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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Dear Editor,
The responses to your editorial "Integrating systems of medicine" are
based on ignorance of the basic principles of alternative systems. I teach
in college of Ayurveda and I know for sure that Ayurveda is the outcome of
following very sound method of "science".
There is a evidence in Ayurvedic texts like "Charaka Samhita" that
there existed a method for arriving at scientific conclusions. So much so
that, there are sound guidelines mentioned for writing a clinical trial
protocol in all detail. Modern guidelines for writing clinical trial
protocol match very well with those of Ayurveda.
This commonness between Ayurveda and modern medicine should act as a
foundation for integration of the two. As such, as modern medical concepts
are advancing, they are coming closer to ancient Ayurvedic concepts of
health and disease.
Regards,
Dr Patil Milind
Competing interests:
None declared
Competing interests: No competing interests
I am a medical student studying Ayurvedic medicine in India. And
having read many of the responses posted here, I wonder if it is too much
to ask for a little tolerance from doctors practicing 'modern' medicine.
Having read a bit about history of medicine, what I derive is in that era
of time, when medicine was in the developmental stages and man built his
knowledge by trial and errors and observation, what must have been
important to him was the RESULT of so-and-so drug acting in a particular
situation. And how this medicine acted didnt probably mean much to him.
And this system of medicine has stood the test of time and researches
going in this field actually consolidate the fact that the system indeed
has scientific basis. I don't see any reason why, as doctors, we cannot
think of combining the best for the patients and in fact give them enough
choices for treatment as well. The primary aim is to provide a safe
effective treatment, and how will the egoistic approach - the so called
modern medicine being superior to complementary medicine!; help the
progress of medicine in any way?
Competing interests:
None declared
Competing interests: No competing interests
First a thank you to the BMJ for printing this article on the current
state of health care. Your theme is indicative of the wants of the lay
public world wide.
To Roger Fisken,
I am deeply saddened by your comments and can only hope that your
patients take your tunnel-visioned approach to health-care with 2 grains
of salt. Pardon me, rather your approach to sickness-care, because
nothing in your letter indicates an interest in restoration and
maintenance of health, but an interventionalist attitude treating only
when symptoms arise.
Isn't it the goal of all health-care practicioners to guide patients
to recovery and health? The vast majority of physicians in China consider
it a failure in care if a patient falls ill.
The Jounal of the American Medical Association has listed as the #5
cause of death in the United States the administration of correctly
perscribed medication. This is more than that of all car and plane wrecks
combined. Given this information, do you still wonder why 2/3-3/4 of fee-
for-service patients choose complementary care as opposed to drugs-and-
surgery methods? Check the track record and efficacy of pharmeceutical
interventions versus those we have evoloved with nature to incorporate
proper homestasis.
Compassion and caring in the modern-day allopath is a white whale.
If you embody these characteristics then God bless you. My self, and my
family, have not met your kind in our quest for well-being. I do not
condemn your profession, rather I make an argument which so many do, and
which has prompted this discussion, that demands on your time and
regulations by insurance dictocrats have transformed many MD's into time-
constrained, care-reduced scrip-pads with not much more to offer (due to
hand-tying).
In conclusion, please do not hide your ignorance of the relevance of
complementary therapies behind your pseudo-erudite rhetoric. We are all
in this game together and our goal is to help people get better. Do your
patients a favor and learn something new, look outside of your shrine of
folk heroes and realize that care of the whole person, not just the
symptom, just might speed their recovery and reduce the treat of harmful
side-reactions.
Repectfully submitted,
Mark Guthrie, DC
Competing interests: No competing interests
Dear Editor,
Re.: Integrated Medicine, BMJ 2001;322:119-20 (20 January)
I read the letter from Roger A. Fisken on the above subject in the South
Asia Edition of BMJ of September 2001. I could not resist my desire to air
my views.
As doctors we are concerned with the welfare of our patient. Common
sense dictates that doctor try his best to bring relief to the patient
irrespective of the kind of medicine. Normally, the current modern
medicine is by far the best type of medical treatment; but that does not
mean that it can treat anything and everything. But at times patient finds
relief from alternative medicines too.
Opponents of alternative medicine and integrated medicine are
invariably ignorant of what they are. They believe that only scientific
rationalism is acceptable and all the rest that do not fall in the
parameters of this scientific rationalism have no right to exist. However,
there are many things in this world that cannot be explained by the
scientific rationalism of the present days.
About 4-5 decades ago, British anaesthetists and surgeons ridiculed
at the acupuncture. But some amongst them wanted to opine only after they
see for themselves the practice of acupuncture. They visited China and
were stunned to see major surgeries being performed under acupuncture
anaesthesia (administered by choice of the patient). Suddenly the
procedure became acceptable though the anatomy, physiology or pathology of
modern medical science cannot explain acupuncture.
A well-known professor of urology in India has reported about his 76
years old relative who had an advanced, ulcerated, painful and smelly
carcinoma of breast. Professor’s spiritual Guru gave her "vibhuti" (sacred
ash) and a "lingam". She was to drink the lingam water daily. To the
disbelief of her oncologist the lesion regressed, pain reduced and ulcer
started healing in a matter of weeks!
Let not rationalists ridicule the old beliefs; they were relevant at
that period of time. Modern medicine itself had many that appear
shamefully irrational now. Take for example the extended radical
mastectomy (commando operation) of the past in comparison to present
breast saving procedures or total gastrectomy of the past and non-surgical
treatment of the present for DU.
As for betrayal, the commercial forces of health care industry are
such that they influence the practitioners of modern medicine in such a
way that thousands of patients are betrayed daily by practitioners of
'evidence based' practice.
A scientific person needs to be humble that he does not know it all
rather than be arrogant. Ancient Rigveda quotes “let noble thoughts come
to us from every side”.
Sincerely Prabhu
Competing interests: No competing interests
Editor
A few examples of patient - physician communication:--
“I know you’ve only 15% chance of improving with my medication but
what else is there?” GP tries to convince a patient to take his medicine.
“I’ve only 4 minutes to take your history, investigate your problem,
examine you, produce a differential diagnosis and formulate a treatment
plan for you so don’t be surprised if it doesn’t work first time” GP
excusing his practice
“You have intermittent bilateral stenosis of the left and right
inguinal vascular membranes, take this prescription 3 times a day while I
find a specialist who knows what it means” GP tries to cover up his lack
of ability to diagnose a patient’s condition.
“Why seek an alternative when we have all the answers?” GP to patient
who asks for advice on the use of CAM for his problem.
“Doctor, I read the other day that modern medicine is the fifth or
sixth major cause of death and injury known to man, can I trust you?”
”Of
course you can, it’s actually the third or fourth”.
“What took you so long to get here?” CAM practitioner to patient.
Regards
John H.
Competing interests: No competing interests
Sir,
"Ironically, although integrated medicine is said to be holistic,
focusing on both minds and bodies, there is little evidence of holism in
many complimentary and alternative approaches, which actively seek to
accentuate the distinction between 'spirit' and mind. This is the same
Cartesian dualism that is responsible for many of the problems associated
with conventional medicine." [1]
These remarks Chalder et al make, in response to Rees and Weil’s
editorial [2], and concerning the term ‘holistic' seem to suggest it
solely means an appreciation of body and mind or spirit. I think it is
only fair to point out that this is not the usual meaning attached to this
term by most CAM practitioners. The term is subtle and complex and thus
deserves greater clarification. It can perhaps be better understood if
compared to the inherent dualism in the scientific worldview - a worldview
upon which chemical medicine very largely and unquestioningly rests. This
worldview, first set rolling by figures like Galileo, holds that our world
of forms is composed of objects which can be dissected into parts
[reductionism], given names and that their various interactions can be
accurately described by mechanisms.
Science as a worldview entirely regards events through this
'conceptual filter' of reductionism, named parts and their interactions in
mechanisms or causal chains. This is not the only way to view this world
or the phenomena in it. It is only one method, though admittedly one that
has become dominant in the last four centuries. Pre-Galileo things were
viewed in a fairly as-is fashion that did not exclude some speculation and
mechanism, but which was not so solely obsessed with such an approach. As
scientists and medical folks are not [overtly or covertly] taught anything
about holism, but only the dominant paradigm of reductionism and
mechanism, it is probably a little rich for them to start pontificating
upon such a theme.
Only once you can get yourself conceptually free of reductionism and
mechanism - by no means an easy task, because most scientists are entirely
saturated in it – only then can you begin to more truly appreciate what
holism really means. It is what Husserl and Hegel termed 'phenomenology',
which means to try to apprehend phenomena directly [as processes], without
recourse to parts, names and mechanisms.
The human organism functions in a phenomenological manner - it works.
Disease also simply ‘works’. As soon as you overlay this with concepts,
parts, names and mechanisms, then inevitably you reduce it, distort it and
simplify it. All scientific models are therefore reductions and
simplifications of reality and thus omit something. Phenomenology attempts
to view things more directly in their pure, holistic functioning,
avoiding, as far as possible, the use of conceptual overlays like parts,
names and mechanisms, with which science is so manifestly obsessed.
Thus, when we look at healing modalities like homeopathy,
acupuncture, nature cure, etc, we tend to find an appreciation of health
and disease processes given in a descriptive, direct, as-is fashion that
often spurns notions of mechanism. This is often described as soft or
lateral thinking. It also describes events that occur in organs, mind,
emotions, modalities, etc, without saying 'this causes that'. Thus, it
cuts across the accepted pathways and mechanisms science has created and
which are deemed by most educated people to be REAL, I mean real in some
absolute sense, as opposed to physical or observable. The picture or model
is all too often taken to be the fact.
In the example of homeopathic Belladonna, the red face, the high
temperature, the burning heat, the twitching of the lips, the delirious
sleep with visions of monsters pouring out of the wallpaper, these are
collectively mere phenomenological aspects of ‘the Belladonna state’, no-
one is trying to say which parts are causes or which parts are effects in
some supposed causal chains – they are simply aspects of ‘the Belladonna
state’. Likewise, in the case of Pulsatilla no-one is saying that the
emotionality of Pulsatilla, the desire for affection or the easy tears are
in any way causes or effects of the rapidly changing symptom picture, the
inconstancy, the desire for fresh air or the feeling of warmth. None of
these aspects are ascribed in a causal mechanism, they are merely
described as aspects of the Pulsatilla state. Similar examples of true
holism can be found in all the CAM therapies.
I think it is obvious even from these two examples that holism does
not mean merely ‘body and mind’, it also means an abdication of all idea
of mechanism, parts, names and labels and the simple and direct viewing of
the organism – in health or disease – in its pure as-is state with no
judgement or conceptual overlay. It also means the abandonment of
mechanistic thinking as a way of looking and a way of seeing the organism
– the abandonment of mechanistic thinking.
I hope this clarifies the ideas Chalder et al presented, in my view
incorrectly, about what is afterall a term and concept of central
importance to the entire field of holistic medicine. And thus I would say
they are wrong when they say: “…there is little evidence of holism in many
complimentary and alternative approaches...” [1] In fact, there is
abundant evidence for those eyes that can look and see without the
distorting overlay of mechanistic conceptuality.
Sources
[1] BMJ letter, An Alternative Integrated Medicine, Chalder T., Reader
Guy's, King's & St Thomas School
http://www.bmj.com/cgi/eletters/322/7279/119#EL36
[2] EDITORIALS, Integrated medicine, Rees and Weil (20 January 2001)
BMJ 2001;322:119-120 (20 January),
http://www.bmj.com/cgi/content/full/322/7279/119
Competing interests: No competing interests
The BMJ (20th January) defined 'integrated medicine' as incorporating
complementary or alternative medicine into orthodox health care1. While we
applaud the movement towards a more integrated approach to healthcare and
welcome a scientific examination of 'complementary therapies' there is an
important alternative to simply accepting the use of complementary
techniques. Many researchers and clinicians have already adopted an
alternative understanding of health best characterized as a 'bio-psycho-
social model'2 and there is a wealth of research evidence demonstrating
that a combination of biological, psychological and social mechanisms
affect health outcomes in major diseases such as heart disease and
cancer3. Ironically, although integrated medicine is said to be holistic,
focusing on both minds and bodies, there is little evidence of holism in
many complimentary and alternative approaches, which actively seek to
accentuate the distinction between 'spirit' and mind. This is the same
cartesian dualism that is responsible for many of the problems associated
with conventional medicine4.
It is true that patients are increasingly abandoning a medicine that
ignores the wider view of their health but to say, in the manner of Marie
Antoinette, 'if they are dissatisfied and we have nothing better to offer,
then let them have their alternative medicine', has several dangers.
First, it allows conventional medicine to rid itself of its 'failures'
rather than learn from them. Second, it marginalises those patients who do
not want 'colonic irrigation' for example, but who would like a doctor who
recognises that they are more than a collection of molecules. Third, it
perpetuates the myth that psycho-social features of illness and health are
too 'soft' to be researchable or too complex to be integrated into
treatment. We suggest that health professionals adopt the more pragmatic
bio-psycho social approach to health care which would result in better
health outcomes in their patients.
1. Rees L & Weil A. (2001) Integrated Medicine. British Medical
Journal. 322; 119-120.
2. Engel GL. (1977) The need for a new medical model: a challenge for
biological science. Science. 196; 129-136.
3. Baum A, Newman S, Weinman J, West R and McManus. (1997) Cambridge
Handbook of Psychology, Health and Medicine. Cambridge University Press.
4. Helman C. (1986) Culture, Health and Illness. Doctor - Patient
Interactions. Chapter 5. Wright
Chalder T, Reader.
Department of Psychological medicine, Guy's, King's and St Thomas School
of Medicine, 103 Denmark Hill, London SE5 8AZ.
(sphatrc@iop.kcl.ac.uk)
White P, Senior Lecturer.
St Bartholomew's Hospital, London
Main CJ, Professor.
Salford Royal Hospitals NHS Trust and University of Manchester.
(cmain@fs1.ho.man.ac.uk)
Lewin B. Professor.
Department of Health Studies, University of York, Heslington, York, Y010
5DG
(rjpl1@york.ac.uk)
Competing interests: No competing interests
A new integrated medicine, not integrating alternatives to medicine.
Medicine is an art and a science of caring for individuals and for
humanity. As such it should integrate everything that touches the health
and well being of people.
The dialogue on integrated medicine relates not medicine's
limitations but our limitations in integrating these diverse aspects of
care adequately. One response to such a difficulty is to find a better way
of integration rather than to embrace non-medical practices.
There are better ways of integration within mainstream science, such
as chaos and complexity theory, from which is derivable a postnormal or
chaos based medicine, as evidence based medicine used in context (1,2,3).
Such new ideas, embraced widely across many disciplines, allow us to
practice good medicine, responding to patients needs, using a medicine
that works.
After all, according to Angell and Kassirer, editors of the New
England Journal of Medicine, there are only two kinds of medicine,
"medicine that works and medicine that may or may not work" (4).
This new post-normal or chaos based medicine provides better
explanations of how and why things happen and how patients' beliefs and
practices, however unscientific, integrate with everything else to
influence health. It could be the centre of a new integrated mainstream
scientific medicine.
Disenchantment with the current practice of medicine or the
limitations of evidence based medicine should not propel us to practice
alternatives to medicine, such as an integrated medicine which includes
complementary or "alternative medicine." It should instead impel us to a
scientific integrated medicine - a better medicine that works, learning
about everything that impacts people's health, responding better to their
needs, and offering better explanations of the nature of health and
disease (5).
References:
1) Rambihar VS. Science, evidence and the use of the word scientific.
Lancet 2000; 355:1730.
2) Rambihar VS. A new chaos based medicine beyond 2000: the response
to evidence. Toronto: Vashna Publications, 1999.
3) Kernick DP. After postmodernism. Lancet 2000; 355: 149.
4) Angell M, Kassirer J. Alternative Medicine - the risks of untested
and unregulated remedies (Editorial). NEJM 1998; 339: 839-41.
5. Rambihar VS. If evidence is the heart of medicine, then chaos
restores its soul. BMJ Rapid Response Feb 19, 2001.
VS Rambihar
Competing interests: No competing interests
Integrated medicine: Finding the time.
Dr Caleb Parry, eminent 18th century physician of fashionable Bath
Spa, and one of the first doctors to describe thyrotoxicosis, once wrote
that 'it is more important to know what sort of patient has the disease
that what kind of disease the patient has'. Unfortunately, the patient
has rather slipped out of focus in the enthusiasm of modern orthodox
medicine for technological solutions and scientific evidence. Patients
with biological disease are frequently objectified as ill stomachs, sick
lungs or damaged kidneys, while the ever increasing multitude of people
with 'functional' illnesses that cannot be explained by a well defined
pathology and cause, often complain that doctors do not listen to them.
It is the latter who make up such a large proportion of people seeking
help from complementary medicine. CAM therapists do what doctors have so
little time to do. They try to understand the sick person and they use
techniques that relax the emotional tension that often keeps the illness
going .
We all know from experience in childhood that getting better is not
just a matter of taking the medicine, it requires time, rest, compassion,
understanding and care. Ill patients need to have faith in their carers
and treatments if they are going to get well. Despite amazing
achievements and dedicated practitioners, faith in orthodox medicine is
at an all time low. This is no doubt exacerbated by an unsustainable
caseload and a cynical media that seems intent on undermining our
institutions .
Integrated Medicine attempts to combine the best of both systems, but
it is not just about adding a bit of acupuncture to the aspirin, it is
about restoring an understanding of the patient, his or her attitudes,
beliefs, personal history and life situation, to health care. Research in
integrated medicine should not just investigate the efficacy of a
'complementary' set of instruments in the medical bag'. We need to
understand more clearly how the disharmony caused by life situations can
make people ill through, for example, long term destabilisation of the
autonomic nervous system and hypothalamo-pituitary adrenal axis , and how
relaxation, contemplation, confidence, and trust might work though
neuroendocrine and neuroimmune mechanisms to facilitate self healing.
Time is ripe for integrating the science and the humanity of health care
around an understanding of the ill person. Let's hope we can find the
time to seize the opportunity.
Nick Read, Professor.
Jack Czauderna, Family Doctor.
Centre for Integrated Medicine, Institute of General Practice and
Primary Care,
Northern General Hospital. Sheffield S5 7AU.
E-mail: N.W.Read@sheffield.ac.uk
Competing interests: No competing interests
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Competing interests:
Professor Joseph Chikelue Obi MBBS MD MPH DSc FRIPH FACAM is also the Chairman of the General Wellness Assembly (GWA); an International Professional Body for Independent Wellness Consultants . He humbly invented the 'Omnipill' ; and warmly believes that Chronic Fatigue Syndrome (CFS) and Multiple Sclerosis (MS) can sometimes be adequately controlled (not cured) , using Advanced Wellness Interventions.
Competing interests: No competing interests