There is no alternative medicine, only unproven medicine

There is no Alternative Medicine.

Thus sprach Phil Fontanarosa and me in a 1998 JAMA editorial in the famous theme issue dedicated to Complementary and Alternative Medicine.

So I went to Mr. Google in 2010 and entered … Alternative Medicine … and clicked — 41,200,000 results; entered Complementary and Alternative Medicine, click — 3,210,000 results; entered CAM, click — 191,000,000 results, but that’s not fair; CAM can stand for many unrelated topics.

Let’s try quackery on Mr. Google, click — “only” 818,000 results.

Meanwhile, back to that 1998 JAMA editorial. “There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking.”

But actually there are three piles:

  • You have a test or treatment that has itself been tested and found to be safe and effective. Use it; pay for it.
  • You have a test or treatment that has been found to be unsafe or ineffective. Don’t use it; don’t pay for it.
  • You have a test or treatment that is scientifically plausible, meaning not preposterous. Test it and then put it into one of the other two piles.

This 1998 JAMA theme issue is credited or blamed by many with opening the door for conversation, study, and serious research. It even promoted respectful consideration of the practices of patients and practitioners of complementary and alternative medicine, since the practices were common, communication almost nonexistent, and understanding veiled at best.

What has happened since 1998?

A large amount of serious research into previously unstudied practices, largely funded by the NIH, has resulted in many articles in mainstream journals. And, guess what, almost all of the long-term traditional CAM practices have been found to be safe but ineffective.

And what has happened in practice? The American Medical Marketing Machine (AMMM) has done its thing.

As the published scientific studies have one by one found CAM practices to be ineffective, more Americans are using CAM than ever. And, such use often is now in mainstream institutions, sterilized, and sold as “Integrative Medicine,” which Mr. Google numbers at 1,230,000 results.

Looks like there will always be snake oil sellers as long as there are snake oil buyers.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

Originally published in MedPage Today. Visit MedPageToday.com for more alternative medicine news.

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  • http://cocoonhealth.co.uk/ Jays S

    Do you know of any websites that compile the results from research into CAM therapies in an edible and accessible format?

    It would be extremely interesting and informative to consumers. Too many practitioners of clinical medicine spend too much time whingeing about such therapies and fail to present the info in a way we lay people can understand.

    @cocoonhealth

    • http://apozt.com Ari

      I was thinking the exact same thing. I would love a website that clearly shows the scientific evidence supporting or contradicting the various alternative medicines available. It would add credibility and transparency to the whole deal. And if one med or many prove to be fake, it will just give the ones that have support more weight.

      I have access to medical journals but looking over http://www.biomedcentral.com, they all come up positive. It’s possible that’s because of confirmation bias, but I am not well taught enough to examine the credibility of these tests.

      A resource of online peer reviewed alt medicine studies would be amazing.

  • http://evimedgroup.blogspot.com Marya Zilberberg

    I have a couple of comments. It is hard to deny that this is an easy field for quacks and charlatans to make a buck, and the phrase “caveat emptor” is potentially even more pertinent here than in allopathic medicine. And given how much we are stressing “consumer empowerment” in healthcare today, it is not unreasonable to expect it in the setting of CAM. However, I think that there are a couple of false assumptions in this post.
    #1. Dr. Lundberg’s argument seems to me to rely on evangelical faith in our scientific methods. In fact, many philosophers and scientists have spoken to the contrary, and quite convincingly. It is only our arrogance that prevents us from admitting it.
    #2. I am not sure that we need to lump allopathic and CAM together and measure them with the same yard stick. In my mind, if an intervention is not unsafe and is inexpensive (e.g., homeopathy, which I personally do not get at all, but do have some tolerance for my friends who swear by it), there is no reason to waste the energy and resources on demanding the same proof of efficacy as an expensive new antibiotic, for example, or a $50K procedure.

    I will confess that my thinking on this subject is evolving, so would be nice to have a civil and cogent debate about it, rather than having it spiral into a name-calling contest, which is what I have seen on other web sites.

    Space precludes me from getting into too much on this topic here, but I have certainly blogged extensively on it here:
    pertinent to #1 above: http://evimedgroup.blogspot.com/2010/09/does-flip-of-switch-cause-bulb-to-light.html
    http://evimedgroup.blogspot.com/2010/09/assume-spherical-cow.html
    pertinent to #2 above: http://evimedgroup.blogspot.com/2010/08/allopathic-medicine-and-cam.html

    • http://leonardof.med.br/ Leonardo Fontenelle

      I agree science has its limitations. But it doesn’t stop “CAM” to have theirs. I don’t believe you would live on a building designed by any kind of alternative engineer.

    • http://leonardof.med.br/ Doutor Leonardo

      Medicine evolved a lot in the last 2 centuries. We (almost) don’t use leeches anymore, and life expectancy has doubled. CAM, on the other side, keeps the same principles for centuries.

    • Amy

      re: #2
      I agree that the actual use of ineffective interventions such as homeopathy may not be harmful. If something lacks an active ingredient, how much damage can it do?

      However, relying on ineffective interventions to the exclusion of others that are safe and effective means that one is basically going without any treatment. For many conditions, this can be quite harmful.

  • http://AdvoConnection.com Trisha Torrey

    George,

    From a patient’s point of view: We don’t care what you call it. We just want it to work.

    Whether it works because our bodies respond scientifically / biologically or whether it works because our brains just think it does, is far less important to us than how we feel, or how we’ve healed when it’s over.

    In the 1940s, we were told that smoking was good for us because it was relaxing, it reduced stress. We used to have “proof” that butter was better for us than margarine. And -remember Vioxx?

    “Proof” isn’t always what it’s made out to be. An open mind might help us better assess whether something works, or doesn’t, or has been tainted by a conflict of interest, or perhaps should be looked at differently.

    Trisha Torrey
    Every Patient’s Advocate

    • http://leonardof.med.br/ Leonardo Fontenelle

      Maybe you should smoke. Who knows? Maybe in the end of this century we’ll find out it actually is good for your health.

  • http://Laprp.com Arnon Krongrad, MD

    Also unsafe and ineffective. Death by Supplements provides example.

  • http://Laprp.com Arnon Krongrad, MD

    There seems to be conflation of several issues: 1) Hucksterism as a force in therapeutic choice; 2) the evolutionary nature of knowledge; 3) patient hopes; 4) realism and more.

    Yes, knowledge evolves. Once ulcers were a surgical disease, but today they are an infectious disease. The process behind this transformation was hypothesis driven science.

    Everyone hopes a patient will do well. At the same time, many patients would like to also set realistic expectations. For many, the “whether it works” is as critically important as the “how we feel.” As partly reviewed in Death by Supplements, you can feel great being led down the primrose path to death. Let us segregate realistic expectation from the potentially dangerous comfort of false hope.

    Let us segregate strategies for coping with illness (tai chi for chronic pain) from curing the illness (a cure for chronic pain).

    Without science, the earth is flat forever.

  • http://flashfree.wordpress.com Liz Scherer

    I have great interest in integrative medicine and have spent decades researching and writing about it, almost as long as I’ve been writing about allopathic medicine and therapies. I consistently refer to the difficulties in assigning Western scientific methodologies to Eastern philosophies, which are approached uniquely and distinctly. However, the ACUFLASH trial and its followup, managed to take Western methodology, tweak it to address the individuality that permeates Eastern, and demonstrate the efficacy of acupuncture in treating hot flashes. To dismiss something as unproven is to ignore hundreds of thousands of databases of published Chinese studies in reputable journals. It is a disservice to patients and researchers alike.
    http://www.biomedcentral.com/1472-6882/7/6
    http://journals.lww.com/menopausejournal/Abstract/2009/16030/The_Acupuncture_on_Hot_Flushes_Among_Menopausal.14.aspx
    http://journals.lww.com/menopausejournal/Abstract/2010/17020/The_Acupuncture_on_Hot_Flashes_Among_Menopausal.11.aspx

    • http://leonardof.med.br/ Leonardo Fontenelle

      I was disapointed to learn that the control group in the Acuflash study was not blinded. While the study group had advice and acupunture, the study group had advice alone. Being in more prolonged contact with a health professional is a good way to improve from subjective symptoms. Knowing to receive treatment is another good way. How about having a control group with the wrong kind of needles, or with aleatory placement of needles?

  • Brian

    Whether it works because our bodies respond scientifically / biologically or whether it works because our brains just think it does, is far less important to us than how we feel, or how we’ve healed when it’s over.

    While this might be true, the question that immediately follows is this: If a doctor knows that the only way a given treatment work is by the patient believing it works (and barring any actual physiological effect), then does that justify the doctor’s effectively lying to the patient in order to produce the desired effect?

    From an ethical standpoint, if a doctor needs to mislead the patient in order for a therapy to work (and not even particularly well, at that), then informed consent is not possible.

  • http://evimedgroup.blogspot.com Marya Zilberberg

    I agree that science is the path to knowledge. I also know that science is only as good as our tools and our scientists. The more uncertainty there is in our science (clinical science is by its nature far from exact, that is why we apply statistics and not straight mathematics to it), the more circumspect we must be about insisting that we have “proven” anything. In pragmatic terms, we of course have to be aware of what current state of knowledge is, but we also have to acknowledge the tremendous variance from the central tendencies that we obscure by focusing on the mean result. This is but one manifestation of uncertainty in our science. That is why Guyatt and his group acknowledge that in evidence-based practice, the n of 1 trial is the highest level of evidence in the evidence hierarchy (see his JAMA September 2000 Guide).

    As for CAM, I agree that care must be taken in what we put in our bodies. I also think that there is no need to pit allopathic against CAM, as they should serve completely different purposes. I would not want CAM treatment for a ruptured AAA, but for a chronic intractable pain I would certainly research what is available. Again, being an informed consumer is key.

  • http://flashfree.wordpress.com Liz Scherer

    I believe that it’s imperative, as Marya says, to acknowledge the different purposes that allopathic and CAM serve rather than continue to pit them against one another, which creates an ‘either-or’ strategy.

    Take traditional Chinese medicine (TCM), for example, whose primary focus is on maintaining health and enhancing the body’s ability to fight off disease. TCM will not focus, for example, on treating specific pathogens like Allopathic medicine does but rather, by evaluating external information vis a vis system discrimination, it can target factors that contribute to and affect the pathogenetic process. Indeed, an integrative approach may ultimately increase efficacy more than either of these approaches alone.

  • Primary Care Internist

    my head is just spinning from all of this bullsh!+

  • http://www.PatientAdvocateFL.com Sheryl Kurland

    Speaking from personal experience and having been raised in the home of an M.D., I am by upbringing “Westernized.” However, when Western/scientific medicine could not resolve a personal medical problem for years, I finally, with extreme trepidation and skepticism, turned to a doctor specializing in homepathic/Eastern medicine. The result: I got my life back. One type of practice — Western vs. Eastern — is not better than the other. In fact, some doctors today are finding their way to merge both to help the needs of their patients. Finding “the cure” for a patient is not always “clear cut,” and sometimes trial and error and pursuing different options is necessary. It can be very frustrating for the patient, but the good news is there is usually a resolution to the medical problem at hand.
    Sheryl Kurland
    Orlando Patient Advocates

  • http://gancao.net/ Al Stone

    Once ulcers were a surgical disease, but today they are an infectious disease. The process behind this transformation was hypothesis driven science.

    Since at least the 2nd century CE Chinese herb Huang Lian (Rx. Coptis) has been used for a stuffy feeling beneath the sternum. The use of this herb has evolved since then to be applied to heartburn and other upper GI issues. It is even used for ulcers, but not all ulcers, only those that conform to particular signs and symptoms. Turns out that this herb is effective on h. Pylori bacteria and the ulcers that result.

    Chinese medicine has not always jumped through those scientific evidence hoops that we like to see, but there has been an enormous number of time tested approaches that in some (many?) cases have been confirmed by more recent medical discoveries. Many have not, but that doesn’t make them quackery, rather it makes biomedicine too young to get it.

    What do you call complimentary medicine that works? Medicine.

    For more on Chinese herbal medicine that is legitimately researched, see the “Kampo” or “Kanpo” medicine research coming out of Japan.

  • http://ProstatitisSurgery.com Arnon Krongrad, MD

    Interventions are not all therapeutic or all harm. There is a gradient and it’s nice to help patients set realistic expectations of relative risk and relative benefit such that they can make informed decisions.

    Take the antioxidant quercetin. In the case of men with prostatitis, randomized trials show it superior to placebo and offering an approximate reduction in CPSI symptom score of 8 points, which is approximately the same as seen with bee pollen, global massage, and finasteride. That is the quantifiable benefit.

    Quercetin is associated in experimental models with kidney cancer. Does this mean patients are at risk for kidney cancer, too? Nobody knows because this unregulated, over-the-counter supplement carries the assumption of safety: There are no phase I safey studies. Why assume safety?

    The unregulated, over-the-counter, natural product aspirin has therapeutic uses; it can also be deadly. Just because something grows on a bush, be it in China or Brazil, doesn’t mean it carries no risk. Patient need the quantitative risk assessments that science can deliver.

  • Gray

    I agree with Dr. Krongrad about the conflation of multiple issues. Additionally CAM represents a constellation of widely divergent modalities, treatments and disciplines each of which need to be considered and examined separately.

    To intimate that the dearth of RCTs and lack of scientific rigor associated with CAM (as compared to allopathic medicine) amounts to “quackery” is misleading at best. Far too many of the procedures, tests, modalities and treatments practiced by allopaths have never been subjected to RCTs and rigorous scientific study; a fact unknown to most patients many of whom would be horrified to understand how often western medicine is practiced as an art rather than as a science.

    Sadly too many MDs subscribe to the author’s point of view and prefer to dictate to rather than collaborate with their patients (as well as CAM practitioners). The demand for snake oil exists only because buyers feel or experience that allopathic medicine cannot meet some or all of their health care needs. Whose fault is that?

  • CHF

    “almost all of the long-term traditional CAM practices have been found to be safe but ineffective.”

    Out of interest, which were found to be safe and effective?
    (Of course, I’d worry more about ones that were simply unsafe, whether effective or not.)

  • Anti-D

    Yawn… of course all orthodox meds are ‘proven’ to be effective, especially the ones that have to be withdrawn from the market because they’re killing patients. Remove the log from your own eye etc…

  • Amanda

    The author neglects to mention that half or more of the care patients receive is not evidence based.

  • http://minochahealth.typepad.com doc

    Of course, there is only one type of medicine, the one that works! We do just as much harm to our patients by closing our minds to all the options available as we do by selectively applying evidence based medicine.
    As has been mentioned, almost half of the practice of medicine may not be evidence based using the strict criteria for quality of studies used to judge complimentary therapy.
    For example, an argument against homeopathy is frequently made based on biological plausibity. This notwithstanding, it is widely practiced across the world inclding by rich and famous and continues to stimulate passionate scientific debate from both sides. http://bit.ly/c93Gs5

  • greg zurbay

    Seems to me I read that only about one quarter of accepted medical treatments have actually been tested, the rest were grandfathered in. Bone setting was part of oriental medicine, and soon will likely have standing in the US government as chiropractic. The US military is using acupuncture, aroma therapy chiropractic, ect., and if I have any thing to contribute will use my system of high pressure deep tissue massage that draws on numerous oriental treatments. Scientific testing is showing effectiveness for many alt. modalities, cyclosporine comes from fungus, a protein in beetle shells speeds healing in humans, aspirin comes from a plant, probiotic bacteria seem to be useful in treating numerous intestinal problems, it would seem to me many of these were alternative med., and become accepted later, usually as the profits are found.

  • http://ProstatitisSurgery.com Arnon Krongrad, MD
  • rezmed09

    Ineffective? Not really. How about no more effective than placebo?

    That’s the difference. If people are willing to spend money for a 20-30% placebo effect, that might be worth it. Because the alternative is no effect.

    • http://leonardof.med.br/ Doutor Leonardo

      Placebo shouldn’t be an option when some treatment is proven to be more effective. So shouldn’t be unproven therapies.

      Deliberate use of placebo has some serious ethical issues. Instead of thinking of it for other people, think about you mother. Imagine she spent a lot of money and time on a treatment, experienced adverse effects (nocebo effect), and you discover that the attending doctor was hiding from her that the treatment was no better tham placebo?

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