Good medical practice is based on a thorough understanding of physiological and pathological mechanisms, is holistic, appreciates the important role of psychosomatic symptoms in human suffering, embraces an evidence-based approach to therapy, and involves appropriate levels of confidence. In contrast, bad medical practice has flawed concepts of bodily function, rejects psychological factors in the production of symptoms, ignores placebo effectiveness, is content with anecdotal evidence and involves inappropriate levels of confidence.
Good medicine is practised by most orthodox and many complementary and alternative medicine (CAM) practitioners. Bad medicine is practised by a small number of orthodox and a significant number of CAM providers. Because of a lack of standardisation for the training of CAM practitioners, it is unarguable that, at the moment, patients are more likely to derive benefit by placing their care in the hands of an orthodox physician rather than a CAM practitioner. The challenge we now face involves creating a converging pathway that will incorporate the best of CAM and orthodox medicine into unified and routine management plans. Given the evidence available, it would be inappropriate to have a patient with osteoarthritis only advised of the potential benefits of glucosamine as an adjunct to therapy if they visited a CAM practitioner.
Consumer protection demands that the continuation of very different, parallel or even divergent systems of care provided by orthodox clinicians and variably trained CAM practitioners do not continue in the long term. Healthcare workforce problems make it obvious that there are important roles for many healthcare professionals with different training and skills within multidisciplinary teams. Mutual respect between doctors and many CAM practitioners is both appropriate and commonplace. Certainly, doctors need a better understanding of the basis of the claims made by CAM practitioners to educate their patients in an informed (rather than a biased) fashion. CAM practitioners who are truly patient-focused have nothing to fear from methods championing convergence. There can be no tolerance for the continuance of “care” provided (often at considerable expense) by ignorant, dangerous and unregulated practitioners.
The medical profession and bureaucracy need to address several questions relevant to the current situation:
Why do so many Australians, particularly women, choose to use the services of CAM practitioners as well as doctors in this most scientific of all ages?1,2
Are the much longer consultation times (at considerably more cost than a visit to a doctor) and the resulting ability to discuss problems a signal that many find the brief, Medicare-funded consultation with their own doctor unsatisfactory?
What, in terms of consumer protection, should be the significance of having “doctor” in front of one’s name and being registered by an appropriate Medical Board?
Should such registration provide patients with confidence that any care given would be acceptable to the vast majority of the doctor’s peers?
Should Medical Boards (and indeed similar statutory authorities monitoring the quality of care given by nurses and allied health professionals) be more vigilant in challenging the appropriateness of renewing registration of those whose diagnostic and therapeutic approaches would not be acceptable to their peers (for example, the use of “live blood analysis”,3 inappropriate chelation therapy,4 infusing massive doses of intravenous vitamin C,5 colonic irrigation procedures6)?
Scientific evaluation of the claims made by CAM practitioners is all-important if convergence is to be promoted. The area is, however, both controversial and difficult. Money to pursue claims of, at best, marginal effectiveness is difficult to obtain. The CAM industry itself should do more with its considerable profits to provide research dollars, but there is much internal resistance to the double-blind, placebo-controlled “gold standard” of orthodox medicine.7
Properly conducted scientific studies of CAM medicines have been most useful (for example, studies which documented both the effectiveness of St John’s Wort for depression,8 and potentially dangerous drug interactions). Science has been able to determine marginal or non-existent benefit for many CAM staples such as garlic, echinacea, ginseng and plant oestrogens; scientific evaluations of CAM products have shown that standardisation is so poor that preparations might not contain ingredients noted on the product label. There is an excellent case to be made for continued government funding of research into the more promising CAM approaches, and many universities have established laboratories for such studies. However, some approaches used by some in the CAM industry should be branded for what they are — nonsense (no science) — and denied funding. Thus, while it would be appropriate to continue to study the physiological changes associated with acupuncture, studies of homoeopathy, iridology, reflexology, healing touch techniques and others should not attract taxpayer dollars.
Currently, Australians are inadequately protected from a thriving and fraudulent subsection of the CAM industry. The problems associated with this subsection extend from the expense of preparations that are harmless but for which there is insufficient evidence that they are effective, through to the “rip-off” of the most vulnerable in our community with incurable or fatal diseases who may understandably suspend their normal commonsense judgement because of the desperate situation in which they find themselves.
Many pharmacists, well trained in scientific method, appear to be abrogating their role in protecting consumers — their shelves often carry products whose efficacy is unproven. Advertising managers at television and radio stations, as well as those with editorial responsibility for the print media, should take far more seriously their responsibility to evaluate therapeutic claims before they allow them to be promoted through their media.
How well is the Therapeutic Goods Administration (TGA) working to protect consumers from fraudulent health claims? The TGA’s current approach seems to be determined by resource issues rather than any proof that its procedures adequately protect consumers. At the moment, the proponents of products listed with the TGA are told that they must keep on record proof of the efficacy of any claims made, and that significant penalties will be applied if the TGA ever finds that such evidence was not available.9 The TGA carries out random checks, but the system is manifestly inadequate. All claims for therapeutic benefit should be subjected to some analysis by TGA officials, who, if suspicious, could refer them on for expert advice before any marketing would be possible. Prosecution for fraudulent activity is relatively rare, with a number of government agencies continuously passing the problem from one organisation to another. For example, the TGA will often refer something to the Australian Competition and Consumer Commission, who may think that the Department of Fair Trading would be better suited to carry out the investigation and prosecution. Punishing those found to be guilty of fraudulent practices has turned out to be a poor deterrent, with many examples of reoffence by individuals found guilty on numerous occasions.10 Health departments should be doing more to warn the public about fraudulent claims.
With federal government assistance, the CAM industry and its various subsections must continue to standardise education (both primary and continuing) and develop a registration technique that can promote confidence among consumers that the care and advice given will be safe and appropriate.
- 1. Shenfield G, Atkin P, Kristoffersen S. Alternative medicine: an expanding health industry. Med J Aust 1997; 166: 516-517. <eMJA full text>
- 2. Adams J, Sibbritt D, Easthope G, Young A. The profile of women who consult alternative health practitioners in Australia. Med J Aust 2003; 179: 297-300. <MJA full text>
- 3. Lowel J. Live cells analysis: high-tech hokum. Nutrition Forum 1986; 3: 81-85.
- 4. Ernst E. Chelation therapy for coronary artery disease, an overview of all clinical investigations. Am Heart J 2000; 140: 139-141.
- 5. Cregan E. Value of high dose vitamin C to benefit patients with advanced cancer. A controlled trial. N Engl J Med 1979; 301: 687-690.
- 6. Jarvis WT. Colonic irrigation. National Council Against Health Fraud. Available at: www.ncahf.org/articles/c-d/colonic.html (accessed May 2004).
- 7. Ernst E. Obstacles to researching complementary and alternative medicine. Med J Aust 2003; 179: 279-280.
- 8. Shelton R, Keller M, Gelemberg A, et al. Effectiveness of St. John’s Wort in major depression. JAMA 2001; 285: 1978-1986.
- 9. Expert Committee Report. Complementary medicines in the Australian health system. Report to the Parliamentary Secretary to the Minister for Health and Ageing (2003). Available at: www.tga.gov.au/docs/html/cmreport1.htm (accessed May 2004).
- 10. Hills B. Fake healers. Sydney Morning Herald 11 Sep 1999; section 4; 1-6.
Abstract
A complementary and alternative medicine (CAM) system divorced from scientific medicine means that patients can only benefit from the best of both systems by dividing their care.
Science must be used to stimulate convergence of complementary and traditional healthcare.
First class research to examine the more interesting claims of the alternative health industry is essential to broaden the range of therapeutic options available, while minimising fraudulent, ill-informed and sometimes dangerous practices.
Mutual respect and interest between orthodox and alternative practitioners is appropriate, but there can be no compromise involving unscientific approaches to care.
Health departments must play a greater role in stopping fraudulent claims being publicised, and in warning consumers about such claims.