail to provide such balance. Instead, he displays an apparent
addiction to self-referencing and focuses solely on reductionist studies.
His alleged EBM approach also omits to say ‘observational studies can be
as valid as randomized control trials’ [3]. I would strongly encourage
readers to seek out and obtain more balanced perspectives on CAM,
especially those increasingly numerous studies from social scientists, who
are less obviously partisan and reductionist than the medically qualified,
who habitually give only one side of the story [3].
“[The]...reductionist probing of the molecular causes of disease...is
becoming prosaic.” [4]. And, any "attempt to reduce the vast complexity of
human life to a few comparatively simple mechanisms has an undistinguished
history" [5]. "While this surge of biological reductionism is
understandable, it risks throwing the baby out with the bath water" [6].
"Issues that are complex, multidimensional, and grounded in individual
experience lend themselves to study by descriptive and qualitative
methods." [7] Such an as-is approach is central to all CAM modalities, yet
it is signally absent from Ernst's work.
As Dr Heptonstall's has pointed out [8], Dr Ernst certainly does seem
to rely heavily on referencing his own work. This deplorable habit makes
it difficult for others to form a balanced evaluation of a sole researcher
in a new field, to develop respect for, or to place much faith in their
work. It appears to bolster all one’s arguments and opinions on previously
published material; yet, such self-citations are about as valuable as
chaff in the wind and comprise a thinly disguised academic deceit if they
continually rely on one’s own previous publications. I think it is self-
evidently true, in any field, that neutral and balanced research thrives
on ‘cross-pollination’ between different researchers. Anyone who deviates
from that must attract suspicion.
As he rarely if ever cites social science perspectives on CAM, he
could be unaware of them or choose not to discuss or publicise them -
presumably because he disagrees with them, does not understand them or
wishes to deny their validity by ignoring them. Either way, he denies BMJ
readers access to an important slant on this matter. Either or both of
these shortcomings could be purely accidental, of course, but they still
deny readers the full picture. This serious failing casts a shadow over
the real quality of Ernst’s work. How can one confidently place any trust
in such an unbalanced approach?
One thinks of Professor Sir Cyril Burt, for example, and his
pioneering work [in the 30s] on twins, when it was discovered [in the
70s], that he had fiddled his results on a massive scale for decades [9].
Although, clearly, Ernst does not stand accused of any such crime, it does
highlight the danger of being a sole, pioneer in a new field. Any type of
'unbiased scientific evaluation' [1] of his work by others, is at a poorly
developed stage, his own prejudices are almost bound to be mirrored in his
work, and much that is really 'dross', could in the short run be regarded
as 'gold'.
He states:
"Complementary and alternative medicine is largely opinion based." [1]
This is a particularly foolish thing to say, because the rest of his
article comprises merely a raft of his own opinions - 16 of the 24
references [67%] are to his own work [10]. These opinions are therefore
stacked like castles in the air - and supported by what? Opinions are
usually based upon experience and neutral research, not conducted by one
person, but by many. On what basis should the opinion of Ernst be
preferred as deserving greater respect than the collective experience of
CAM therapists or other researchers? It is denigrating, dismissive and
belittling to use this term 'mere opinion'. By portraying therapeutic
efficacy as 'mere placebo', and the views and observations of thousands of
practitioners as 'mere opinion', seems a tad too severe and does not seem
to denote a neutral, sober or even-handed evaluation of CAM in the year
2000. His impatience to denigrate CAM suggests anything but an unbiased
approach.
In no sense can this article be regarded as a fair appraisal of 'the
role of CAM' at this point in time, as the title of the paper misleadingly
suggests. Indeed, it is wrongly titled, as it fails even to acknowledge
any role at all for CAM in modern medicine, let alone discusses it. Being
a highly critical and dismissive appraisal, it also claims that 7 out of
11 [77%] CAM modalities have no therapeutic value [1] and cannot be shown
to have any usefulness. Even a child could see that such a claim flies in
the face of patients flocking to these therapies, around the world, in
ever-increasing numbers, and also in the face of the accumulated skills of
CAM practitioners, who he should credit with more brains, as they daily
and yearly accrue many sound observations of the clinical usefulness of
these modalities. What actually makes his opinion so superior to everyone
else's?
Why should anyone denounce and dismiss the 'mere opinions' of
millions of patients and thousands of satisfied practitioners, or the
research of social investigators, and select instead the 'opinion' of one
researcher, who mostly references his own publications? Does this denote
someone who has neutrally empathised with his subject of study, or one who
seeks to stand above it, and to systematically demolish its credibility
before the medical profession? On what basis can such conduct inspire
respect for detached and scrupulously neutral work? Stated simply, it does
not. In the final analysis, and to arrive at a sober judgement, one must
try to weigh up who is providing the most balanced and neutral account of
this matter, and why. Clinicians need to place together a range of
approaches to that of Ernst in order to arrive at a wider view of CAM.
Finally, consider the following quotes:
“People turn to alternatives because they have become disillusioned with
conventional medicine which has failed to deliver the promise of
eradicating suffering and providing good health.” [11]
“People turn to alternatives because of dissatisfaction with the
doctor-patient relationship...[they] spend too little time with and have
little respect for their patients.” [11]
“Today’s medicine, it is argued, can best be described as Fordist
medicine, which emphasises quantity rather than quality and produces
alienated and dissatisfied patients.” [11]
“...they believe GPs spend too little time with patients...and
believe that [they] do not listen to what their patients have to say.”
[11]
Such valid, patient-centred, and human observations are never even
mentioned by Ernst, let alone discussed. OK, so he offers 'rejection of
science and technology', 'rejection of the establishment' and
'desperation' as reasons. By gazing solely through the ‘conceptual
spectacles’ of reductionist RCTs, systematic reviews and meta-analyses, he
seems content to blithely ignore the other half of medicine - the human
dimension.
Siapush again:
“It is dissatisfaction with the medical encounter that leads to a
favourable attitude towards alternatives. People turn away from
orthodoxy...because of the way they are treated by doctors.” [11]
“Although studying attitudes is important...the examination of
behaviour proper provides a more valid investigation of the reasons for
the growth of alternative medicine.” [11]
This is valuable material that deserves consideration and that does
comprise "a challenge to regular medicine" [2]. Moreover, what is the
observed behaviour of actual patients? They flock to these CAM modalities,
year on year. Why?
“The widespread use of unconventional therapies...shows that patients are
seeking treatment which conventional scientific medicine cannot provide.”
[12]
Yet, Ernst still insists:
“No single determinant of the present popularity of complementary medicine
exists.” [1]
Such a brazenly inaccurate comment beggars belief. He might just as
well come clean with his readers and say: ‘I saw nothing because I did not
even bother to look’. Such a position is just about as banal as that of
Pope Urban VIII, who refused to look through Galileo’s telescope at the
moons of Jupiter ‘because there aren’t any there according to scripture’.
I think that reflects the dismal quality of Ernst’s so-called ‘research’.
Sources
[1] Ernst, E, The Role of Complementary and Alternative Medicine, BMJ
2000; 321:1133-1135 (4 November)
http://www.bmj.com/cgi/content/full/321/7269/1133
[2] BMJ 1994, 309; 1669 [17 December] Medicine and Books, Challenging
Medicine, Ed Jonathan Gabe, David Kelleher, Gareth Williams, review by
Donald L Madison
http://www.bmj.com/cgi/content/full/309/6969/1669
[3] David L Schriger, One is the Loneliest Number: Be Skeptical of
Evidence Summaries based on limited literature reviews, Annals of
Emergency Medicine, 36.5, November 2000, 517-19
[4] Education and Debate, Clinical academic medicine: a Socratic
dialogue, BMJ 1997, 315, 593-5 [6 September] D G Grahame-Smith
http://www.bmj.com/cgi/content/full/315/7108/593
[5] BMJ 1998; 317:1728-1728 (19 December), Sacred cows: to the
abattoir! The promise of the neurosciences, A M Daniels,
http://www.bmj.com/cgi/content/full/317/7174/1728
[6] BMJ 1996; 313:957-958 (19 October), Editorials, "Is my practice
evidence-based?" T Greenhalgh,
http://www.bmj.com/cgi/content/full/313/7063/957
[7] BMJ 1999; 319:1296 [full] (13 November), The impact of
informatics, Universities without walls: evolving paradigms in medical
education, Roderick Neame, Brooke Murphy, Frank Stitt, Mark Rake,
http://www.bmj.com/cgi/content/full/319/7220/1296
[8] BMJ letter, New Definition Required, John Heptonstall, 9 Nov 2000
[9] Cyril Burt links:
http://webhome.idirect.com/~cometx/essays/burt.htm
http://www.britannica.com/seo/s/sir-cyril-burt/
http://www.discovery.org/lewis/bettleheim.html
http://oldsca.lib.liv.ac.uk/collections/archive/burt.html
[10] Two further examples - in the article "Complementary medicine:
From quackery to science?" [Editorial], Journal of Laboratory &
Clinical Medicine, 127(3): 244-245, March 1996, 6 out of the 13 references
are to Ernst's own work = 45% self-citation. In the article: "Location
bias in controlled clinical trials of complementary medicine", J of Clin
Epidemiol., 53, 2000, 485-9, of the 37 references, 5 are to Ernst himself
= 14%.
Some Ernst BMJ self-citation rates:
http://www.bmj.com/cgi/content/full/311/7004/551 2 in 16 [12.5%]
http://www.bmj.com/cgi/content/full/313/7061/882/b 1 in 3 [33%]
http://www.bmj.com/cgi/content/full/313/7072/1569 2 in 12 [16.5%]
http://www.bmj.com/cgi/content/full/314/7078/439 2 in 3 [67%]
http://www.bmj.com/cgi/content/full/314/7091/1362 1 in 13 [7.7%]
http://www.bmj.com/cgi/content/full/315/7112/886/b 1 in 3 [33%]
http://www.bmj.com/cgi/content/full/317/7152/160 3 in 13 [23%]
http://www.bmj.com/cgi/content/full/317/7156/478 1 in 3 [33%]
http://www.bmj.com/cgi/content/full/317/7173/1654 1 in 1 [100%]
http://www.bmj.com/cgi/content/full/318/7182/536 1 in 3 [33%]
http://www.bmj.com/cgi/content/full/320/7228/188/a 2 in 5 [40%
http://www.bmj.com/cgi/content/full/321/7258/395 4 in 13 [31%]
http://www.bmj.com/cgi/content/full/321/7262/707/a 2 in 3 [67%]
This sample yields a mean self-citation rate of 38.2% with a range of
7.7 to 100%. Although this is bad enough, if we include four or five of
his regular co-authors [such as White, Pittler, Abbott, Assendelft], then
their pooled mutual and self-citation rates reach an even higher average.
I am sure it would be very easy to show that these self-citation rates are
extremely high if compared to most other BMJ articles or academia in
general.
[11] M Siahpush, Postmodern values, dissatisfaction with conventional
medicine and popularity of alternative therapies, J of Sociol, 34.1, March
1998, 58-70
[12] J J Chan and J E Chan, Medicine for the Millennium: the
challenge of postmodernism, Medical Journal of Australia, 2000, 172, 332-4
Competing interests: No competing interests
EDITOR - I expect that many of us would agree with Professor Ernst's
view that "only well designed clinical investigations can establish the
truth" 1. For herbal remedies better than placebo, the well tested method
of randomised controlled trial is appropriate. For diagnostic procedures
(Table 1 of Ernst), an evaluation could be based on a panel of patients
being assessed by conventional and alternative medicine. The hard question
is how can the healing effects of placebo be evaluated? How often have we
GPs used antibiotics as placebo to help patients heal themselves?
Starting with the proposition that it is a combination of tools or skills
in the hands of a particular practitioner or healer that promotes healing,
then a suitable clinical trial requires a new design. In standard double-
blind controlled trials, the design attempts to eliminate the role of the
individual investigator. In contrast, for the evaluation of the placebo
healing effect, I suggest that the trial design should include the
individual investigator as a key variable for facilitating that placebo
healing effect.
Personally, I normally practise along conventional lines but there are
occasions when I prefer to recommend specific therapists to patients,
attempting to match patient need with therapist's skills. Patients'
responses have convinced me that a placebo healing effect can be highly
beneficial but how can I prove it? I have made one suggestion but I hope
that your readers will be able to fill the gaps in formulating a viable
design of a clinical investigation of the placebo healing effect.
1 Ernst E. The role of complementary and alternative medicine. BMJ
2000;321:1133-5. (4 November.)
Dr Helen Hubert
Old Denshott,
Leigh,
Reigate,
Surrey RH2 8RD
Competing interests: No competing interests
Editor
Complementary and alternate systems of medicine are here to stay.
Their increasing popularity is common knowledge. Recent articles published
in BMJ(1,2) and the response to them vouch for this. The focus on
integration mentioned by Vickers(1) is very pertinent, given the wide
spectrum of health care options available to patients. As pointed out in
that article training, education and regulation are vital elements that
would directly impact on integration.
The practice of chiropractic is now regulated in countries such as
Australia, New Zealand, Canada, UK and the USA. Practitioners of this
profession are required to undergo a rigorous training program. In
Australia this training is currently offered at two Universities -
Macquarie University in Sydney and the Royal Melbourne Institute of
Technology in Melbourne.
At Macquarie University the students have to complete a two-year
masters (MChiro) program (following a 3 year BChiro course) to be eligible
to apply for registration to practice. The curriculum includes basic
medical science subjects (viz. anatomy, physiology, pathology,
microbiology) during the undergraduate/postgraduate part of the program.
The program also encourages critical thinking and evidence based practice.
This form of training fosters a critical approach as evidenced by the
research activities of the Department of Chiropractic in various clinical
fields such as asthma, backache and migraine as well as basic research
into mechanisms of pain, using animal models.
More and better research would no doubt boost the image of any system
of medicine, be it mainstream or complementary. However, no genuine
research is possible in an atmosphere of suspicion. The way forward is for
a healthy collaboration.
1 Vickers A. Complementary medicine. BMJ 2000;321:683-6.
2 Ernst E. The role of complementary and alternative medicine. BMJ
2000;321:1133-5.
Competing interests: No competing interests
To the Editor - Ernst's thoughtful analysis of complementary and
alternative medicine (1) works less to support his exhortation for
increased scientific evaluation of such therapies and diagnostic
techniques than it does
to expose the almost universal superficiality of them.
Although his article lists the major benefits and side effects of
alternative and complementary medicine he fails to consider the most
serious possible side effect: delaying a diagnosis for which orthodox
allopathic medicine offers a cure. Far more convincing is Diamond's
negative review of alternative medicine(2).
While no one would dream of using such a misnomer as 'astrologic science',
alternative and complementary approaches to health care have gained an
unearned credibility by assimilating the term 'medicine' into their name.
In addition, their labeling of allopathic medicine as 'orthodox' connotes
a blind adherence to unchallenged doctrines, when quite the opposite is
true. For example,
while a mere two decades ago it may have been considered 'alternative' to
treat duodenal ulcers with antibiotics,
accumulating evidence capped by Marshall et al's seminal study(3) led to a
rapid rewriting of medical 'dogma'.
This is not to say that allopathic medicine is without flaws, but as a
branch of study that employs the scientific method and questions itself,
it is unlikely for its principles to harden into dogma.
Ernst's identification of a positive correlation between affluence and
complementary and alternative medicine likens those to the participative
entertainment aspect of palmistry and astrology; but as for finding cures
to human health problems they all make poor second choices.
I hereby declare that I have no competing interest.
Fredric M Steinberg MD MBA
member, Board of Directors
American Council on Science and Health
1995 Broadway
New York, NY 10023-5860, USA
SHO, Paediatrics
The Lister Hospital,
North and East Herts NHS Trust,
Coreys Mill Lane,
Stevenage,
Herts
SG1 4AB
1. Ernst E. The role of complementary and alternative medicine. BMJ
2000:321:1133-5.
2. Diamond J. Close Encounters of an alternative kind. BMJ
2000;321:1163-4
3. Marshall BJ, Goodwin CS, Warren JR, et al, Prospective double-
blind trial of duodenal ulcer relapse after eradication of Campylobacter
pylori. Lancet 1988;ii:1437-42.
Competing interests: No competing interests
Sir,
Dr Ernst says:
“There is an intriguing positive correlation between signs of affluence
and the sales figures of commercial complementary and alternative medicine
[CAM] products.” [1]
Intriguing? Far from being intriguing, such a pattern is to be
expected. This statement lacks some human insights. Affluent and better-
educated people are precisely the sort of people who show a greater
interest in CAM. They show an interest in their health, are more
articulate and are likely to question medical decisions [2]. Those people
who are most likely to visit CAM therapists, are generally those who are
dissatisfied in some way with the conventional medical care they have
received. That could be either through a longstanding problem being
unresolved or through experiencing ADRs from a treatment. In both cases,
the more articulate and intelligent patients, who are also generally the
more assertive [3], will wish to try some new approach. Unfortunately, the
less well-educated patients do not yet seem to proceed in this way, being
much more deferential in manner towards, and acquiescent in the diagnosis
and treatment they are given by their GPs.
A marked ‘preference by the affluent’ for CAM modalities has also,
historically, long been the case:
"[Hahnemann] eventually settled in Paris...he won over a large and
often fashionable clientele and captured a significant fraction of the
medical profession across Europe and America..." [4]
"Homeopathy was especially successful among the more wealthy and
educated classes in the United States..." [5]
"Homeopathy rapidly became extremely popular among the wealthy in
many communities throughout the country..." [6]
"...homeopathy still had much support from people in high places in
the mid-nineteenth century..." [7]
"Homeopathy, on the other hand, appealed primarily to those urban
middle and upper class persons who were seeking an alternative to regular
medicine...homeopathy was extremely fashionable among the European
nobility and upper classes, whose tastes were often copied by affluent
Americans." [8]
"...homeopathy...retained an elite clientele, including members of
the royal family." [9]
"Queen Mary and King George VI were firm followers of homeopathy, the
King even calling one of his horses Hypericum which won the 1000 Guineas
race [in 1946]." [10]
"In the USA homeopathy was an early challenge to regular medicine
since it appealed to a more affluent clientele with well-trained doctors,
who offered, in addition, a less heroic type of therapy...the body of
homeopathic doctors was a relatively small sect, concentrated
geographically in the North-East and in the large cities...[upon] a
clientele from a high and correspondingly influential class." [11]
If only these researchers would actually take the trouble to read the
history of CAM first, and mix with CAM therapists, before pontificating in
public about what they think their patients think, say, and do, it could
save many embarrassing errors and gaffes.
Dr Ernst continues:
“...if there are no funds there will be no research.” [1]
He is quite right to imply that until some of the ‘big players’ in
medicine [e.g. drug companies] start putting the funding in, then it
remains a vicious circle [poverty trap] that looks like being with us for
some time to come. As a leading researcher in this field, perhaps Dr Ernst
can suggest how such an impasse might be overcome. And if the research is
going to be conducted by allopaths then it seems pretty worthless, as they
have just tended to endlessly find fault with every trial undertaken.
Meanwhile, the public keep choosing CAM therapies regardless. Drug
companies hardly seem likely to pump research funding into systems of
medicine that are likely to contribute to their own demise!
Sources
[1] Ernst, E, The Role of Complementary and Alternative Medicine, BMJ
2000; 321:1133-1135 (4 November)
http://www.bmj.com/cgi/content/full/321/7269/1133
[2] BMJ 2000; 321: 867-871 (7 October), General Practice, Do patients
wish to be involved in decision making in the consultation? A cross
sectional survey with video vignettes, Brian McKinstry, BMJ 2000; 321: 867
-871
http://www.bmj.com/cgi/content/full/321/7265/867
[3] BMJ letters to McKinstry article, Social class, educational
status and trust in doctors, 9 Oct and Disempowerment, 17 Oct 2000, Peter
Morrell
[4] Porter, Roy, 1998, For the Benefit of Mankind - a Medical History
of Humanity, Norton, London and New York, p.391
[5] Blake, John B, 1981, Homeopathy in American History, Trans. Stud.
Coll. Phys., Philadelphia, Series 5, vol. 3, 1981, pp.83-92, quote from
p.85
[6] Rothstein, William G, 1972, American Physicians in the Nineteenth
Century - From Sects to Science, Johns Hopkins Univ, Press, p.234
[7] Sharma, Ursula, 1992, Complementary Medicine in Britain -
Patients & Practitioners, RKP, London, p.183
[8] Rothstein, op cit., p.160
[9] Sharma, op cit., p.185
[10] Inglis, Brian, 1964, Fringe Medicine, Faber, London, p.81-2
[11] Dinges, Martin, 1998, The Role of Medical Societies in the
Professionalisation of Homeopathic Physicians in Germany and the USA in
Juette, Risse and Woodward (Eds.), 1998, Culture, Knowledge and Healing:
Historical Perspectives on Homeopathy in Europe and North America,
Sheffield Univ. Press, UK, p.186
Competing interests: No competing interests
Editor
Prof. Ernst begins by applying a definition of CAM, and refers to
that originating from 'Ernst et al' 1995 as some kind of confirmation of
his definition.
His definition requires that to be a 'complementary or alternative'
medicine (CAM) necessitates reference to 'mainstream medicine'.
I and many colleagues would disagree with this definition, to be a
'complementary' or 'alternative' medicine one needs no particular
reference to any specific medicine, merely that there be more than one on
offer.
One can select either acupuncture & moxibustion or homeopathy,
then each would be an 'alternative'; or one can combine the two and each
becomes 'complementary' to the other ie. homeopuncture. Western Medicine
(WM) need not be in the picture. The only group who tend to prefer the
titles 'alternative or complementary' with respect to 'mainstream
medicine' are 'mainstream medics' such as Ernst.
Western medicine (which Ernst refers to as 'mainstream') is merely
another complementary or alternative form of medicine, albeit having
massive financial and political backing, and many CAMs can boast a greater
public use than 'mainstream' thus for many people, as Ernst points out
through statistics of CAM use worldiwde (eg. 60% of Americans preferring
CAM consultations to Western medicine) their CAM may be their 'mainstream
medicine' rather than than Western medicine.
The popularity of many powerful CAMs such as WM, homeoptahy,
herbalism, Ayuvedic and Traditional Chinese Medicine (acupuncture &
moxibustion, and herbal being two main modalities) and positive track-
record in recent years necessitates a move towards greater understanding
of when a medicine needs to be an alternative and when one can be
complementary.
Ernst lists one reason for support for many CAMs as being due to
'perceived effectiveness'; this adjective suggest that he does not really
accept the public perception of what has been and what is not effective -
they merely 'perceive' it to be effective. Clearly he finds difficulty
accepting the word of patients who believe that their condition has been
cured or improved by CAMs - would he accept that most RCTs gain results
through the same 'perceived effectiveness' of many trial patients?
He also states that 'via a telephone poll' he found that expenditure
on CAMs is perhaps £1.6 billion in Britain annually; then why has the NHS
not reduecd its budgets by a billion pounds since patients have drifted
away to fund their own treatments? Surely the NHS budget could now fund a
billion pounds worth of CAM intervention or the government could divert
such funds into CAM practices to fund this public requirement?
First one needs to separate forms of medicine as the title CAMs is
unsuitable when it clumps together such diverese and indvidual doctrines
and methods of healing. Many forms, such as my own practice Traditional
Chinese Medicine (TCM), or homeopathy, herbalism and others have their own
well-defined and long-practiced science and methodology. They cannot be
srutinised suitably unless analysed individually as their inherent
knowledge and methodlogy is too complex to study as some form of correlate
amongst other CAMs. Ernst illustrates this when he says that CAM
'comprises a confusingly large and homogeneous array of techniques'; by
continuing to refer to CAMs genrally rather than having studied, in-depth,
the individual doctrines - in some cases almost paradigms apart - he
illustrates his limitations in understanding any of them; the remainder of
the article supports this contention.
I would like to see in-depth detail on individual CAMs; I would be
very happy to enter a long and detailed discourse on TCM modalities such
as acupuncturte & moxibustion with Ernst and his regular co-authors
(who I note are providers of 17 of the 24 referenced articles in Ernsts
list - Ernst appearing in 16 of them) via the eBMJ if possible so at least
one CAM can be properly, and accurately represented in this prestigious
journal and true scientific appreciation of this CAM gained.
Regards
John H.
Competing interests: No competing interests
Dear Editor,
I read with interest Edzard Ernst’s article on Complementary
Medicine, and would broadly agree with most of his comments. I would,
however, like to take up a couple of points.
With respect to regulation, as osteopaths we are the first of the
‘complementary’ professions to achieve this, but this is certainly not
seen as a substitute for evidence. It is there to give the public a
safeguard in knowing that anyone who calls themselves an osteopath will
have to have a minimum level of training (usually 4 years full time to
honours degree level), and be subject to regulation similar to that of
doctors and dentists.
With regards to musculoskeletal pain there is still much that is not
understood, and no one profession has all the answers. As an osteopath I
believe I have had as good a training as anyone in the assessment,
differential diagnosis and management of in particular musculoskeletal
‘conditions’. I have no doubt that many of my patients get better because
I have been able to listen to them, reassure them, and touch them, and I
see nothing wrong in this. The next question is whether the approaches I
use are the most appropriate for my patients.
Taking back pain as an example, much of the research supports the use of
manipulation and mobilization, exercise, and the importance of taking into
account patients’ attitudes and beliefs; in other words treating each
patient as an individual. This is what osteopaths have been doing for
years.
The methods I use to try and help my patients are based partly on my
training as an undergraduate, but have also been changed and modified with
time as I am exposed to other approaches and professionals, and try to
assimilate current evidence in my treatment approach. This is the approach
I try and encourage in my undergraduate osteopathic students. All
professionals need to be prepared to challenge their belief systems, to
incorporate evidence where applicable, and to change practice where
appropriate. This applies as much to western orthodox medicine as to other
systems of medicine.
Yours faithfully,
Nicolas J. Snelling BSc(Hons)DO Osteopath
European School of Osteopathy, Maidstone, Kent
Private practitioner, Barnes, London.
Correspondence to:
White Hart Lane Clinic, 10 White Hart Lane, Barnes, London. SW13OPY.
e-mail: nick.snelling@ic24.net
Competing interests: No competing interests
Now that we know complementary and alternative medicine (CAM) is
widely used, what practical advice can we give our patients?
CAM can be efficacious as well as toxic, witness the use of the
herbal product PC-SPES in prostate cancer.(1,2,3) Most of us have little
time or resources to comprehensively review the primary data when
confronted with CAM. Besides, most data are anecdotal or from in vitro
and animal studies, making it difficult to apply clinically. Rather than
dismissing the whole idea of CAM, I suggest using the following simple
three-step approach:
1. First, do no harm. Most CAM have doubtful efficacy; a low
threshold should be set for any acceptable potential adverse effects. For
instance, breast cancer patients should know that soy products may control
menopausal symptoms but also stimulate breast tumour growth.(4)
2. Trial plan. This is formulated with the assumption that a CAM
may, however remotely, potentially benefit a patient. We cannot all
conduct N-of-1 trials, but the following questions should at least be
addressed:
- Efficacy: How would the patient know if the CAM is working or not –
would the cancer disappear, stop growing, or simply improved well being?
Should the CAM be discontinued or increased in dose if the disease
progresses?
- Duration: How long would the patient have to take the CAM before we
know it is working or not? If it works, how long would the treatment last
for?
- Toxicity: What are the potential adverse effects (including
interaction with conventional therapies)? How would they be recognized and
managed?
The patient can decide on how much confidence to invest in a CAM depending
on how well these questions can be answered, based on information from the
original CAM resource and what has been found by the patient or the
clinician.
3. Human cost. Patients should be reminded that a trial of CAM
incurs more than just financial costs, particularly in terminally ill
patients. It can be stressful and takes up time, which the patients could
have spent doing enjoyable things with their families. A social or
spiritual counsellor can be a useful resource for some patients to learn
to accept the idea of an incurable disease.
This simple bedside approach has the advantages of maintaing
patient's confidence by incorporating CAM into the overall care, utilising
minimal time and resources, and, most importantly, provide evidence to
support or refute any efficacy in a particular patient.
Yours sincerely,
Mário de Lemos, PharmD
Conflict of interest: none.
References
1. de la Taille A, Buttyan R, et al. Herbal therapy PC-SPES: in vitro
effects and evaluation of its efficacy in 69 patients with prostate
cancer. J Urol 2000;164:1229-34.
2. DiPaola RS, Zhang H, Lambert GH, et al. Clinical and biologic
activity of an estrogenic herbal combination (PC-SPES) in prostate cancer.
N Engl J Med 1998;339:785-91.
3. Pfeifer BL, Pirani JF, Hamann SR, Klipel KF. PC-SPES, a dietary
supplement for the treatment of hormone-refractory prostate cancer. BJU
International 2000;85:481-5.
4. Hsieh CY, Santell RC, Haslaam SZ, Helferich WG. Estrogenic
effects of genistein on the growth of estrogen receptor-positive human
breast cancer (MCF-7 cells in vitro and in vivo. Cancer Res 1998;58:3833-
8.
Competing interests: No competing interests
Correction to reference
Reference 8 begins on page 276 rather than 226 as given. The correct
reference is as below
Pittler MH, Ernst E. Ginkgo biloba extract for the treatment of
intermittent claudication: a metaanalysis of randomized trials. Am J Med
2000;108:276-81.
Competing interests:
None declared
Competing interests: No competing interests