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Jonny Martell: The magic of alternative medicine

12 Mar, 10 | by julietwalker

Jonny MartellI was working next to a world renowned psychic and spiritual healer in the healing sanctuary of a music festival. This made me nervous: my own training in complementary medicine before medical school gave me no such special powers. Many of the people I treated had the customary battle wounds of a sedentary office bound existence. Others came in just to feel better. These people were clearly treating themselves. Who else uses complementary and alternative medicine (CAM) and why?

Many users of CAM have medically unexplained symptoms. This non-diagnosis is a big burden for primary care, accounting for a quarter of consultations in England. It’s also a big burden for the patient, implying that it’s all in the head. Much of the literature and nomenclature surrounding medically unexplained symptoms is from psychiatry, which serves to reinforce this implication. If a profession largely dedicated to the scientific exploration of phenomena cannot articulate the problem it is unsurprising that patients look for other explanations.

Several approaches in CAM employ language and metaphors redolent of Eastern concepts of balance and energy flow. These are strikingly at odds with the reductionist technical lexicon of allopathic orthodoxy. This perhaps appeals to patients interested more in the “why” as opposed to the “what.” If stripped of its more esoteric overtures, this is of course no different to the best practice offered by general practitioners. A crucial difference, however, is the luxury of time.
Another commodity sparingly used in modern medicine is touch. Whereas the doctor-patient relationship is ever more impersonal, with the growing battery of diagnostic technology, many CAM therapies thrive on a greater intimacy. Perhaps part of CAM’s appeal is that touch offers patients something magical and mysterious. It is also for many, the purveyor of the natural, free from the market hungry wolf of big bad pharma and the side effects of its drugs.

Working at the festival brought home to me how the tensions that exist between CAM and allopathic medicine can illuminate each other’s blind spots. Where primary care’s 10 minute consultation, spot of reassurance, and some tablets fail to hit the spot, I suspect that in some cases the holistic principles underpinning some CAM approaches are as instrumental in making the patient feel better as the intervention itself. In such instances the therapy is unlikely to perform too well in randomised controlled trials, focusing as they do on an illusory magic bullet.

A willingness to develop an understanding of the appeal of CAM, despite its shortcomings, might be more likely among doctors if they had a better understanding of the fallible foundations on which their own pedestal of evidence based medicine is built. At the very least, it might make for a bit more humility and less flippant mockery when confronted with the popularity of the clairvoyant shop next door.

Jonny Martell is a third year medical student at Kings College London

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  • bsvaishnav

    The synthesis between mainstream medicine and CAM can be best achieved by rising above the domain of Health/Healing from that of Medicine/ Treatment

  • Kausik Datta

    Tall claims from someone who has already put on the rose-tinted glasses of CAM. I understand the appeal of CAM, but do you understand its shortcomings? Where is the solid scientific evidence that any of that works? Care to comment upon the plausibility of different CAM approaches?

    And what exactly do you mean by fallible foundations of evidence based medicine? Your comment betrays your complete ignorance and/or lack of understanding of evidence-based medicine, or of science in general, I am afraid.

  • Jonny Martell

    Thanks Kausik, to answer your last question, I had in mind and recommend Greenberg’s ‘How citation distortions create unfounded authority: analysis of a citation network’ (BMJ 2009;339:b2680). As for CAM, it is a broad church with many sub-sects. Some of it is ludicrous in its implausibility and dearth of evidence, some of it entirely consistent with medical science with sound evidence to support its use.

  • Niall Anderson

    Jonny, interesting reply to Kausik – would you care to name names? Which treatments would you reject (and why) and which do you see as promising (and why)?

  • Niall Anderson

    Sorry – another point occurred to me… You mentioned that
    “…the holistic principles underpinning some CAM approaches are as instrumental in making the patient feel better as the intervention itself. In such instances the therapy is unlikely to perform too well in randomised controlled trials, focusing as they do on an illusory magic bullet”. In the first sentence, aren’t you really just describing the non-specific (“placebo”?) effects of a treatment? If you want to understand what the actual therapeutic mechanism is, don’t you have to do something to remove the non-specific effects from the experiment? If so, don’t you then end up with something that looks remarkably like a clincial trial? So why would RCTs be a problem area?

  • Don

    CAM works as well as any other “magic” approach; the placebo effect is well known. As for CAM with sound evidence, when sound evidence is shown, it’s known as “medicine” . . . .

  • Andy

    Jonny,

    It sounds like you are saying that it is the extended consultation period and the hands-on touch of the CAM approach which could provide the perceived benefits. Is that correct?

    If so it would suggest that the conditions are more psychiatric in nature than physical.

  • moderation

    “AS for CAM … some of it entirely consistent with medical science with sound evidence to support its use” … really!? Examples, please – because if you can provide some you will be the first person to do so. Then you really will have information worthy of being published in the BMJ!

  • http://blogs.nature.com/austinelliott/ Austin Elliott

    Jonny, while your last sentence about CAM may be just about true as written, the reality as attested in books like Singh and Ernst’s Trick or Treatment, or Barker Bausell’s Snake Oil Science, is that the former category (frank implausibility) vastly outweighs the latter (consistent with science and supported by believable evidence). Indeed, the imbalance is so big that I suspect it would be hard to find many lay CAM practitioners whose work is even mostly evidence-based. To take one of the best known (and officially regulated) CAM modalities, while there may be chiropractors who stick to lower back and musculo-skeletal problems, the surveys tend to show that there are many others who do one or more of: pushing chiropractic for just about anything; flogging patients iffy nutritional advice and unnecessary “wellness check-ups”; and advising parents not to vaccinate their children.

    The one thing I do agree about is that doctors need to understand the basis of CAM’s appeal to patients. But is there really any evidence that this amounts to more then “being able to promising patients all the stuff that doctors aren’t allowed to promise them because it isn’t true”?

  • http://blogs.nature.com/austinelliott/ Austin Elliott

    PS Sorry, meant the last sentence of your reply to Kausik Datta, if that wasn’t clear.

  • Peter Flegg

    The “magic of alternative medicine” can be neatly summed up in one word: Placebo.
    Jonny Martell seems to understand this, but fails to put a name to it.

  • http://blogs.nature.com/im_brooks/ Ian Brooks

    But again we are not furnished with this missing data. proponents of CAM constantly claim they have evidence of non-placebo effect efficacy for homeopathy, acupuncture etc.. All we ever see is in unerring inability to perform literature searches, and failure to provide any evidence other than cherry-picked, badly performed ‘trials’.

    “A willingness to develop an understanding of the appeal of CAM, despite its shortcomings, might be more likely among doctors if they had a better understanding of the fallible foundations on which their own pedestal of evidence based medicine is built. At the very least, it might make for a bit more humility and less flippant mockery when confronted with the popularity of the clairvoyant shop next door.”

    This paragraph alone shows you have little or no understanding about how science works and what science means.

  • AnthonyK

    Dear Jonny, you may be interested to know that your post is demolished on Orac’s blog “Respectful Insolence”:
    http://scienceblogs.com/insolence/2010/03/another_example_of_why_i_fear_for_the_fu.php
    Would you care to comment there?
    But really

    a world renowned psychic and spiritual healer

    !!!
    I bet you weren’t taking stimulants in purely homeopathic doses…;)

  • Johannes9126
  • Jonny

    Niall, NICE suggests manual therapy (including manipulation) and acupuncture be considered for the management of lower back pain. Austin is right that such examples vastly outweigh the treatments for which there is no evidence.
    Don, it is problematic for the likes of acupuncture and osteopathy (with evidence for some indications) to become ‘known as “medicine”’ as you put it. Their philosophical roots, professional identity and range of practice/practitioners that have no effect on a variety of conditions are strongly at odds with the scientific principles of medicine.
    Andy, time and touch are very appealing for many people and as you say these ‘could provide the perceived benefits.’ I wouldn’t go with the suggestion that this makes these conditions more psychiatric.
    Austin, I agree wholeheartedly. As for your point about, ‘being able to promise all the stuff that doctors aren’t allowed to…,” I think this is quite true but it can’t be said for all CAM practices and practitioners. (One remark edited from my piece was that it is almost impossible to generalise about CAM without misrepresenting it.)
    Moderation, see above.
    Peter, yes I could have mentioned the placebo word, but its use seems to stifle any thought on what it actually is.
    Ian, yes much of the evidence is very shaky, some of it less so, and yes I have a lot to learn about science.
    Anthony and Johannes, I was hoping that my opening sentence and indeed the whole piece would be taken with the irony with which it was intended!

  • Hildegard

    This is a spoof blog, yes?

  • Kausik Datta

    Jonny, you agree with Don, Andy, Austin, Ian and others, and yet you fail to see the irony of your position. Perhaps you could start by providing some solid evidence for your intrepid assertion:
    “As for CAM … some of it entirely consistent with medical science with sound evidence to support its use”

    Your examples of “manual therapy” (whatever that means; if you mean Physiotherapy, I can accept it, but then Physiotherapy is not CAM) and “acupuncture” for lower back pain are rather weak, don’t you think? Perhaps you could point us to some studies which show acupuncture works, and works better than sham / non-specific / null controls.

  • Dominic Haigh

    CAM is mainly owned by Big Pharma.

  • ricky hindmarsh

    Kausik, presumably you find Jonny’s position ironic because you cannot accept his unwillingness to draw as convenient a dichotomy between CAM and evidence based medicine as you would seem to have it.

    Look at how NICE’s guidance is drawn up before dismissing acupuncture and manual therapy as ‘rather weak’ examples. If you then reject their methodology, do you still deign to ‘accept’ your capitalised physiotherapy when so many physiotherapists perform manipulation and acupuncture in the treatment of lower back pain? If you approve of their methodology, do you still ‘accept’ GPs, some of whom still prescribe anti-depressants as first-line treatment for uncomplicated mild depression? Or other off-label practice? I won’t go on.

  • Richard

    Thank you, Jonny for a well thought out and obviously thought provoking (or at least knee-jerking) article. I, if not others, appreciated the ironic humor, as well as the point of view. A few thoughts if I may for your critics:

    To try to say that CAM by definition is non-evidence based and that if something is evidence based it somehow magically stops being CAM, is absurd. When an herb used in Traditional Chinese Medicine is shown to be effective in an evidence based study, it does not stop being Traditional Chinese Medicine.

    As a treatment advocate for patients living with HIV/AIDS, I have had to analyze and explain to lay people more than my fair share of “evidence-based scientific studies”. A lot of good ones and a lot of crap. Just because the pharmaceutical reps provided good food and wine didn’t make their claims any more legitimate.

    I have watched my patients use all kinds of CAM to stomach the gut wrenching (literally and figuratively) medicines that were available to them in the 1980s and early 1990′s. Who cares why therapeutic touch or acupuncture worked for them, if it kept them from puking up their meds.

    And that was after western medicine developed something. Prior to that the only thing available was CAM, and CAM kept many people alive long enough to benefit from the drugs that did come years later.

    Let’s not forget that when AIDS medicines were firs introduced they were given in mono-therapy, which meant most patients developed resistance within six months. As one of the better (and humbler) AIDS docs in town years later was heard to say, “Our patients who are doing well now are the ones who have lived long enough to find out that everything we told them to do was wrong.”

    We have learned more about the human human system in the last thirty years than we did in the last three hundred. And guess what? A lot of what we knew “scientifically” was wrong.

    I have now lived long enough to see AIDS become a chronic manageable disease in the developed world. Thank God & Big Pharma. Now I see the same issues with my friends who are dying of cancer.

    Along the way i have seen every kind of snake oil pitched to “cure” my patients. And i have seen things that didn’t come out of a pharmaceutical company that did help them. As of yet, I have not seen a “cure” from either side of the fence.

    A little humility is in order folks. No one knows why one person lives with a disease and another one dies. There will always be a percentage of patients who do not respond to any “evidence-based” treatment and a percentage of patients who will only respond to CAM.

    I am all in favor of using scientific method to prove the value of CAM approaches. Anyone who says there is none is refusing to see evidence that exists. Some CAM works for some things for some people. Some pharmaceutical and surgical interventions work for some things for some people.

    In my time, the people I have seen have the best clinical outcomes are those who have taken the best of both.

    To me asking whether you use modern western medicine or CAM is like asking whether you wear pants or shirts. Each has its role to play and they can actually go pretty well together.

  • Anci

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  • alternativemedicine

    The terms 'alternative medicine,' 'complementary medicine,' or 'unconventional medicine' refer to diagnostic methods, treatments and therapies that appear not to conform to standard medical practice, or are not generally taught at accredited medical schools. The scope of alternative medicine is broad, with widespread use among the American public of a long list of treatments and practices, such as acupuncture, homeopathy, relaxation techniques, and herbal remedies.

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