| |
Complementary and alternative medicine (CAM) has become
increasingly popular over the past decade. Out-of-pocket
expenditure in the United States has doubled between 1990 and 1997,
from $US14 billion to $US28 billion,1 a situation that is likely to
be mirrored in Australia, both in the general population and among
cancer patients.2,3
CAM is difficult to define. The British Medical Association (BMA) has
suggested that it encompasses treatments not taught as part of the
medical undergraduate curriculum.4 The major CAM treatments are
usually considered to be acupuncture, homoeopathy, herbal
medicine, manipulative medicine (osteopathy and chiropractic) and
nutritional medicine, although this is based on patient and
practitioner use rather than on definitive evidence.5 Further, the use
of CAM treatments varies regionally. For example, while homoeopathy
is particularly popular among general practitioners in the United
Kingdom and Holland,6,7 acupuncture seems to be
the CAM treatment of choice in Australia.8 This is not necessarily
related to evidence of efficacy, but correlates with a number of
historical and cultural factors, including, in Australia, the
enthusiasm of a small number of medically qualified acupuncturists
in the late 1970s and early 1980s, which led to the reimbursement of
acupuncture through Medicare.
|
|
In this issue of the Journal, articles by Pirotta and
colleagues,9 and by
Newell and Sanson-Fisher10
address doctors' knowledge and use of CAM in general practice and in
cancer care. Both articles highlight extensive use of CAM among both
doctors and patients. Pirotta et al found high levels of acceptance of
acupuncture, hypnosis and meditation among GPs, and that
considerable proportions of GPs had trained in, or expressed
interest in training in, these and other CAM treatments, but that they
still underestimate its use in the Australian
population.9 Newell and Sanson-Fisher
show that Australian oncologists have very variable knowledge of the
therapies that are being used by 22% of their patients,3,10 and that,
while they appear to accept and understand meditation, acupuncture
and chiropractic, they have very little knowledge of the widely
available homoeopathic approaches used for cancer in Germany, such
as Iscador. Newell and Sanson-Fisher suggest that Australian
oncologists viewed this therapy as potentially
dangerous,10 while preliminary
evidence suggests that it may be both useful and safe.11
In the UK, doctors who practise CAM are predominantly GPs, and a
similar situation seems likely in Australia. As GPs act as mediators
between the public demand for treatment and the evidence-based
provision of medical services,12 it is inevitable that
economic and social pressures in a free market system such as
Australia's will encourage the development of CAM in the general
practice environment. Further, it is GPs who manage patients with
chronic illnesses for which conventional medicine all too often
offers inadequate solutions.
Disenchantment with conventional medicine is not necessarily the
reason why patients turn to CAM.13 One suggestion is that
patients are increasingly knowledgeable about CAM and seek a more
egalitarian process within the consultation.14 It has been
confirmed that patients seek CAM because of an intuitive feeling that
it could offer them a more appropriate medical model for their
illness.15,16 Patients may
therefore not be seeking proof of efficacy of particular treatments,
but meaning and context for their illness, thus allowing them the
freedom to benefit from therapeutic consultations within their
chosen milieu.17 Why should we impose our
medical model on patients? Their use of CAM may be their process of
empowerment, which in turn allows them to contain and manage their
chronic illness. It is perhaps difficult for those of us educated
within the conventional medical system to allow our patients the
freedom to make such journeys in a truly egalitarian manner.
As physicians, we do, of course, have statutory and moral
responsibilities. We are obliged to attempt to design and conduct
studies for evaluating CAM treatments so that they can be safely
integrated into medicine, and so that patients can make informed
choices about the risks and benefits of particular treatments.
Clinical trial work within CAM presents enormous challenges. How do
we evaluate physical therapies such as acupuncture and
individualised approaches such as homoeopathy?18
CAM research, like the development of general practice research in
the 1970s, needs specific skills and teamwork. It requires proactive
policies and, as Bensoussan suggests, a collegiate
approach,13 whereby those involved in
CAM and in conventional medicine genuinely communicate with each
other to develop a research agenda. Such a process has recently been
completed in the United Kingdom with the support of the Foundation for
Integrated Medicine. A research agenda looking specifically at the
problems of priority setting, research methods, research capacity
and support, potential funding streams and the dissemination of CAM
research has been established.5 Core funding for centres of
excellence was considered an essential part of developing a specific
academic discipline for CAM. It was envisaged that, once established
with relatively small amounts of funding, such centres could compete
equally for specific project grants. Bensoussan's vision of
cooperative ventures13 could then inform all
practice, both through original research and through access to
appropriate databases and systematic reviews.
The BMA has responded very clearly to the expansion of CAM by
expressing a desire to expand both undergraduate and postgraduate
CAM education.4 Over half the medical
schools in the UK and nearly all those in the US now include some CAM
familiarisation courses in their undergraduate curricula. The BMA,
as well as Pirotta and Newell, indicate that such educational
initiatives would also be of great value at the postgraduate level.
CAM is clearly popular among patients in Australia and throughout the
Western world, but it may be a mistake to read too much into the use of any
particular therapeutic intervention. Patients may be using CAM
largely to empower themselves in the management of their chronic
illnesses. We certainly need to understand more about CAM, why
patients choose it, why doctors provide it, and what is it within CAM
that seems to be effective. On the other hand, while it may be easier to
answer these questions than to conduct large, randomised controlled
trials into complex therapeutic interventions, such research may
usefully challenge many of our preconceptions about conventional
medicine. Without adequate research funding and the establishment
of a high quality research network, as well as a critical and
evaluative approach to education and practice, it will be impossible
for us to answer these vital questions about the increased use of CAM
and its individual or combined therapeutic efficacy. CAM may have
much to teach us about the practice of medicine and the increasing
desire for patients to play an active part in the management of their
own illness.
George T Lewith
Honorary Senior Research Fellow and Honorary Consultant Physician
School of Medicine, University of Southampton, United Kingdom
- Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative
medicine use in the United States, 1990-1997. JAMA 1998; 280:
1569-1575.
-
MacLennan A, Wilson D, Taylor A. Prevalence and cost of alternative
medicine in Australia. Lancet 1996; 347: 569-573.
-
Begbie SD, Kerestes ZL, Bell DR. Patterns of alternative medicine
use by cancer patients. Med J Aust 1996; 165: 545-547.
-
Integrated healthcare. A way forward for the next five years?
Discussion document. The Foundation for Integrated Medicine on
behalf of the Steering Committee for the Prince of Wales Initiative on
Integrated Medicine, London: Foundation for Integrated Medicine,
October 1997.
-
British Medical Association. Complementary medicine: new
approaches to good practice. Oxford: Oxford University Press, 1993.
-
Lewith G, Reilly D. An examination of the effectiveness of
complementary and alternative medicine in the UK NHS, with focus on
homoeopathy. Health Matters in Prisons 1999; 6: 13-17.
-
Visser G, Peters L. Alternative medicine and general
practitioners in The Netherlands: towards acceptance and
integration. Family Practice 1990; 7: 227-232.
-
Easthope G, Gill GF, Beilby JJ, Tranter BK. Acupuncture in
Australian general practice: patient characteristics. Med J
Aust 1999; 170: 259-262.
-
Pirotta MV, Cohen MM, Kotsirilos V, Farish SJ. Complementary
therapies: have they become accepted in general practice? Med J
Aust 2000; 172: 105-109.
-
Newell S, Sanson-Fisher RW. Australian oncologists'
self-reported knowledge and attitudes regarding non-traditional
therapies used by cancer patients. Med J Aust 2000; 172:
110-113.
-
Kiene H. Klinische Studien zur Misteltherapie
karzinomatoser Erkrankungen. Eine Ubersicht.
Therapeuticon 1989; 3: 347-353.
-
Wharton R, Lewith G. Complementary medicine and the general
practitioner. BMJ 1986; 292: 1498-1500.
-
Bensoussan A. Complementary medicine -- where lies its appeal?
Med J Aust 1999; 170: 247-248.
-
Vincent C, Furnham A. Complementary medicine. A research
perspective. Chichester, UK: John Wiley & Sons Ltd, 1997.
-
Moore J, Phipps K, Marcer D, Lewith G. Why do people seek treatment
by alternative medicine? BMJ 1985; 290: 28-29.
-
Astin JA. Why patients use alternative medicine. JAMA
1998; 279: 1548-1553.
-
Mitchell A, Cormack M. The therapeutic relationship in
complementary health care. Edinburgh: Churchill Livingstone,
1998: 149-159.
-
Lewith G, Vincent C. The evaluation of the clinical effects of
acupuncture. A problem reassessed and a framework for future
research. Pain Forum 1995; 4: 29-39.
©MJA 2000
Make a
comment
Readers may print a single copy for personal use. No further
reproduction or distribution of the articles
should proceed without the permission of the publisher. For
permission, contact the
Australasian Medical Publishing Company.
Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>".
<URL: http://www.mja.com.au/>
© 2000 Medical Journal of Australia.
We appreciate
your comments.
|
