Science, Evidence-based Medicine and CAM…..it´s controversial!

Guest Post Written by Uta Mittelstadt (The Author)

Introduction

Patients are increasingly making their own healthcare their own responsibility, and are becoming more selective in what treatment and therapies they use in their recovery from illness [click to tweet]. Dissatisfaction with conventional treatment that is indifferent of a holistic view of health may produce more or less severe side-effects or even concomitant diseases, makes patients seek new approaches for relief of their suffering. Frequently, the choice is an alternative and complementary medical discipline [1] [2] [3].

This happens much to the dismay of practitioners and representatives of orthodox medicine. They view the practices of alternative and complementary medicine critically. They describe Complementary and Alternative Medicine (CAM) as being unscientific and treatments as lacking proof of effectiveness [2] [3] [4] [5] [6]. Yet, this critique itself needs to be viewed critically. The impression is that it follows a distinct purpose, may be far from justified and not necessarily reflects the best interest for patients.

Who says what science is?

Traditional Chinese Medicine (TCM) and Ayurveda, beside others, are folk medicines that have withstood the test of time, and are in use since 2000 to 3000 years, treating their patients successfully with a holistic view of healthcare and disease [4] [7]. Only very recently, compared to the time-span of the existence of the old folk medicines, came a novel, modern therapeutic approach, termed western medicine. This medical branch darted to the top and became acknowledged as the principal approach to health care, having overtaken the older, traditional medical systems and having become, by the implementation of frameworks and paradigms, largely the only form of patient health-care acknowledged as scientific. The older, traditional treatment forms have increasingly, more or less successfully, been pushed into the periphery of medical practice, and are being discredited as being non-scientific according to the scientific standards that have evolved with the rising of this newer, allopathic treatment approach [4]. As such the newer western approach has become the conventional, allopathic medical system, and all other practices of medicine, the unconventional or alternative therapies [8].

The conventional approach demands all other treatment approaches provide evidence of scientificity of their practices, to be measured against those newly implemented conventional standards, in order to be acknowledgeable as safe treatment practice [4]. As such an evidence-based practice is sought to be created, whereby “individual clinical experience” is teamed “with the best available external clinical evidence from systematic research” [9] (p.52). By insistence on this, practitioners of the allopathic medical route have over the years manifest their practice as the “superior” form of treatment, as scientific, evidence-based, against the methods of old that have been in practice much longer than the creation of the “young” allopathic medical concept, but do not meet up to the new scientific paradigm.

Viewed from a historical perspective, according to Riley [4] (p.552), “the emphasis on science was intended to eliminate the unorthodox kinds of medicine”, to further modernization and improve the quality of medical practices. In his article Riley [4] demonstrates with the example of Thailand how, in particular from the USA, educational boards and foundations funded the establishment of orthodox medical schools and systems, seeking to promote digression toward the newer system of health care. In the consequence of such progression that took place in many countries during the colonisation, as Riley mentions, an eradication of folk medical practices took place. This development was most successful in underdeveloped countries. In China and India, for example, this was less effectual, as the indigenous treatments there, TCM and Ayurveda respectively, had been successful for thousands of years without any dependence on scientific proof of efficacy [4].

CAM and Science

The call for evidence of scientificity of the unconventional practices has in its persistence suggested that science is immediately a true fact and that consequently a therapy that is measurable by the scientific framework of conventional medicine, is equally as immediately a treatment that is efficacious [4]. This is not so. While it must be acknowledged that with the development and progression of science have come life-saving treatments that were yet unknown to folk medical practices, such as the identification and development of penicillin, it has to be noted that medical science has limits, and does not provide a cure-all for all diseases [4] [6]. In fact, the extent of “curing” disease under the label of medical science has been relatively small, the greatest praise having to be accredited to the improvement of hygienic conditions [4].

The demand for scientific evidence is flawed at the fundamental baseline of the claim, because, “although discrimination in the name of science is practiced, it is difficult to find an explicit basis for characterizing one specific medical system as more scientific than another” [4] (p.549). Furthermore, there is a lack of consensus as to what is to be considered as proof of evidence [5].

The notion, therefore, that all therapeutic treatment approaches to health care, should be applicable to methods of allopathic testing and be thus supported by an evidence-base is unrealizable; too different are the underlying philosophies of the different disciplines [3]. Yet, to assume that the disciplines of CAM entirely lack evidence of efficacy is incorrect and to adopt the presupposition that the allopathic practices do is equally deceptive.

Investigations into the efficacy of CAM therapies have been and are problematic. Science follows the concept of a “materialistic causality” [3] (p.669), and the CAM therapies fall short of fitting into the framework this concept of materialistic causality has generated. It appears that changes in the inherent world-view of the predominant scientific paradigm are necessary in order for the concept of CAM to be valuable [10] [3]. The core of Sciences´ primary conflicts with the CAM practices, demonstrates dissonance of the conventional concept of standardization with that of individualization that is fundamental to the alternative, non-conventional practices [11]. As such, therefore, the gold standard of the randomized controlled trial (RCT) as the principal tool for evaluation of efficacy of a treatment approach is rendered inapplicable, to investigations into holistic medical concepts of health [11].

Alternative therapies such as homeopathy, for example, have proceeded to adopt the testing methodologies inherent of conventional trials and studies, and are following the standard procedures as outlined by the Consort statement [13] (plus extensions [16]), but have extended investigations to include data specific to homeopathic treatment practice, by reporting on aspects that are outlined in the Reporting data on homeopathic treatments (REDHOT) guidelines [14].

While most trials and studies into CAM are undertaken with the focus of investigation being on the efficacy of the alternative treatment compared to placebo, Walach [5] insists that testing CAM therapies with the RCT should follow a different structure. He stresses that the holistic treatment is better tested against the efficacy of a treatment of another discipline as opposed to that of placebo. Riley [4] considers the placebo a bias to the claim of scientificity itself. “Placebos depend upon a patient’s (and perhaps a physician’s) belief that a therapy is likely to work” [4] (p.556); a subjective experience, and therefore, science itself has an ‘unscientific’ aspect.

Is allopathy EBM?

Besides all the heated discussions and the persistent demand for evidence-based medical practices of CAM, one issue frequently receives little attention, namely, the extent to which the orthodox medical practices are in fact practicing what they preach and provide scientific evidence of efficacy. LaRiccia [8] and Patel [3] point out that few good quality trials exist that have investigated CAM therapies but fail not to stress that this is likewise an issue in the evaluation of those practices described as evidence-based or scientific.

“Clinical Evidence comprises a database of high-quality, rigorously developed systematic overviews assessing the benefits and harms of treatments” [15] , and has proceeded to categorise the effectiveness of 3000 treatments with an astonishing and in fact shocking outcome. The data exhibited reflects to what extent treatments are evidence-based. The outcome of this categorisation has shown that a mere 11% of trials and studies show beneficial outcome, 23% are considered likely to be beneficial with the remaining 66% ranging from questionable, of unknown effectiveness, to ineffective or harmful [15].

Chart from: http://clinicalevidence.bmj.com/x/set/static/cms/efficacy-categorisations.html

This elevation draws into question the justification for the persistent and resolute demand for evidence of efficacy of CAM treatments. With so little profound evidence available from so-called scientific medicine, the legitimacy of critique from the medical orthodoxy, concerning an insufficiently existent evidence base of the non-conventional practices, is questionable and appears shameful.

Why, therefore, is the insistence on proof of the efficacy of the CAM practices so persistently demanded, in particular from the conventional medical spheres? The reason becomes quite obvious if one takes into consideration the increase of interest in, acceptance of and use of CAM disciplines by ever increasing patient numbers. CAM has advanced to become somewhat of a threat to conventional medical practice [3].

The therapies of CAM are in existence because patients demand treatments outside of the conventional realm of medical practice [10]. Patients notice and experience that orthodox medicine has flaws [6]. They are not blind to the impact a course of treatment makes on them, to adverse effects or to the concomitant developments that frequently originate from the mainstream treatment of diseases.  Patients have become sensitized for their own well-being and health, and have therefore become critical of the handling of their discomforts and ailments [5] [6]. Consequently, patients demand to be treated holistically, gently, alternatively.

Conclusion

Patel [2] stresses that an integrative approach to treatment may be most valuable to the patient.  He emphasizes that the factor `time of existence´ of a discipline is inappropriate as a measure of efficacy and that testing with standard scientific means is necessary for the acknowledgement of a non-conventional practice. Yet, he maintains that there are many challenges to such evaluation and that CAM therapies should not aim at providing evidence of being a superior approach to healthcare. Rather should the emphasis be on discovering “ the strengths and weaknesses of each system in order to be able to show that specific types of cases should be treated by specific holistic therapies, while other specific types of cases should be treated by scientific medical physicians” [2] (pp.173-174).

If CAM practices were found to fully comply and be testable with the standard scientific methodologies, the alternative and non-conventional therapies would lose what makes them `different´. If CAM became scientifically standardised according to the orthodox scientific paradigm it would have to be incorporated into mainstream medicine and would consequently become conventional. The CAM practices would have to be reclassified, as specialities of conventional practice [10]. Is this at all favoured?

LaRiccia [8] points out that “the lack of RCT´s does not disprove a therapy”, and albeit Patel´s [2] call for CAMs compliance with the scientific methodologies of investigation, the traditional medical practices offer valuable concepts of health care. Practitioners cannot ignore the evidence of efficacy of a treatment that has been practiced successfully and is documented by experience in practice, only on account of philosophical unacceptability within a fixed superimposed framework. It is the currently inexplicable that promotes investigation and has “in the past, been linked with significant scientific advances” [3] (p.669).

References:

[1] Michlig, M, Ausfeld-Hafter, B. & Busato, A. (2008) Patient satisfaction with primary care: A comparison between conventional care and traditional Chinese medicine. Complementary therapies in medicine http://www.ncbi.nlm.nih.gov/pubmed/19028336

[2] Patel, M. (1987a) Evaluation of holistic medicine. Social Science & Medicine. http://www.ncbi.nlm.nih.gov/pubmed/3105078

[3] Patel, M. (1987b) Problems in the evaluation of alternative medicine. Social Science & Medicine. http://www.ncbi.nlm.nih.gov/pubmed/3317884

[4] Riley, J. (1977) Western medicine´s attempt to become more scientific: Examples from the United States and Thailand. Social Science & Medicine. http://www.ncbi.nlm.nih.gov/pubmed/339357

[5] Walach, H. (2009a) The campaign against CAM and the notion of “evidence-based”. The Journal of alternative and complementary medicine http://connection.ebscohost.com/c/articles/44759644/campaign-against-cam-notion-of-evidence-based

[6] Walach, H. (2009b) The campaign against CAM – a reason to be proud. The Journal of holistic healthcare . http://www.ecpm-europe.ch/Campaign_against_CAM.pdf

[7] Patwardhan, B. Warude, D, Pushpangadan, P. & Bhat, N. (2005) Ayurveda and traditional Chinese medicine: A comparative overview [online] article from Evidence-based Complementary and Alternative Medicine last accessed November 2012 at URL https://web.archive.org/web/20160115142645/http://www.iaim.edu.in/pdf/eCAM-indo-china.pdf

[8] LaRiccia, P. (2003) Point of view: A Physician´s experience with integrating complementary and alternative medicine: Opportunities, problems & directions. Seminars in integrative medicine. http://www.sciencedirect.com/science/article/pii/S1543115003000619

[9] White, B. (2004) Making evidence-based medicine doable in everyday practice. Family Practice Management . http://www.aafp.org/fpm/2004/0200/p51.html

[10] Chez A. & Jonas, W. (1997) The challenge of CAM. American Journal of Obstetrics & Gynecology. http://www.sciencedirect.com

[11] Yamey, G. (2000) Can complementary medicine be evidence-based? Western Journal of Medicine . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070951/

[12] Huffard, D. (2003) Evaluating complementary & alternative medicine: The limits of Science and Scientists [online] article from Journal of Law, Medicine & Ethics . http://onlinelibrary.wiley.com/doi/10.1111/j.1748-720X.2003.tb00081.x/abstract

[13] Schulz KF, Altman DG, Moher D, for the CONSORT Group. CONSORT 2010 Statement: http://www.consort-statement.org/downloads BMJ 2010;340:c332.

[14] Dean, M., Coulter, M., Fisher, P., Jobst, K. & Walach, H. (2007) Reporting data on homeopathic treatments (RedHot): A supplement to CONSORT. The Journal of alternative and complementary medicine. http://www.homeopathyjournal.net/article/S1475-4916(06)00150-0/fulltext 

[15] BMJ (2012) What conclusions has Clinical Evidence drawn about what works, what doesn’t based on randomised controlled trial evidence? Clinical Evidence. http://clinicalevidence.bmj.com/x/set/static/cms/efficacy-categorisations.html

[16] Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, Elbourne D, Egger M, Altman DG, for the CONSORT Group. CONSORT 2010 Explanation and Elaboration: updated guidelines for reporting parallel group randomised trial. British Medical Journal http://www.bmj.com/content/340/bmj.c869 (http://www.consort-statement.org)

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About the author: Uta Mittelstadt

Uta Mittelstadt

I was born in Germany but now settled in Portugal. I have studied homeopathy for many years, both in Portugal and in the UK. I have a B.Sc in Homeopathic Medicine and am currently writing the thesis for the M.Sc (Homeopathic Medicine) with the University of Central Lancashire, UK. I am passionate about homeopathy, run a blog, Clever Homeopathy. As a practitioner, I seek  to provide my patients with the best possible treatment for their re-instatement to health. I spend my free time painting landscapes in oil on canvas.

 

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The above article was originally published by Uta Mittelstadt in her blog Clever Homeopathy on 8th Oct 2012 and is republished here with her explicit permission. The Copyright is reserved with the author (Uta Mittelstadt). All opinions are that of the author.

The above Guest Post is the ninth in the GUEST BLOG SERIES. For reading previous Guest Posts check out https://drnancymalik.wordpress.com/2012/08/23/guest-blog-series

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