I read “Are You Ready to Discuss Complementary and Alternative Medicine?” [July/August 2007] by Janine Blackman, MD, PhD, with increasing dismay. The article avoided the central question: Does CAM work? This could have been answered by providing links to Web sites that specialize in clinical evidence. One example is Bandolier (http://www.jr2.ox.ac.uk/bandolier). Instead, the article refers to a range of partisan and noncritical sources (e.g., CAM practitioners and CAM journals). The value of randomized controlled trials to answer clinician questions was never mentioned, which is surely a damning omission.
The title of Dr. Blackman's article asks readers to decide if they should bother learning the subject. The title is a typical marketing ploy complete with the implied judgment that CAM is a good thing and that family physicians are obliged to become knowledgeable enough to discuss it with their patients. Because we have been conditioned throughout our professional lives to feel obliged to “know everything” about health care, we are at risk for being taken in by the implication that we are ignorant about something important.
A careful reading of the article suggests that the benefits of CAM are largely illusory. To evaluate providers in our communities, the article recommends we ask them how good they are. It is difficult to conclude that CAM is science-based and does not involve magical thinking.
Few CAM concepts are supported by valid research that meets today's medical research standards. The National Center for Complementary and Alternative Medicine Web site (http://www.nccam.nih.gov) lists the results of four major clinical trials: a modestly favorable study of glucosamine and chondroitin sulfate in osteoarthritis, a negative study on Echinacea in rhinovirus infections, a “promising” study on acupuncture for knee arthritis and a negative study of St. John's Wort in major depression. No regulatory agency comparable to the FDA regulates the promotion and quality of CAM products.
Family physicians should tell their patients that they have chosen not to study CAM and do not give advice about it, with one exception: To minimize the risk of adverse interactions with physician-prescribed medicines and procedures, patients must tell their physicians about CAM treatments they receive or products they take.
The article concedes that “the field is very broad and still largely uncharted.” If that is so, why promote it so heavily and promise benefits that are only hoped for? Why distract busy family physicians who are already burdened with keeping up with advances in scientifically valid patient care?
Mr. Rose's letter allows me to discuss a common misconception about CAM. While there are many credible review sources for randomized controlled trials (e.g., the Cochrane Collaboration at http://www.cochrane.org/reviews), I should point out that these trials require standardization of the treatment strategy, which often does not accurately mirror CAM treatment in practice. CAM is individualized for each patient and involves the simultaneous use of multiple agents in contrast to the single drug intervention in these trials. This is not just my personal view. The National Institutes of Health has recently funded practice-based observational studies to try to measure the effectiveness of integrating CAM into a medical setting. The aim is to develop innovative, yet rigorous, scientific methodologies that allow for the production of meaningful data on CAM.
Dr. Gillette raises a relevant argument that, as family physicians, our training in CAM is nonexistent or very minimal, and asks why should we be burdened to learn about it now. As family physicians, we can choose to stick our heads in the sand and hope that CAM and integrative medicine go away, or we can invest some of our valuable time learning about this field. By ignoring the subject, we leave ourselves with little or no option but to disregard all forms of health care beyond our current ideology of medicine. By exploring other fields of health care and by broadening our own perspectives on health and healing, we create a debate that allows us to see limitations in our own practice of medicine and ways to potentially improve. It is obvious that we need to objectively investigate CAM from a macro and micro perspective. A growing number of academic medical centers and government-funding entities agree. Also, it is important to correct Dr. Gillette's misperception that the FDA does not regulate CAM practices and products, as it certainly does.
Dr. Gillette claims we are a heavily burdened profession. This burden could be lightened if the American health care industry were free of mercenary marketing tactics. In CAM and integrative medicine, we aim to broaden our perspective from the narrow, cynical and unhelpful forces of market-driven medicine. The fact that the jury is still out does not indicate the verdict.