Complementary medicine
Some patients want treatments outside the realms of conventional medicine, say Timothy Woo and Lesley Wye
A patient comes back for a review after investigations. “I’m sorry,” says the doctor, “but unfortunately the condition is
chronic, and there’s nothing we can do to cure it. However, with drugs we can probably control your symptoms.” “Is there no
other way?” asks the patient. The doctor shakes his head. “It’s just that I was browsing on the internet the other day, and
there was an alternative treatment that I would like to try instead.”
Use of complementary and alternative medicine is widespread. In the United Kingdom in 2004 a survey by Sheffield University
found that about 10% of all people surveyed had in the past year received complementary treatment from a conventional medical
professional trained in complementary medicine.w1 Lifetime use has been estimated to be about 46%.w2
Research on complementary medicine is abundant. The Cochrane Library lists more than 6700 randomised trials of treatments,
but many are of poor methodological quality, leading to the conclusion that more research is needed.w3
What is complementary medicine?
“Alternative medicine” is treatments that are not included in general medical curriculums in the United States and Europe.
“Complementary medicine” is alternative treatments that are used alongside conventional medicine.
“Integrative medicine” is a system of care that emphasises wellness and healing of the entire person as primary goals, with
biological, psychological, social, and spiritual dimensions. It draws on conventional and complementary approaches in the
context of a supportive doctor-patient relationship.”w4
Complementary medicine includes many forms of treatment. The five main types in the United Kingdom identified by a House of
Lords report in 2000 are osteopathy, chiropractice, herbalism, homoeopathy, and acupuncture (box). Massage and reflexology
are also popular.w5
Non-conventional medicine
The recent rise in interest in non-conventional treatments has several reasons. Patients tend to turn to complementary treatments
when conventional medicine fails—if no treatment or cure is possible, such as in some cancers, or if orthodox treatments offer
little benefit, such as in chronic lower back pain. Patients can be scared of the side effects of conventional treatments,
and complementary treatments are generally thought to be inherently safer and more natural, which is not always true.
Chiropractice focuses on disruptions of the spine that impinge on the function of the nervous system in healing disease
The philosophies of complementary treatments are also attractive because they often include a spiritual facet and tend to
focus on improvement of lifestyle and symptoms rather than causes. Many people feel that practitioners take more time with
their patients, and treatments may cater more for patients’ individual personality and circumstance.w6 The philosophies may also offer comfort and hope to patients by making sense of an illness that has no conventional diagnosis.w7
These aspects of unconventional treatments offer benefits in addition to the proposed physical effects. Although physical
effects may be attributed to placebo effect, remember that many conventional drugs work barely better than placebo and that
patients’ attitudes to treatment often affect outcome.w8
The advent of the internet; the spread of the ubiquitous Chinese medicine shop; and the increasing power of the British patient
to determine their own management means that more information reaches patients and they have more ability to shop around for
treatment.
Limited evidence
Most trials of complementary treatments have been small and the results inconclusive. Inconsistencies in methodology often
make it difficult to make comparisons between trials.
An ongoing concern about complementary treatments is the contrast between the preconceptions of conventional doctors and any
clinical evidence of effectiveness. For example, a study of British general practitioners in Devon and Cornwall in 1997 showed
that as many as 44% endorse osteopathy or chiropractic treatment despite the evidence being poorer than for other complementary
treatments.w9 w10 In contrast, herbal medicine has the strongest evidence base of any complementary treatment,w11 but belief in the effectiveness of herbalism is far lower (0.4%).w9
Some doctors say that there should be no difficulties in testing complementary treatments in the same way as pharmacological
interventions, however, methodology and trial size often make evidence from trials of complementary treatments difficult to
review and compare. Unlike conventional medical interventions, which can be strictly defined, complementary interventions
can vary greatly in the same type of treatment. For example, it is easy to define the treatment of tricyclic antidepressants
for depression. In Chinese medicine, however, treatment for hot flushes may include needling, moxibustion, cupping, or herbal
remedies, depending on what is most appropriate for the patient. Because complementary treatments often are complex and personalised
interventions, they do not lend themselves easily to placebo controlled trials of efficacy.w12 In many cases, similar treatments, such as acupressure or laser acupuncture, may be included under the same category, making
data more difficult to analyse. Also, finding controls can be a problem because some control interventions may have therapeutic
effect—for example, fake needling in acupuncture.w13
The problem with the size of trials is largely financial. Because patent protection does not exist for most complementary
treatments, drug companies have less interest in sponsoring research, and companies producing complementary products are similarly
apathetic.w14
Regulatory concerns
Standards of care in complementary medicine vary widely—in the training of practitioners and the quality of products. Many
treatments lack standards of training and audit that conventional medicine enjoys. Although a herbal remedy may have proved
efficacy, similar remedies produced by different companies may not have the same effect. Because many herbal preparations
contain recognised pharmacologically active constituents, the capacity for interaction with conventional drugs and inherent
safety is also of concern. And expensive complementary treatments may be a financial burden to the patient.
The extent to which complementary medicine should be provided by the National Health Service is much debated. Full integration
is perhaps an impossible concept, but the NHS provides a surprising number of treatments. Surveys as early as the mid-1990s
show that general practitioners were providing some complementary treatments, more than 70% of which were funded by the NHS.
Most of it was provided by doctors and nurses in general practice.w15 Additionally there are five hospitals for homoeopathic treatment in the UK funded by the NHS, and some complementary services
have contracts with the NHS, but they are financially vulnerable.w16
Complementary thinking
The UK National Institute for Health and Clinical Excellence has produced guidelines for the use of complementary medicine
in conditions such as Parkinson’s disease and depression, but it lacks guidance about the safety and efficacy of specific
treatments.w17 Accepted scientific evidence for effectiveness is lacking for many treatments. But as Douglas Kamerow wrote last year, so
many people use and benefit from complementary medicine that it seems nonsensical to dismiss it completely.w18
We should aim to identify patients who use complementary treatments. Practitioners should discuss their interventions with
conventional medical services in case of clashes with pre-existing treatment, and they should be accredited and appropriately
insured, although this may not be enough to ensure that a practitioner is “safe.” Patients should be informed of any consequences
of suddenly stopping conventional treatments or starting complementary treatments without medical supervision.
In recommending complementary services, a conventional medical practitioner should have basic knowledge of the methods and
evidence for popular alternative treatments to prevent patients pursuing an expensive treatment that might not work. Junior
or inexperienced doctors should consider referring patients to colleagues who have more knowledge about complementary treatments.
When recommending a practitioner, accreditation organisations such as the British Register of Complementary Practitioners
and the British Complementary Medicine Association or bodies for specific professions, such as the General Council for Chiropractors,
can ensure that practitioners abide by ethical rules of conduct and are competent to practise. In January 2008 the Complementary
and Natural Healthcare Council started a voluntary accreditation scheme to ensure minimum standards and identify unsafe practitioners
of complementary treatments.w19
Popular treatments
Traditional Chinese medicine—Disease is caused by imbalances between yin and yang, the two principal components of the universe, or the five elements,
wood, metal, fire, earth, and water. It also emphasises the flow of qi, or vital energy, along meridians inside the body and
the division of internal organs according to yin-yang and element. Treatments include herbal remedies, acupuncture and cupping,
tui na (massage), and qigong (mind-body exercises, such as t’ai chi ch’uan).
Chiropractice and osteopathy—These share the philosophy that the structure of the body is strongly related to the function and that disruptions in homoeostasis
result in disease. Chiropractice focuses on disruptions of the spine that impinge on the function of the nervous system in
healing disease. Osteopathy takes a more general approach. Treatment often involves manipulation of the body to restore function
and appropriate conventional medical referrals if necessary.
Herbalism (phytotherapy)—The use of herbs targeted to specific stressed systems of the body to support natural mechanisms of self healing and homoeostasis.
Homoeopathy—This is the second most used medical system in the world according to the World Health Organization. It claims to operate
on the “law of similars”—that if a substance causes the symptoms, a homoeopathic dose will stimulate curative mechanisms to
combat them. Homoeopathic medicines are given in such minute doses that often no molecules of the original substance are measurable
and so proponents postulate an effect outside conventional science.
Competing interests: In 2003-7 LW was funded by the National Coordinating Centre for Capacity in Research Development of the
Department of Health as part of their complementary medicine programme.
Provenance and peer review: Not commissioned; externally peer reviewed.
References w1-w19 are on student.bmj.com.
Timothy Woo final year medical student University Hospital Coventry and Warwickshire, Coventry CV2 2DX
Lesley Wye research associate University of Bristol, Bristol BS6 6JL
Email: T.D.H.Woo@warwick.ac.uk
Student BMJ 2008;16:164-165 | 17
- w1 Thomas K, Coleman P. (2004) Use of complementary or alternative medicine in a general population in Great Britain. Results from the National Omnibus survey. J Public Health (Oxf). Jun;26(2):152-7.
- w2 Thomas KJ (2001) Use and expenditure on complementary medicine in England: a population based survey. Complementary Therapies in Medicine 9 (Issue 1): 2-11
- w3 www.cochrane.org – last accessed 13-2-08
- w4 Bell IR, Caspi O, Schwartz GE, Grant KL, Gaudet TW, Rychener D, Maizes V, Weil A. (2002) Integrative medicine and systemic outcomes research: issues in the emergence of a new model for primary health care.Arch Intern Med. Jan 28;162(2):133-40.
- w5 House of Lords (2000). House of Lords Select Committee on Science and Technology Sixth Report on Complementary and Alternative Medicine. HMSO: London.
- w6 Furnham A, Vincent C (2003) Reasons for using CAM. In Complementary and alternative medicine: challenge and change. Edited by Kelner M, Wellman B, Pescosolido B, Saks M. New York: Routledge.
- w7 Paterson C, Britten N (1999) Doctors can't help much: the search for an alternative. British Journal of General Practice 49: 626
- w8 Wampold BE, Imel ZE, Minami T. (2007) The placebo effect: "relatively large" and "robust" enough to survive another assault. J Clin Psychol. 63(4):401-3; discussion 405-8.
- w9 White AR, Resch KL, Ernst E. (1997) Complementary medicine: use and attitudes among GPs. Fam Pract. Aug;14(4):302-6.
- w10 Ernst E. (2001) Complementary & Alternative Medicine - A Desktop Reference
- w11 Ernst, E. (2003) Complementary medicine: where is the evidence? Journal of Family Practice, vol. 52, no. 8, pp. 630-634.
- w12 Walach H, Falkenberg T, Fønnebø V, Lewith G, Jonas WB. (2006) Circular instead of hierarchical: methodological principles for the evaluation of complex interventions. BMC Med Res Methodol. Jun 24;6:29
- w13 Pariente,J, White,P, Frackowiak,K, & Lewith,G (2005). Expectancy and belief modulate the neuronal substrates of pain treated by acupuncture. Neuroimage May 1;25(4):1161-7
- w14 Ernst E. (1999) Funding research into complementary medicine: the situation in Britain. Complement Ther Med. Dec;7(4):250-3.
- w15 Zollman C, Vickers A (1999) ABC of complementary medicine: Users and practitioners of complementary medicine. BMJ. 319: 836-838
- w16 Clews G (2007) PCTs consider alternative to homeopathic hospitals. Health Serv J. Mar 15;117(6047):8.
- w17 Franck L, Chantler C, Dixon M (2007) Should NICE evaluate complementary and alternative medicine? BMJ 334: 506
- w18 Kamerow D (2007) Wham, bam, thank you CAM BMJ 335:647
- w19 Hawkes N (2008) New Laws to govern Alternative Medicine - The Times – Published 05-01-08
|
EDUCATION
Complementary medicine
(Timothy Woo and Lesley Wye, April 2008)
|
|
Carl Kenner
(April 4th, 2008)
Software Engineering, University of South Australia, carl.kenner@gmail.com
|
|
|
This is outrageous nonsense! How can articles like this possibly pass peer review?
This article states, among other absurdities, that disease is caused by an imbalance of chinese elements. That is totally untrue, as anyone with a primary school (or even kindergarten) level of education knows. Disease is caused by bacteria, viruses, fungii, parasites, injuries, poisons, and failures of the bodies internal systems. That is the most well proven fact in the history of the world, and yet you still allow it to be contradicted in supposed medical journals (which would more accurately be described as women's magazines).
Alternative medicines are not "lacking in evidence". Alternative medicines are, by definition, DISPROVEN. That is why they are called alternative medicine, and not called scientific theories. They openly contradict not just a few proven scientific laws, but every scientific law that has ever been proven. They contradict every known medical fact. And worse than that, every kind of alternative "medicine" contradicts every other kind of alternative "medicine", and almost always contradicts itself.
I realise that evidence based medicine is the new sacred cow and magic bullet of medicine, but the supposed "evidence based" medicine techniques used for alternative "medicine" are a total laughing stock and a total failure at separating what works (nothing) from what doesn't work (everything).
The principles used in evidence based medicine rely on the many well proven scientific assumptions. For example it relies on the fact that a chemically inert substance will have no medicinal effect except psychologically, and thus can be used as a placebo when testing pharmaceutical chemicals. Obviously if you rely on this well proven scientific fact, you can't use it to prove that chemically inert bullshit like homeopathy does have an effect. Otherwise you are comparing a placebo with a placebo.
But most importantly, evidence based medicine relies on the people doing the research being honest academics seeking only the truth. The alternative medicine loonies are not honest academics, and their livelihood and continued employment depends on being able to con people into thinking that magic exists and science is nonsense. With such extreme biases, a total lack of scientific integrity, and the knowledge that what they are trying to prove is impossible, these "people" will resort to any level of fraud when writing up their "experiments" (or not writing up their experiments whenever they don't get the results they want to hear).
Of course even in the unlikely event that honest results were published of "tests" on alternative "medicine", the results would be totally useless, because without science it is completely impossible to generalise from the results and apply the results to anything but the exact same circumstances used in the testing. Which is why after every test disproving alternative "medicine", the authors call for more testing of the same technique but with a tiny variation.
Evidence based medicine is also completely illegal under international law, except when there is a rational scientific reason to believe that it will provide some benefit. Testing disproven medicines on humans has been officially a war crime since the Nazis did it in WW2.
There are other fields of science besides medicine. These fields of science are equally academic, peer reviewed, and reliable (actually much, much more so). And they all show, without the slightest doubt, that it is impossible for alternative medicine to have any positive health effect whatsoever.
So the problem is definately not that there is a lack of evidence for alternative medicine. And using "evidence" and "alternative medicine" in the same sentence is utterly absurd. The problem is that superstitious idiots with no scientific accountability are treated as though they were medical scientists, rather than being accurately labelled as loony con artists.
I demand an immediate retraction of this article, and an appology from the authors and the publishers. I further recommend that the authors, peer reviewers, and editors be replaced with more scientifically knowledgeable people who know more about medicine, such as kindergarten students.
|
|
|
EDUCATION
Complementary medicine
(Timothy Woo and Lesley Wye, April 2008)
|
|
Dr Avinash Aujayeb
(April 4th, 2008)
Speciality Trainee Year 1,Core Medical Training, Gateshead Hospital aujayeb@doctors.net.uk
|
|
|
I read this article with interest but what captivated me most was the first paragraph as a patient came to a medical doctor first and then sought alternative therapies. However, in many parts of the world, the situation is usually reversed.
I have been lucky to be able to work in rural hospitals in India and Mauritius. On many occasions, we encountered patients who had been taking herbal remedies or animal extracts for a fabulous array of ailments ranging from tuberculosis to dental caries and who now present with a complication of that alternative therapy. We saw people die from liver failure secondary to some random herbs, removed goat's teeth from someone's throat (the goat's teeth was meant to stay in the oral cavity to help potency) and saw people accuse us of witchcraft when their urine turned red with rifampicin in tuberculosis treatment and run away to come back moribund.
We do not really see these things in everyday practice in the UK but as the globalisation makes the world a smaller place, as doctors, we should be aware of the other side of the coin so that we are prepared for it. The reason why those paitents choose alternative herbs before conventional drugs might be deeply entrenched in their religious/cultural values and only a lot of education and patience will make the happenings in the above paragraph things of the past.
|
|
|
EDUCATION
Complementary medicine
(Timothy Woo and Lesley Wye, April 2008)
|
|
Jonny Martell
(April 6th, 2008)
GEP medicine 2008, University of Newcastle upon Tyne jonnymartell@yahoo.co.uk
|
|
|
As an osteopath and from September, medical student, I enjoyed reading last month's focus on holistic medicine. However, there was some inevitable confusion on a subject that eludes generalisations. Timothy Woo and Lesley Wye claim part of the appeal of complementary medicine lies in it's tendency to focus on the improvement of symptoms. Yet Angad Dhillon suggests that many orthodox treatments' inability to tackle the origin of a disease is the cause of CAM's growing popularity.
Caution should be exercised when describing complementary medicine. It is a broad church. Regarding musculo-skeletal pain, the osteopath aims to identify and treat the structural cause, whereas the acupuncturist is primarily concerned with altering pain signals, the symptom. Many complementary treatments don't lend themselves well to randomised controlled trials, but not all, herbalism and homoeopathy are notable exceptions.
The growing trend of medical students taking modules in complementary medicine is an exciting development. The doctors of tomorrow will learn about treating people, as well as their disease. They will also be better informed of the risks and benefits of specific complementary treatments for their patients.
|
|
|
EDUCATION
Complementary medicine
(Timothy Woo and Lesley Wye, April 2008)
|
|
Dr.Anup Shrestha
(April 21st, 2008)
intern, Kathmandu Medical College shresthaanup2001@hotmail.com
|
|
|
I read the articel by timothy woo and lesley wye and the responses to the article.
I was thinking of getting details on the topic, as we talk about it often amongst ourselves and hear from the medias in our part of the world. it was informative reading the article on it in studentbmj.
then i went through the responses. i felt that the message the writers wants to give is probably wrongly taken by mr.karl jenner. the writers here is not trying to say that conventional medicine fares less than the alternative medicine. what they're trying to say is that if we run out of the choices that we have in conventional medicine, than why not suggest the patient for the alternative medicine, if only can it help to alleviate the symptoms. moreover it doesn't have much side effects as the writer puts it. end of the drugs of choice for a disease is not an end to the life.
it's ridiculous how frantically mr. jenner uses the term bullshit for homeopathy. if WHO term it as the second most popular practice of medicine and also there are many RCTS done in the practice( may be not enough stock of evidence) then we can't totally overrule it, tagging it bullshit. and moreover if it's being practiced so popularly, then it's definite people are gaining some benefits from it.
my point here is that writer is promoting alternative medicine as a second choice. this is probably right for the patient who has no option left from the conventional treatment than giving him the blank option.
|
|
|
EDUCATION
Complementary medicine
(Timothy Woo and Lesley Wye, April 2008)
|
|
FAHAD ALAM
(April 22nd, 2008)
student/MBBS,final, kathmandu medical college,NEPAL amicus_fahad@hotmail.com
|
|
|
Well first of all i would like to congratulate Timothy Woo and Lesley Wye for there wonderful article. i say it is wonderful because so many people especially in our part of the world alernative medicine such as homeopathy and accupuncture and they also belive in it since ages even before allopathy existed.i would also like to mention that people in our part of the world especially the rural part first visit the traditional healers(known locally as dhammi and jhakriss) for there relief of symptoms and when they fail they visit hospitals.these people have faith in traditinal medicines like homeopathy and accupuncture and millions have been benefitted from it.
people also have a attitude to visit hospitals ie allopathy if they want their symptoms or illness to be cured as soon as possibel but people prefer alterantive medicine (as the auther has already mentioned) if they know that there is no prompt treatment for their present illness.
i would also like to bring in notice to the author that a system which is also practiced here is naturopathy and people have benefited from them.
i also went through the responses and found that some were interesting and valid too but responses are not meant for confrontations are they? the author is trying to say something it better taht we listen and congratulate him for his brilliant and must know /read article.
|
|
|
EDUCATION
Complementary medicine
(Timothy Woo and Lesley Wye, April 2008)
|
|
Edmond O`Flaherty
(April 30th, 2008)
GP, GP edmondf@indigo.ie
|
|
|
I am a GP and most of my work is the same as other GPs. However I have found it extremely valuable to learn about two types of complementary medicine. The first one is use of a small dose of naltrexone,a drug widely used for over 50 years to block opiate receptors in heroin addicts. In a dose of 3-4.5mg it seems to give a great boost to the body`s immune system.I use it as additional treatment for MS, many forms of cancer and fibromyalgia mostly. You can read all about it at www.lowdosenaltrexone.org
The second type I use is an attempt to get the biochemistry right in mental illness and this has become a big part of my work in recent years.I use antidepressants and antipsychotics of course but the extra mile you can travel with proper biochemistry is really worthwhile in my experience. One of my patients with schizophrenia is 55. He has been on 30mg olanzapoine for 15 years and has done little with his life in that time.I found that he was low in zinc,high in copper and low in histamine.This is typical of paranoid schizophrenia. I added 50mg zinc and 1.5g niacinamide bd. Now he says he feels "great" while before life was "dire".He has started a get back to work course . See details at www.omega3.20megsfree.com
|
|
|
