Tuesday, May 23, 2006

Alternative medicine in conventional medicine

The expansion of offering so-called complementary and alternative medicine services in the context of "conventional" medical centers and private medical practices has been on my mind of late. Orac just recently posted an encore discussion of the topic that makes for good reading. Serendiptously, a number of British scientists issued yesterday a scathing indictment of the British National Health Service (NHS) Trusts for their financial support of alternative therapies in the UK while access to known, beneficial conventional medicines is often denied. Among those signing the letter to the NHS is Sir James Black, the 1988 Nobel laureate whose team brought us histamine-H2-selective antagonists for gastric ulcers and beta1-selective adrenergic antagonists for heart disease.

The British have had a very open and sober discourse on alternative medicine for a number of years. Part of the problem with discussing this issue in a scientific context is that alternative medicine ranges from conceptually-accessible plant-based herbal medicines to homeopathy and crystal healing. Dismissing all of alternative medicines is like making that converse statements that drugs are dangerous. The British are different, however, since the NHS will pay for some alternative therapy services. Hence, the issue is of greater public concern since all citizens ultimately pay for alternative medicine whether they agree with it or not.

In the US, the issue is more straightforward because very few managed care companies reimburse the insured for alternative therapies and services. Hence, a number of academic medical centers have jumped onto the alternative medicine bandwagon because most of those seeking services have the financial capacity to pay for services out of pocket. As a result, alternative therapies in the US are becoming the medicine of the rich and famous.

A bigger issue, worthy of further discussion after upcoming grant deadlines, is that US academic medical centers are promoting these services under the guise of "integrative medicine." In some institutions, these efforts are rigorously overseen, led by MDs well-trained in internal medicine and an appropriate sub-specialty, and only offered where evidenced-based medicine supports their use. In other institutions, integrative medicine programs operate as programs on the fringe, aggressively promoted to the community but often not even known to researchers and clinicians and within the very same institution.

A commentor at Respectful Insolence recently raised my awareness of the Consortium of Academic Medical Centers for Integrative Medicine, programs within academic medical centers in North America offering some sort of alternative medicine services. Those that I know of personally vary considerably in the quality and scientific rigor of their programs; even more interesting is the glaring omission of outstanding integrative medicine centers who are not part of this collaborative group. Were they not invited to join? Or, did they choose not to participate?

As a PhD researcher whose training and career has always been associated with US medical schools, I firmly believe that it should be safer and wiser for a patient to pursue alternative medicine approaches in academic medical centers than in the community. Contingent to this belief is that academic medical centers will be committed to providing the highest-quality, most rigorously supported therapies and services based in scientific fact and evidence-based medicine.

The biggest challenge to this notion, though, is how well these integrative medicine programs are themselves integrated within the medical center/health system to which they belong.

Moreover, if academic medical centers get into this business, should there be integrative medicine services specific to each medical specialty as opposed to one large overriding integrative medicine service? Compare everyone's hot-button target NCCAM who tries to fund research for all types of alternative modalities across all types of diseases to the quietly and highly-successful OCCAM that operates under the roof of the US National Cancer Institute, researching those modalities most likely to benefit the cancer patient and cancer survivor.

Some of my colleagues contend that there should be no need for integrative medicine. Test alternative therapies, keep what works and incorporate it into conventional medicine, and discard the rest.


At Tue May 23, 10:30:00 PM EDT, Blogger Clark Bartram said...

I agree with your colleagues. To call it integrative medicine furthers the fallacy that there is "Western" medicine and then other methods of providing healthcare that is equal. It is all medicine. Some works and some doesn't. Academic centers have a duty to root out what works and only then encorporate it into healthcare. They should not just invent some new medical entity as an excuse to give one segment of society what it wants. Being popular doesn't it make it right.

At Wed May 24, 04:18:00 PM EDT, Blogger Ewen M Callaway said...

But being popular is still being popular, and many patients, for a host of reasons, will continue to seek out alternative therapies. I'm not too familiar with intergrative medicine, but if you can keep people inclinced to alternative medicine in a real clinical setting, they may feel more comfortable seeking traditional treatments. If doctors completely delegitimize alternative therapies, people are more likely to end up in the whole Foods medicine aisle or worse, using using a crystal provided by a "shamen" who dropped out of Bennington.

At Wed May 24, 11:53:00 PM EDT, Blogger Clark Bartram said...

You are missing the point. Alternative medicine doesn't exist. There is only medicine that works and medicine that doesn't. Academic centers should only offer medicine that works while trying to figure out what works amongst all available therapies. It should also avoid giving legitimacy to unproven therapies and have the courage to say enough is enough when evidence shows that a particular therapy is bogus. This is my biggest pet peeve with the NCCAM which has yet to my knowledge state that something doesn't work. Well that and wasting millions of dollars. I think that if the average consumer thinks that quantum vibrational crystal energy enemas are legit because they are offered at Duke then they are even more likely to obtain said quack therapy in other venues. Just by making that up there is probably at least one person out there who will claim that doctor's support it and make a website to sell it. I may have created a new alternative medicine. I better get a patent quick before someone else does.

At Thu May 25, 12:01:00 AM EDT, Blogger Shelley said...

Never underestimate the power of the placebo effect. Or, people that have more money to throw at a problem than quality science.

At Thu May 25, 06:09:00 AM EDT, Blogger Abel PharmBoy said...

Both of Clark's points are well-taken and that academic med center who wish to use what I will call "alt med" must be equally committed to testing the modality for efficacy and safety before integrating it into the system. However, calling it alternative or integrative often becomes more of a marketing tool to bring people into the academic health systems who would otherwise bring their out-of-pocket dollars to community alt-med practitioners.

Ewen, one of the best integrative medicine centers in the country is at your institution (as deemed by an in-depth Wall Street Journal report), is led by an outstanding internist, yet does not belong to this so-called consortium of premier academic med centers. What I'm saying is that there is already a club atmosphere operating in the academic integrative medicine community that is almost as exclusive as the good ol' boy (and girl) network that operates in conventional medicine and science. And you're right, I have personally overheard the most frightening "patient counseling" recommendations being offered in the aisles of Alfalfa's, Whole Foods, or Vitamin Cottage, although certain local Whole Foods stores actively bring in folks with expertise like mine to hold lectures and training sessions for their staff.

Shelley points out wisely that there is a great deal of money to be made from the 25-40% of patients who are going to get better anyway because of the natural course of their disease or any of the other reasons that bogus therapies seem to work.

Great points all - and I plan to elaborate on these more substantively after grant deadlines. The integration of so-called alternative therapies into academic medical centers is a very serious issue and one deserving of our further consideration.


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