Correspondence
Unconventional Medicine
N Engl J Med 1993; 329:1200-1204October 14, 1993
- Article
To the Editor:
Having spent many years actively studying and working with different healing systems in various parts of the world, I feel justified in saying that many unorthodox cures work, usually repeatedly, in ways that defy the placebo effect. The laws of consumerism seem to dictate that the popularity and longevity of various medical systems are related to their ability to effect cures. Hence, it is almost unheard of for a patient to seek unorthodox treatment for emergency care; it is only in areas where orthodox treatment fails that these “growth industries,” as Dr. Campion refers to them (Jan. 28 issue),1 flourish.
There is no doubt that many unorthodox therapies do not fit our Western medical paradigm. Yet to call them silly is shortsighted. Acupuncture, for instance, has been used effectively in Asia for 2000 years, and it is estimated that one third of China's population currently uses it. By personal account, and that of others,2-4 it has the ability to reverse both functional and organic disease. The effectiveness of acupuncture as anesthesia during brain and abdominal surgery is only partially explicable by our laws of physiology.
4 ReferencesSteven Amoils, M.D.
Cincinnati Family Medicine, Loveland, OH 451401
Campion EW . Why unconventional medicine? N Engl J Med 1993;328:282-283
Full Text | Web of Science | Medline2
Li Y ,Tougas G ,Chiverton SG ,Hunt RH . The effect of acupuncture on gastrointestinal function and disorders. Am J Gastroenterol 1992;87:1372-1381
Web of Science | Medline3
Vincent CA ,Richardson PH . The evaluation of therapeutic acupuncture: concepts and methods. Pain 1986;24:1-3
CrossRef | Web of Science | Medline4
Richardson PH ,Vincent CA . Acupuncture for the treatment of pain: a review of evaluative research. Pain 1986;24:15-40
CrossRef | Web of Science | Medline
To the Editor:
I am one of those educated, upper-income white Americans with a chronic health problem who lives in the West and who uses unconventional medicine along with traditional medicine. Why? Because I want to feel better. It is not any more complicated than that.
I discuss any unconventional medicine that I use with traditional doctors, but only if they are knowledgeable about these options. Since many physicians, appropriately, charge according to the amount of time they spend with a patient, why should I pay extra to explain what I am doing when I have not perceived a lot of interest in these therapies on the part of doctors who are unfamiliar with them? For me it is not an issue of approval; it is a matter of money.
Many of us are searching for a cure, and we take it wherever we can get it -- and that is not entirely with traditional medicine.
Diana Korte
564 Linden Park Ct., Boulder, CO 80304To the Editor:
The survey on unconventional medicine by Eisenberg et al. (Jan. 28 issue)1 and the accompanying editorial by Campion unfairly link the chiropractic profession with the likes of homeopathy and “energy healing.” Although the authors make no explicit judgments about these various therapies, merely mentioning them in the same context suggests equivalency among them.
The survey found that the most common symptom for which patients sought unconventional care was back problems, and the practitioner most commonly seen for back problems was a chiropractor. Many investigators (both chiropractors and nonchiropractors alike) have found spinal manipulation in general and chiropractic treatment in particular to be an indicated, if not the preferred, treatment for a variety of back problems2,3. The use of the word “unconventional” to characterize this treatment is inaccurate and prejudicial. It is conventional, commonplace, and appropriate. A more accurate description of chiropractic in this context would simply be “nonmedical.”
Campion urges his colleagues to be “honest about the lack of scientific evidence supporting most unorthodox therapies.” Indeed, they should., and they might also mention the scientific shortcomings of their own profession. The British Medical Journal observes that “only about 15 percent of medical interventions are supported by solid scientific evidence”4. The Journal comments that there is a “growing worry about the unknown quality and outcomes of medical services”5. To observe that most health care is unsupported by scientific evidence excuses no one, neither chiropractors nor medical doctors, from the responsibility of demonstrating the safety and effectiveness of what they do. Chiropractors treat problems other than back pain, and we are diligently going about the business of conducting the clinical research necessary to demonstrate the effectiveness of these treatments or the lack thereof. It is the results of these investigations, and not theory, that will define our role in the health care system.
5 ReferencesCraig F. Nelson, D.C.
Northwestern College of Chiropractic, Bloomington, MN 554311
Eisenberg DM ,Kessler RC ,Foster C ,Norlock FE ,Calkins DR ,Delbanco TL . Unconventional medicine in the United States -- prevalence, costs, and patterns of use. N Engl J Med 1993;328:246-252
Full Text | Web of Science | Medline2
Meade TW ,Dyer S ,Browne W ,Townsend J ,Frank AD . Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. BMJ 1990;300:1431-1437
CrossRef | Web of Science | Medline3
Shekelle PG, Adams AH, et al. The appropriateness of spinal manipulation for low-back pain: indications and ratings by a multidisciplinary expert panel. Santa Monica, Calif.: RAND, 1991. (Monograph no. R-4025/2-CCR/ FCER.)
4
Smith R . Where is the wisdom . . . ? BMJ 1991;303:798-799
CrossRef | Web of Science | Medline5
Relman AS . Assessment and accountability: the third revolution in medical care. N Engl J Med 1988;319:1220-1222
Full Text | Web of Science | Medline
To the Editor:
In its 98 years, the chiropractic profession has become the world's third-largest among providers of health care. Its practitioners (45,000 in the United States alone) are recognized and licensed with the rigor exerted by medical boards in every state and province in North America, as well as in Australia, New Zealand, and many jurisdictions in Europe, Africa, and the Middle East. Fourteen chiropractic colleges in the United States are accredited by the Council for Chiropractic Education, which was granted accrediting-agency status by the Department of Education in 1974 and by the Council on Postsecondary Education in 1976. Dr. Campion's editorial is therefore misleading in implying that the credentials of chiropractic are equivalent to those of such other alternative therapies as healing with crystals.
Chiropractic research must also be addressed. In the management of lower back pain, the superiority of chiropractic over other approaches (bed rest, medication, physiotherapy, and massage) has been demonstrated by more than 25 randomized clinical trials in the peer-reviewed and indexed literature1,2. Further validation is provided by a literature survey and findings respecting appropriateness by the Rand Corporation and three meta-analyses3. These publications constitute strong support for the effectiveness of chiropractic therapy, as concluded by a panel of the Agency for Health Care Policy and Research. In the treatment of lower back pain, it was evident from the September 1992 hearings conducted by the agency that chiropractic has the most documented evidence of patient outcome of any of the available therapies.
3 ReferencesAnthony L. Rosner, Ph.D.
Foundation for Chiropractic Education and Research, Arlington, VA 222091
Meade TW ,Dyer S ,Browne W ,Townsend J ,Frank AO . Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. BMJ 1990;300:1431-1437
CrossRef | Web of Science | Medline2
Koes BW ,Bouter LM ,van Mameren H , et al. Randomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up. BMJ 1992;304:601-605
CrossRef | Web of Science | Medline3
Shekelle PG ,Adams AH ,Chassin MR ,Hurwitz EL ,Brook RH . Spinal manipulation for low-back pain. Ann Intern Med 1992;117:590-598
Web of Science | Medline
To the Editor:
Eisenberg and colleagues defined unconventional therapies “as medical interventions not taught widely at U.S. medical schools or generally available at U.S. hospitals.” “Relaxation techniques” were considered unconventional therapy and were the most frequently used intervention. Although herbal medicine, energy healing, and folk remedies may not be widely taught at medical schools or generally available, this is not true of relaxation techniques.
We contacted 62 U.S. medical schools (47 percent of the total number of medical schools) and found that at 36 (58 percent) the therapeutic use of relaxation techniques is being taught in either required or elective courses.
To help define the broader role of relaxation techniques in conventional medicine, standard clinical textbooks1-7 were examined to determine their recommendations for therapy for the six medical conditions for which relaxation techniques were cited in the Journal article as the most used unconventional therapy. For four of these conditions -- insomnia,1 depression,2 anxiety,2 and headache3 -- relaxation techniques were uniformly and prominently listed as “appropriate,” “typical,” “effective,” and “valuable.” Relaxation was commonly recommended as the treatment of choice1-3.
. . . Twenty years ago, relaxation techniques were not widely used in medicine. A review of the MEDLINE data base reveals that since 1972 more than 2700 articles relating to relaxation techniques have been published in the medical literature. These publications yielded sufficiently encouraging data to result in the widespread therapeutic use of relaxation techniques and the inclusion of this material in medical schools. In fact, relaxation techniques should serve as a model of how to integrate worthy, unconventional therapies into the practice of mainstream medicine.
7 ReferencesRichard Friedman, Ph.D.
State University of New York, Stony Brook, NY 11794Patricia Zuttermeister, M.A.
Mind/Body Medical Institute Deaconess Hospital, Boston, MA 02215Herbert Benson, M.D.
Deaconess Hospital Harvard Medical School, Boston, MA 021151
Hauri P. Primary insomnia. In: Kryger MH, Roth T, Dement WC, eds. Principles and practice of sleep medicine. Philadelphia: W.B. Saunders, 1989:442-7.
2
Task Force Report of the American Psychiatric Association. Treatment of psychiatric disorders. Washington, D.C.: American Psychiatric Association, 1989:1856, 2429-30.
3
Syrjala KL. Relaxation techniques. In: Bonica JJ, ed. The management of pain. 2nd ed. Vol. 2. Philadelphia: Lea & Febiger, 1990:1749.
4
Knauer CM. Alimentary tract. In: Tierney LM Jr, Schroeder SA, McPhee SJ, Papadakis MA, eds. Current medical diagnosis & treatment. Norwalk, Conn.: Appleton & Lange, 1993:491.
5
Forsmark C, Watts HD. Gastrointestinal disorders. In: Skach W, Daley CL, Forsmark CE, eds. Handbook of medical treatment. 18th ed. Greenbrae, Calif.: Jones Medical, 1988:262.
6
Stapleton A, Fine R. Hypertension management. In: Skach W, Daley CL, Forsmark CE, eds. Handbook of medical treatment. 18th ed. Greenbrae, Calif.: Jones Medical, 1988:129.
7
Massie BM, Sokolow M. Systemic hypertension. In: Tierney LM Jr, Schroeder SA, McPhee SJ, Papadakis MA, eds. Current medical diagnosis & treatment. Norwalk, Conn.: Appleton & Lange, 1993:358.
To the Editor:
. . . The theory of herbal medicine is rooted in the same principles as pharmacology: the application of active chemicals to the disease process. The National Cancer Institute screens more plants for medicinal properties than any other agency in the world. Twenty-five percent of the agents prescribed annually in the United States are derivatives or synthetic analogues of plant constituents. The efficacy of many herbal medicines is well documented. For example, echinacea, or purple coneflower, has been shown to be superior to antibiotic therapy for upper respiratory tract infection in 1280 children1. Numerous other examples of proved whole-plant remedies can be found in Weiss's Herbal Medicine2.
Dr. Campion's call for nonjudgmental inquiries about a patient's use of unconventional therapies is questionable when he displays such an ill-informed bias himself. The widespread use of unorthodox therapies requires the wise physician not only to be aware and tolerant of them, but also to consider that they may offer something of value to the patient. Indeed, great scientists are able to create and function well within a given paradigm, as well as recognize the limitations of their model and the need for an open mind.
2 ReferencesBrad Roter, M.D.
School of Medicine, University of Washington, Seattle, WA 98195Lisa Meserole, N.D.
Bastyr College of Naturopathic Medicine, Seattle, WA 98103Jeff Rahlmann, D.C.
7522 20th Ave. N.E., Seattle, WA 98115To the Editor:
Dr. Campion seems to think that any system of medicine other than the one he practices is of little scientific value. All medicine, including the conventional form, originates in an anecdotal fashion or serendipitously and withstands the test of time, only later to be proved scientific by so-called scientists. It is up to science to explain phenomena, even if they are rare, and not vice versa. It takes as much proof to disprove something as it takes to prove something. How much truly scientific proof do we have that enables us to call others unscientific and silly?
I know two physicians who were cured of migraine by acupuncture administered by a physician in the United States. . . . I had rheumatoid arthritis, diagnosed by synovectomy for carpal tunnel syndrome, palliated by high-dose ibuprofen for 10 years. One year of herbal medicine cured it, and this was a side effect, because I took the herbal medicine for biopsy-diagnosed lichen planus of 12 years' duration, which also improved markedly. I did meditate on lymphocytes during treatment. My herbal physician has cured a case of ulcerative colitis for which total colectomy was advised by practitioners of conventional medicine in the United States. The value of homeopathy for vitiligo and hemorrhoids is well known in India.
Subramaniam Santosh, M.D.
Lourdes Hospital and Regional Cancer Center, Binghamton, NY 13905To the Editor:
. . . Patients may have various reasons for choosing alternative therapies. Patients with a serious disease who depend on physicians for their care often feel devalued and weakened, not only by the illness but by the relationship -- as many physicians have found when they become patients. In this position, patients are likely to resist total acquiescence in medical control. Engaging alternatives may represent one method of gaining power. The patient-doctor relationship will always be asymmetric, but a shared power relationship is possible.1 Such a relationship could foster an honest negotiation between conventional and alternative therapies.
1 ReferencesFrank A. Stackhouse, M.D.
Seattle Veterans Affairs Medical Center, Seattle, WA 98108To the Editor:
. . . A goal of “feeling better” and alleviating suffering is in tune with customer needs in the 1990s, given that many illnesses remain incurable yet treatable. When traditional medicine exhausts its means, I fail to understand the reluctance to augment a patient's comfort with chiropractic, therapeutic massage, and acupuncture. Why have we lost so much interest in using the “placebo effect” and pain-modification pathways?
Heather R. Dawson, M.D., C.C.F.P.
340-5 Fairview Mall, Willowdale, ON MJ 2Z1, CanadaTo the Editor:
The fascinating and important study by Eisenberg et al. shows that Americans are paying out of pocket almost as much for unconventional medicine as they are paying, largely through third parties, for medical hospitalization. Perhaps they do not perceive this expenditure as medical. Presumably, conventional medicine does not meet the needs they perceive. In the face of the threat of national economic collapse precipitated by conventional health care costs, there is an almost equally large amount of discretionary funds that middle- and upper-class Americans can and do choose to invest in attempts to relieve their symptoms outside the standard system of medical care. That says something about the effectiveness of our system. Perhaps we could capture some of those funds if we found out what it really is that people are apparently quite willing to pay for.
Nada L. Stotland, M.D.
University of Chicago Pritzker School of Medicine, Chicago, IL 60637To the Editor:
Part of scientific medicine's problem is the uncontrolled, unfiltered, and unqualified flow of medical information to the public. Unconventional medicines usually offer, in sharp contrast, a minimum of explanation or extremely simplistic explanations of disease causation, therapy, and prevention. A degree of health-information fatigue, perhaps analogous to compassion fatigue, may be affecting the public with respect to conventional medical information and health-risk communications. Conventional medicine has failed to educate the public about how to derive meaning from the enormous field of medical knowledge to which it is continually, even involuntarily, exposed. This stimulation to the point of fatigue may be among the reasons that the public has turned to unconventional therapies with such zeal. It may be no coincidence that explanations of how unconventional therapies achieve their effects, if offered at all, are often so rudimentary. They do not demand thought or further burden the public with health data. In its present unmoderated form, the scientific conveyance of information has acted to conventional medicine's detriment. Alternative systems, even without evidence of a medical benefit, provide a more satisfying interaction for many health care seekers because they are straightforward, often global in use and explanatory capacity, and sometimes even magical. . . .
George A. Gellert, M.D., M.P.H., M.P.A.
Arizona Department of Health Services, Phoenix, AZ 85015To the Editor:
As a member of the second-largest healing profession in the United States -- chiropractic -- I was pleased to read your article and editorial on unconventional medicine, a term that suggests a right brain-left brain dialectic: orthodox Dr. Think Right versus maverick Dr. Feel Good. However, the statistics contradict these caricatures. Eighty-four percent of those seeking alternative treatments also consulted their medical doctor. No inconsistency, no sacrilege. “Whatever gets me well,” as many patients tell me. What doubtless raised many eyebrows was the dollar figure tallied by the unconventional treatments, which nearly equaled the out-of-pocket monies paid to hospitals. All matters of efficacy aside, some might regard this a deplorable leak in the system, if not a hemorrhage. . . .
If anything is unconventional, it is the age we live in. Patients are armed with the Physicians' Desk Reference. Many know the recommended daily allowances for vitamins better than their doctors do. Patients with terminal illnesses are checking themselves out of hospitals and going home to “die with dignity.” Respected allopaths, such as Brugh Joy, Deepak Chopra, and Bernard Siegel, are giving lectures and publishing bestselling books on mental power and self-healing. Why bestselling? Because a well-read and well-educated public (here 34 percent seems a low figure) seeks the knowledge that, if not setting one absolutely free, can at least reduce trips to the family doctor or the health maintenance organization. No longer is the phenomenon right brain versus left brain. Each has penetrated the other.
An opening of minds and a broadening of perspectives threaten neither the public nor the true professional. All we risk losing, on both sides of the corpus callosum, are our prejudices.
Toby Campion, D.C.
1803 W. Sunset Blvd., Los Angeles, CA 90026Author/Editor Response
The authors reply:
To the Editor: We appreciate the comments of Ms. Korte and agree that medical doctors should ideally be more familiar with the basic theory and practice of unconventional therapies commonly used by their patients. This is a formidable challenge, however, since it requires knowledge of each technique's history, theoretical principles, and clinical application and a review of relevant controlled clinical trials. Toward this end, at least four American medical schools and several universities across the country are developing courses in this area.
Dr. Stackhouse is correct in emphasizing the importance of the patient-doctor relationship in both conventional and unconventional medical settings. It has been argued that the efficacy of unconventional therapies relies principally on patient-provider interactions. This hypothesis can and should be tested in carefully designed controlled trials. Opportunities abound for clinical and scientific discovery relating to patient-provider interactions.
Dr. Gellert's speculation that unconventional therapies are increasingly popular because they offer a minimum of explanation and do not further overwhelm the public with clinical data is intriguing. Our hope in the future is to offer the public more information based on well-designed studies to assess the efficacy, safety, cost effectiveness, and proposed mechanisms of each unconventional therapy. This strategy is shared by the National Institutes of Health Office of Alternative Medicine and researchers in Great Britain1 and the Netherlands2.
Nelson, Campion, and Friedman et al. highlight the inherent difficulties in distinguishing “unconventional” practices (alternative, complementary, holistic, and mind-body) from “conventional” medical practices. Our definition of unconventional therapies is imperfect. However, disagreement about which therapies are conventional or unconventional is likely to increase as the medical profession investigates more actively and with greater rigor the spectrum of “unconventional” practices. Currently, data from controlled trials to assess the efficacy of chiropractic3,4 or relaxation techniques5 remain highly controversial.
The labels “conventional” and “unconventional” are arbitrary and judgmental and may inhibit the collaborative inquiry and discourse necessary to distinguish useful from useless techniques.
5 ReferencesDavid Eisenberg, M.D.
Thomas Delbanco, M.D.
Beth Israel Hospital, Boston, MA 02215Ron Kessler, Ph.D.
University of Michigan, Ann Arbor, MI 481061
Charlton BG . Philosophy of medicine: alternative or scientific. J R Soc Med 1992;85:436-438
Web of Science | Medline2
Knipschild P . Searching for alternatives: loser pays. Lancet 1993;341:1135-1136
CrossRef | Web of Science | Medline3
Koes BW ,Assendelft WJJ ,van der Heijden GJMG ,Bouter LM ,Knipschild PG . Spinal manipulation and mobilisation for back and neck pain: a blinded review. BMJ 1991;303:1298-1303
CrossRef | Web of Science | Medline4
Shekelle PG ,Adams AH ,Chassin MR ,Hurwitz EL ,Brook RH . Spinal manipulation for low-back pain. Ann Intern Med 1992;117:590-598
Web of Science | Medline5
Eisenberg DM ,Delbanco TL ,Berkey CS , et al. Cognitive behavioral techniques for hypertension: are they effective? Ann Intern Med 1993;118:964-972
Web of Science | Medline
Author/Editor Response
Dr. Campion replies:
The assessment of any therapy and particularly of unconventional treatments is only hindered by uncritical zeal. Amoils, Santosh, and Roter are physicians, but they try to avoid critical assessment of unconventional treatments by claiming to apply another paradigm, which is naive at best. By contrast, Ms. Korte's candor is refreshingly clear. Friedman et al. certainly understand that wide acceptance of appealing methods such as relaxation techniques is not proof of efficacy. Indeed, a recent meta-analysis calls into question such techniques for the treatment of hypertension1. Dr. Dawson's goal is worthy, but the use of even interesting, popular placebos raises serious ethical questions2. Drs. Nelson and Rosner are from the chiropractic profession (which the survey by Eisenberg et al. listed as unconventional), but they ask that their methods be judged scientifically, which is encouraging. They must recognize, though, that many questions still remain about the effectiveness of physical manipulation, even as a treatment for back pain,3 much less for the many other ailments for which it is claimed to be effective. Moreover, randomized, controlled trials cannot provide proof of a theory of pathophysiology.
The comments of Drs. Stackhouse, Stotland, Gellert, and Campion (whose parents I share) seem particularly germane. We are in an unconventional age, surrounded by science, still enticed by magic and mystery, and desperate for control over disease. Unconventional remedies will always be with us, as will surprises in science. Patients who have a strong relationship with an effective physician will have the best chance of keeping things in perspective.
3 ReferencesEdward W. Campion, M.D.
1
Eisenberg DM ,Delbanco TL ,Berkey CS , et al. Cognitive behavioral techniques for hypertension: are they effective? Ann Intern Med 1993;118:964-972
Web of Science | Medline2
Brody H . The lie that heals: the ethics of giving placebos. Ann Intern Med 1982;97:112-118
Web of Science | Medline3
Deyo RA . Conservative therapy for low back pain: distinguishing useful from useless therapy. JAMA 1983;250:1057-1062
CrossRef | Web of Science | Medline
- Citing Articles (2)
Citing Articles
1
L. Clark Paramore. (1997) Use of alternative therapies: Estimates from the 1994 Robert Wood Johnson Foundation National Access to Care Survey. Journal of Pain and Symptom Management 13:2, 83-89
CrossRef2
David Eisenberg. (1996) Alternative medical therapies for rheumatologic disorders. Arthritis Care & Research 9:1, 1-4
CrossRef
