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Mainstream and Alternative Medicine: Converging Paths Require Common Standards

Stuart Bondurant, MD; and Harold C. Sox, MD, Editor
[+] Article, Author, and Disclosure Information

From Georgetown University School of Medicine, Washington, DC 20057.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Customer Service, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

Current Author Addresses: Dr. Bondurant: Georgetown University Medical Center, 4000 Reservoir Road NW, Building D, Room 120, Washington, DC 20007.

Dr. Sox: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106-1572.

Ann Intern Med. 2005;142(2):149-150. doi:10.7326/0003-4819-142-2-200501180-00015
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The health care practices subsumed under the title “complementary and alternative medicine” (CAM) are now a substantial and growing part of health care. In the United States, office visits to CAM providers now outnumber visits to primary care physicians (1). The U.S. population spends more than $30 billion on CAM each year (1). Despite patient interest, CAM has existed largely outside of the world of mainstream medicine until recently, and evaluative research on CAM practices has lagged behind research on conventional medicine. Now, CAM and mainstream medicine are on converging paths as research funds become available and health systems search beyond conventional medicine for ways to attract—and help—patients.

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Posted on February 3, 2005
Linda L. Isaacs
Conflict of Interest: None Declared

As a physician with more than a casual interest in alternative medicine, I was very pleased to read the editorial "Mainstream and Alternative Medicine: Converging Paths Require Common Standards" in the January 18, 2005 issue. I thought that it was a fair, constructive and reasoned article, and I completely agree with its conclusions regarding the need for research in CAM.

It was ironic to read in the same issue the story of a physician who had a type of operation which was subsequently found when studied to be ineffective, and which probably contributed to his severe osteoarthritis of the knee. Also in the same issue was an article on the failure of a significant percentage of primary care physicians to utilize the same method of FOBT that was found to reduce colorectal cancer death rates in randomized trials, or to follow-up a positive result of FOBT with appropriate studies.

I agree with Drs. Bondurant and Sox that "the culmination of clinical research is the accumulation of a cohesive body of high-quality evidence that supports recommendations for practice." This accumulation is far from complete in mainstream medicine. I have seen practice guidelines that were based on expert opinion rather than a cohesive body of high-quality evidence. Even when the evidence is there, a substantial challenge remains - getting physicians to follow the guidelines. I would hazard that far more people have died preventable deaths from colon cancer because of sloppy screening techniques than have died from taking ephedra.

Perhaps the "extreme distrust" sometimes shown by mainstream physicians toward the CAM community might be diminished by a greater awareness of how often the mainstream community itself has failed in the past and present to live up to the high standards of evidence based medicine. Mainstream or alternative, we all have a lot of research to do in order to provide the best possible care for our patients.

Conflict of Interest:

None declared

Whether To Test, Not How
Posted on February 3, 2005
Douglas F Stalker
University of Delaware
Conflict of Interest: None Declared

In their editorial(1), Bondurant and Sox say the sensible thing about how we should get evidence when it comes to alternative therapies: viz., the same way we do with conventional therapies. However, they do not say anything, directly at least, about whether we should get evidence about alternative therapies in the first place.

Since it is impossible to test all hypotheses, we must choose which are worth testing and which are not(2). This involves considering the probability that a hypothesis is true. There is simply no scientific reason for running studies that test hypotheses with vanishingly low chances of being true. This is pointless as well as wasteful.

Bondurant and Sox note that most alternative therapies are biologically implausible, while some are biologically impossible. This means that they have a very low, if not vanishingly low, chance of being true, and so should not be tested at all. No doubt there are other, typically conventional hypotheses with higher pre-test probabilities and they ought to be tested instead.

Bondurant and Sox say that we cannot ignore alternative therapies because they are widely used. One can only wonder if they are so widely used, and pose such a public health or economic problem, that we need to deal with them by diverting research money away from other things. No end of people fritter their time and money away, sometimes to their detriment, and the medical community does not see fit to intervene--indeed, at the research level-- on their behalf. Why here? Or, perhaps, why here instead of other exposures in everyday life?

References. 1. Bondurant S, Sox HC. Mainstream and alternative medicine: converging paths require common standards. Ann Intern Med. 2005; 142: 149-150. 2. Stalker D. Evidence and alternative medicine. Mt Sinai J Med. 1995; 62: 132-43.

Conflict of Interest:

None declared

A duty to do what?
Posted on January 19, 2005
Carl E. Bartecchi
U. of Colorado School of Medicine
Conflict of Interest: None Declared

Dear Sir, The Bondurant, Sox editorial (1) in the January 18 Annals presents some real problems for science based physicians. A recent Wall Street Journal article by Petersen (2) quotes Bondurant, "Complementary and alternative medicine (CAM) use is widespread and here to stay." Yes it is widespread. And yes, it will be here to stay if, as so many of it's proponents have concluded, it includes such entities as diet, exercise, rest and relaxation, and massage. Isn't it convenient that these mainstream medicine therapies are considered among the most commonly used of the CAM therapies. The editorial goes on to state that "health professionals have a duty to their patients to bring these 2 worlds of contemporary medical practice closer together." I am seriously bothered by that directive. Are we to actively encourage the support or acceptance of what we feel are the real CAM practices - homeopathy, acupuncture, magnetic therapy, chelation therapy, aromatherapy, energy medicine,iridology,therapeutic touch,reiki,reflexology, etc. etc. all of which might easily be branded as quackery? These "real" CAM practices are the ones that we need to reflect on when we must consider the ethical implications of these unproven therapies. Carl E. Bartecchi, M.D., FACP Clinical Professor of Medicine University of Colorado School of Medicine

References 1. Bondurant, S, Sox, HC. Mainstream and Alternative Medicine: Converging Paths Require Common Standards. Ann Intern Med. 2005;142:149-150 2. Petersen, A. Fringe Therapies Need More Study, Advisers Report. The Wall Street Journal. Jan.13, 2005, D2

Conflict of Interest:

None declared

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