Medical revolutions are often led by unique biological discoveries, like penicillin, or by technical advances, like microsurgery. Evidence-based medicine (EBM) is a more recent example of a movement led by clinicians seeking greater certainty in outcomes for patients; the Human Genome Project is a movement led by benchtop scientists driven by the vision for more tailored and effective medicines. Not so with complementary and alternative medicine (CAM), where the patient heads the revolution, in the vanguard of an apparently insatiable demand for therapies that may vary from the acceptable face of acupuncture to the more extraordinary claims of crystal therapy. In Australia, each year, we spend more on CAM products than our out-of-pocket contributions to pharmaceuticals.1 In the United States, there are now more CAM consultations than conventional consultations in primary care, while demand for and expenditure on CAM has doubled over the decade of the 1990s.2 A similar situation exists in the United Kingdom.3

In this issue of the Journal we begin a special series on CAM. Rather than dissecting its various diagnostic and therapeutic modalities, the series aims to take a look behind the scenes at CAM’s place in healthcare, in our ethical and legal frameworks and in society generally. We hope to initiate proper debate on CAM, and to promote better understanding of its current and potential roles in healthcare.

Coulter and Willis (page 587) start this series with a comprehensive review of the background to the growth of CAM, and propose that the reasons for this growth relate to general societal changes rather than intrinsic concerns with medicine.4 They argue that this change within society might be interpreted as part of the ascendancy of patient self-empowerment, and describe approaches that conventional medicine can take to respond to this growth.

It is strange that, at a time when we can do so much more with conventional medicine than we could 50 years ago, increasing numbers of individuals seek CAM for illnesses (such as asthma) which can be effectively and safely managed with conventional approaches. This can place doctors in a very difficult position. What do they do when confronted with a patient who seems to know more about herbal medicine or acupuncture than they do? How do they assess and evaluate an article that claims herbal medicine is effective in the management of inflammatory bowel disease, and to whom do they refer? How should we counsel our graduates to manage these demands, and how should we prepare them for a process of lifelong learning with respect to CAM? These are issues not generally dealt with in most Australian medical schools, and which will be tackled in the series.

The emphasis on EBM has at its foundation a desire for improved patient safety, appropriate healthcare expenditure and better disease management. While it is no longer appropriate to dismiss CAM as an evidence-free zone, nor to dismiss educated consumers as misguided individuals, an accelerated research effort remains essential to determine clearly the effectiveness and safety of many CAM products and services. The high (and growing) levels of CAM use indicate that patients, at least, perceive that CAM interventions are effective.

Among the issues that will form the focus of debate in the series are questions like:

• Do many conventional physicians assume patients seek CAM because they believe it to be a more, or equally, effective treatment?

• On what basis should we integrate CAM into conventional medical care and do we need evidence before integration?

• Are we, as physicians, medicalising the CAM model when perhaps our patients are trying to escape that model through their use of a particular mind–body therapy?

These issues reflect directly on conventional healthcare delivery and the therapeutic relationship between doctor and patient.

Almost all doctors in clinical practice will at some point “share care” with a complementary medicine practitioner. This may, of course, not be disclosed to them by their patients! However, if a doctor refers patients to a CAM practitioner, or vice versa, what is the professional relationship and what are the legal and ethical considerations within that relationship? Above all else, we have a duty of care to our patients — “primum non nocere”. With this in mind, it is essential that we establish the professional competence and safety of CAM practitioners and the products they prescribe.

The following terms have been variously applied to the relationship between CAM and conventional medicine:

• Pluralism — a positive outcome of multiculturalism, attempts to encourage mutual respect for contrasting systems;

• Harmonisation — the diplomatic approach of the World Health Organization, where conventional and traditional (indigenous) medicines work together with no predetermined outcomes or biases; and

• Integration — the selective incorporation of elements of CAM and conventional medicine. However, true integration will only be possible if CAM commits to appropriate scientific scrutiny and if treatment guidelines are developed that clearly dictate when one option should be selected over (or alongside) another (based on effectiveness, safety, cost, convenience, etc).

CAM raises a number of very important issues for medical practice, not least the sanctity, integrity and power of the therapeutic relationship. As our patients become more educated, vocal and vociferous, the medical profession can no longer just be the “possessor of knowledge” but must also provide interpretation and wise counsel. The debates around CAM bring this to the fore and highlight the need for more research, not only on efficacy, but also the cultural and political changes demanded of medicine in the 21st century. The sooner we can understand and manage the change, the more comfortable our role will be as caring physicians. Yet the growth in the use of CAM may have outpaced the development of government policy and the capacity for healthcare professions, insurers and industry to manage emerging issues effectively. It is therefore essential that we sustain, support and develop a coherent research strategy for CAM, and this series will generate suggestions as to how this might be best developed within an Australian context.

Medical science holds no unique handle on truth. Much of what is taught now will be unlikely to be practised in 20 years’ time, bearing in mind recent examples such as changes in the evidence for use of HRT (in pharmacotherapy). We hope you enjoy the series, and we look forward to reader participation in the discussion and debate of the issues it raises.