|
|
By 1993 it was estimated that Australians were spending almost twice
as much on complementary medicines (CMs) ($621 million per year) than
their contributions to pharmaceuticals, and were spending a further
$309 million on CM practitioners each year.1 Recent government
estimates are that each year 57% of Australians and 42% of Americans
use CMs.2,3 In 1997 there were more
visits by Americans to CM practitioners (629 million) than to primary
care physicians (386 million),3 and high levels of use of CM
are reported throughout the industrialised world.3,4 Furthermore,
the international market for CM products -- worth around $20 billion
at retail level in 1996 -- is estimated to be expanding at more than 15%
per year.5
As substantial numbers of consumers choose CM, professional and
regulatory responses have emerged. The United States National
Institutes of Health has established the National Center for
Complementary and Alternative Medicine, with a current budget of
$US50 million ($78 million).6 Government
reviews,7,8 new journals, dedicated
sections in medical journals,9,10 teaching of basic CM in
medical schools,11 and increased media
coverage are all evidenced.
"Complementary", "alternative" or "unconventional" medicine are
umbrella terms that encompass health practices ranging from
relatively new modalities (eg, rebirthing and magnetotherapy) to
ancient skills of an initiated community (eg, yoga, meditation among
Buddhist monks), and traditional practices that are quite orthodox
in some cultures (eg, traditional Chinese medicine). Various
definitions of CM have been proposed, but these fall short because of
both the breadth of the term and the changing profile of activity.
Eisenberg's definition of CM as "interventions neither taught
widely in medical schools nor generally available in US hospitals" is
unsatisfactory, because CM is now taught in up to 60% of US medical
schools3,11 and is part of
conventional medical practice in Europe. CM has been referred to as
"unproven" medicine,12 but this would include a
range of conventional health practices. CM should be defined as
therapeutic practices based on theory or explanatory mechanisms of
action that do not conform with current medical thinking.13 Most
researchers in the interim have used a list of common practices to
define their meaning of CM.
Why are patients choosing CM? The report by Easthope et al in this issue
of the Journal14 suggests that
acupuncture under Medicare is used more by middle-aged and elderly
people as an alternative to other (conventional) treatments and
largely for chronic pain. One study found Australian users of CM were a
younger, healthier and optimistic group.1 Yet, use of CM is also
reported to be high among cancer sufferers (22%).15 A recent
government report on Chinese medicine found that more than 75% of
patients were being treated for recurrent complaints, often
rheumatological or neurological in nature.7
Others propose that people who use CM are more likely to hold
postmodern (opposed to scientific rationalism and supportive of
individual perspectives), "new age" values,16,17 or are dissatisfied
with the orthodox medical encounter.17 This includes a sense of
not being valued sufficiently as a person within the medical system.
But do the elderly Australians who use acupuncture under Medicare
largely hold postmodern values? Is there a greater proportion of
postmodern thinkers among sufferers of rheumatic or
musculoskeletal disorders or those afflicted with cancer? This
would hardly seem the case. The reasons for selecting CM are
inevitably more pragmatic. Too often the popularity of CM has been
dismissed as a sign of rejection of scientific authority, an
expression of new values of natural medicine, or of increased time and
personal attention given by CM practitioners. Too often these
reasons are given to eclipse the more central purpose consumers shop
around for healthcare services.
When health consumers develop uncomfortable symptoms and choose CM,
they pay for treatment mostly out of their own pockets. It is a time when
patients do not consider too actively whether their healthcare
practitioner is oozing warm fuzzies, but, rather, target what they
believe to be the most effective way to get better. If they believe from direct or indirect experience they are not getting
broad enough advice or making adequate progress with conventional
medicine, then they will try an approach that might offer other help.
This is fundamental pragmatism. CM consumers accept the possibility
of a different perspective or understanding of their illness -- in
fact welcome it -- as it opens a window of opportunity for treatment not
previously apparent.
A study of 300 Canadian patients found that patients choose specific
kinds of practitioners for particular problems, and use a mixture of
practitioners to treat specific complaints.17 The choice of type of
practitioner is multidimensional and cannot be explained solely by
disenchantment with medicine or by an "alternative ideology". This
is supported by US findings that dissatisfaction with conventional
medicine does not predict use of CM.16 Porter's historical
review of medicine states it quite simply: ". . . regular medicine has
ceased to convince the public that it is the only, or the best,
means to cure their ills" (my emphasis).19
The recent push to apply the principles of evidence-based medicine to
CM is important. For clinicians to feel comfortable in recommending a
particular CM approach an acceptable standard of evidence must be
demonstrable. However, acceptable levels of evidence for the
clinician and patient may differ. In the eyes of the consumer, trying a
herbal formula that has been used and documented in classical medical
literature for many centuries may not be such a brash step. Consumers
may be less convinced by a clinical trial of a new drug that has been
applied only to a well-defined sample group. However, to the
scientific audience, the latter represents the stronger evidence.
The medical profession has approached CM with caution, but it also has
an interest and responsibility in understanding and developing new
approaches (often sourced from ancient traditions) that can be
successfully applied to contemporary healthcare problems. Yet, CM
proposes mechanisms of action that are not currently scientifically
plausible -- this represents a distinct barrier to its adoption. It is
this alternative theoretical understanding of the pathophysiology
of disease that defines (and isolates) CMs, but also opens a window of
opportunity for successful treatment for some patients.
With such high proportions of the population using CMs, specific
actions need to be taken. Appropriate structures and mechanisms that
reflect the healthcare practices of the community need to be
identifiable in government agencies and policies that serve that
community. In Australia, no government agency reflects in its
structure the high level of use of CM. Consumers deserve support both
in terms of statutory regulation of practice where required, and
increased relevant research. Applying the principles of
evidence-based medicine will bring scientific rigour to the field of
CM. There is no conflict here -- CM has always had a clinical-outcomes
focus. The medical profession also needs to become more familiar with
CM practices. Communication rates across practitioner groups are
still too low.7,15 We need to develop less
adversarial, more collegial relationships, which can be done
through better education.
To the scientist, the evidence in support of CM may be weak, but to the
patient the instinctive search for a remedy that brings relief knows
no such intellectual boundaries. This is a search ruled by
pragmatism. The searches are relatively new because so many doors
have recently been opened by globalisation (eg, traditional Chinese
medicine) and increased public access to health information,
coupled with a sensitivity towards traditional cultural practices.
Medical practitioners, other healthcare professionals and
patients are exploring CM for good reasons.
Alan Bensoussan
Head, Research Unit for Complementary Medicine
University of
Western Sydney, Macarthur, NSW
- MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of
alternative medicine in Australia. Lancet 1996; 347:
569-573.
-
Commonwealth Department of Health and Family Services.
Government response to recommendations arising from the
Therapeutic Goods Administration Review. Canberra: Commonwealth
Government, 1997.
-
Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative
medicine use in the United States, 1990-1997: results of a follow-up
survey. JAMA 1998; 280: 1569-1575.
-
Goldbeck-Wood S, Dorozynski A, Lie LG, et al. Complementary
medicine is booming worldwide. BMJ 1996; 313: 131-133.
-
Gruenwald J. The emerging role of herbal medicine in health care in
Europe. Drug Information J 1998; 32: 151-153.
-
Jonas WB. Alternative medicine -- learning from the past,
examining the present, advancing to the future. JAMA 1998;
280: 1616-1618.
-
Bensoussan A, Myers SP. Towards a safer choice: the practice of
traditional Chinese medicine in Australia. Sydney: Faculty of
Health, University of Western Sydney, Macarthur, 1996.
-
Steering Committee for the Prince of Wales's Initiative on
Integrated Medicine. Integrated healthcare: a way forward for the
next five years? London: Foundation for Integrated Medicine, 1997.
-
Alternative medicine [section]. Med J Aust 1998; 169:
573-586.
-
Alternative medicine [theme issue]. JAMA 1998; 280(18):
1549-1640.
-
Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses involving
complementary and alternative medicine at US medical schools.
JAMA 1998; 280: 784-787.
-
Fontanarosa PB, Lundberg GD. Alternative medicine meets
science. JAMA 1998; 280: 1618-1619.
-
Eskinazi DP. Factors that shape alternative medicine.
JAMA 1998; 280: 1621-1623.
-
Easthope G, Gill GF, Beilby JJ, Tranter BK. Acupuncture in
Australian general practice: patient characteristics. Med J
Aust 1999; 170: 259-262.
-
Begbie SD, Kerestes ZL, Bell DR. Patterns of alternative medicine
use by cancer patients. Med J Aust 1996; 165: 545-548.
-
Astin JA. Why patients use alternative medicine: results of a
national study. JAMA 1998; 279: 1548-1553.
-
Siahpush M. Postmodern values, dissatisfaction with
conventional medicine and popularity of alternative therapies.
J Sociol 1998; 34: 58-70.
-
Kelner M, Wellman B. Health care and consumer choice: medical and
alternative therapies. Soc Sci Med 1997; 45: 203-212.
-
Porter R. Greatest benefit to mankind. A medical history of
humanity from antiquity to the present. London: HarperCollins,
1997; 688.
©MJA 1999
Make a
comment
|
Katharine A See, Peter S Lavercombe, Jasmine Dillon and Riesa Ginsberg. Accidental death from acute selenium poisoning Med J Aust 2006; 185 (7): 388-389. [Notable Cases]