07.16What Is Complementary and Alternative Medicine
by Steven Novella, MD
There is a growing phenomenon in this country which is very diverse and yet can be grouped collectively under a single name: alternative medicine. What this term basically represents is any health care which is not part of the mainstream medical establishment, and it includes all such therapies from chiropractic to crystal healing. Despite the tremendous disparity in philosophy, organization, practice, and origins of the myriad types of alternative medicine , the growing acceptance and use of these therapies is part of a single cultural phenomenon. It is also an extremely dangerous and costly one.
First let me address what the critical difference between mainstream medicine and alternative medicine truely is, and why the latter is cause for concern. In short, mainstream medicine is a scientific endeavor, and alternative medicine is not.
Medical practice was not always steeped in the traditions of science. Two centuries ago the discipline of medicine was based on dogma and authority, research was sporadic and uncoordinated and was not generally accepted as the way to improve the practice of medicine. Slowly, however, a few gifted scientists began to show how research and experimentation, in the modern sense of the terms, can yield real knowledge which can be used to treat and cure patients. One by one, diseases began to fall under the understanding and control of physicians, and the results were undeniable.
Today, medical research is a multi-billion dollar industry. Every physician is exposed to basic science and clinical research to some degree during their training and the links between the science of medicine and the practice of medicine are strong. Physicians in training learn early on that authority means little, if one does not have the facts to back up what one is saying. It is common for medical students, the lowest members of the academic medicine hierarchy, to politely ask their attendings for the article which demonstrates their assertion. I have never met an attending to be offended by or to refuse such a request, because such behavior would expose them as dogmatic and not scientific, destroying their reputation in academic circles.
Physicians also learn through clinical experience to be highly skeptical of just such experience. That is, simply because a treatment seems to be effective by casual observation is not enough to conclude that it is. Time and time again, with stunning regularity, our own naive assumptions and observations are invalidated by careful scientific research. We learn to question everything we think we know, to base our clinical practice on solid research, and not to be swayed by so-called anecdotal experience. One cannot be a competent physician today without subscribing to an array of medical journals in order to keep up with the latest research.
Why is anecdotal experience so fallible? In part it is because human biology is extremely complex and variable. Physicians are fond of saying that no two patients are exactly alike, and therefore the results of our interventions are never completely predictable. Also, we rely heavily on the patient’s subjective experience of their own disease and symptoms. I can only know how much pain a patient is experiencing by what they tell me; there is no objective measure. Patient’s expectations, the so-called placebo effect, are very powerful and greatly affects their beliefs about whether or not they are getting better or worse. Physician expectation is also a factor, for if we believe a patient should be getting better, our assessment of them may be biased in that direction.
Another feature of modern medicine that is important to understanding the alternative medicine phenomenon is that it is greatly imperfect. Medical knowledge is vast, but medical ignorance is even more vast. Many illnesses still have no cure or only imperfect cures. Physicians are often reduced to managing symptoms, which is important and improves a patient’s quality of life, but does not offer hope of altering the disease course itself. Many diseases are not understood or only poorly understood, and even proper diagnosis is often a challenge. Another reality medical students learn early in their training is the limitations of their own knowledge and power.
Medical practice today is also highly technological. This is one of its strengths, but it is also a potential weakness. Patients often perceive their experience with mainstream medicine as being impersonal and uncaring. They are often put through a scary battery of tests and examinations which they have little chance of understanding. It is easy for patients to become overwhelmed by the complexity of the delivery of modern medicine and the technology of its practice, all at a time when they are especially vulnerable because they are sick.
Enter alternative medicine.
It is easy to understand why people would be drawn to the allure of alternative medicine. Those therapies that are most successful are often very good at the personal “warm and fuzzy” aspect of heath care. They also make very straightforward claims with regard to diagnosis and treatment. What patient does not want to hear “this is what your problem is, and here is the cure?” There is rarely any gray zone or uncertainty. Also, the interventions tend to be very hands-on and often even pleasurable, such as massage therapy or therapeutic touch, very different from the needles, probes, and x-rays of mainstream medicine.
What is the problem, then? It sounds like mainstream medicine can learn a great deal from alternative medicine, rather than the other way around. The problem is that many, if not all, forms of alternative medicine make claims which are not based on firm scientific research. Some, such as crystal healing, healing touch, and Rei-so (spiritual diagnosis), are based on the concept that physical health depends upon spiritual health or having the proper balance and flow of life energies. Others, such as aromatherapy, homeopathy, and herbalism, cite physiologic mechanisms for their actions. Still others, such as the Laetrile society, claim that the treatment they have to offer is the product of scientific research but that a corrupt medical organization is conspiring to keep this genuine therapy from patients.
Often, proponents of any particular form of alternative medicine can recite long and complex explanations for the basis of their therapy. They can often claim that the knowledge they use is thousands of years old, or is widely used in other cultures but neglected in western European culture. They all will make bold statements about the power of their therapy and even be able to provide stunning testimonials to support their claims. What none of them can produce, however, is solid, reproducible scientific research to back up their claims.
It is this fact alone which distinguishes alternative from mainstream medicine. If any therapy, no matter how unorthodox, were grounded in research, and could be repeatedly shown to be safe and effective, then it eventually would be incorporated into mainstream medicine. Novelty will always meet with initial resistance, but the history of medicine, and indeed science in general, has repeatedly shown that the facts in the end reign supreme.
Defenders and practitioners of alternative medicine claim that their therapies are natural and holistic, whereas mainstream medicine is artificial, invasive, and treats patients as diseases. They will often say that physicians are as dogmatic as their predecessors of previous centuries and that their attacks against alternative medicine are based solely on their desire to protect their own monopoly on health care. These verbal attacks by adherents of alternative medicine against their perceived enemies are a simple distraction from the real question – why should a skeptical individual believe that there is any credibility to the diagnostic and therapeutic claims of a particular form of alternative medicine? In short, medical scientists state that a particular therapy has no scientific basis, and the practitioners of that therapy reply, not with evidence or research, but with cries of dogma and protectionism.
On closer examination, the criticisms of mainstream medicine listed above are largely empty. The terms “natural” and “holistic” have been so broadly applied as to become virtually meaningless. The trend in medical education towards a more complete view of the patient (the so-called biopsychosocial model) is largely ignored. Making comparisons between modern medicine and the beliefs of previous centuries serves only to reveal extreme ignorance about the fundamental revolution in science and medicine that has occurred in our society. And claiming that physicians speak out against alternative medicine only to protect their monopoly belies a complete misunderstanding of the organization of academic medicine as distinct from private practice. In the end the attacks of alternative medicine practitioners are revealed for what they truly are, preemptive strikes against the one segment of society that can reveal the emptiness of their claims – the medical community.
This, of course, is not to suggest that mainstream medicine is beyond criticism; it is not. Nor am I implying that all forms of alternative medicine are without value, but they lack a mechanism of systematically testing their value.
The FDA was established to protect the public from so-called snake oil salesman, slick con-artists who sold useless or even harmful concoctions with a long list of unsubstantiated health claims. Before a physician can prescribe a drug to a patient, that drug must be proven, through many years of stringent research, to be safe and effective for specific indications. The medical community, through licensure, hospital privileges, referrals, and peer review regulates the activities of all physicians so that a certain standard of care is maintained. Alternative medicine operates completely outside of this system. They can make claims without the burden of scientific proof and prescribe therapies without any precautions for their safety.
In future issues of The Connecticut Skeptic I will explore specific forms of alternative medicine, delving deeply into their claims and practice. My goal will be to provide readers with the tools and information necessary to critically assess any health care claims, whether from alternative or even mainstream practitioners. Through such education, many of the myths of alternative medicine can be dispelled, providing critical protection from costly and perhaps even dangerous intervention.