The recent and rapidly growing popularity of complementary and alternative approaches (CAM) to patient health care in the past five years seems to have elicited just this kind of reaction.Following the publication of David Eisenberg's "shot heard round the world," a study on the utilization of alternative medicine in 1993,1 a rapid succession of papers has followed that shows a continued rising trend of public and professional interest in CAM.2-11 The trend has become so pronounced, in fact, that the Journal of the American Medical Association has gone on record as actively pursuing manuscripts describing research in this field.12 The backlash has been evident in reports from the Millbank Memorial Fund;13 a recent editorial by both the executive editor and editor-in-chief of the New England Journal of Medicine;14 and a study on therapeutic touch published in JAMA, which included among its authors an 11-year-old girl and an individual renowned for his activities opposing health fraud with an e-mail address listed as "quackwatch.com."15
The Millbank report outlines chiropractic as one of the alternative therapies under discussion and then suggests categorically that: (I) practice guidelines are not available in CAM and are unlikely to be developed any time soon; (II) persons who have contributed to the Millbank report say, off the record, that alternative practitioners threaten both electoral reprisal and lawsuits as a way to avoid evaluation; (III) practitioners of CAM should be more receptive to evaluation of their interventions by the best available methods of medical science; and (IV) the reputation of medical licensing boards for protecting professions rather than the public is now no longer deserved.13
It gets better. The September 17th issue of the NEJM is virtually a cornucopia of articles which document side-effects and complications of dietary supplements and herbal remedies, spearheaded by a lead editorial which gives the impression of setting apart alternative from mainstream practices somewhere to the left of the Rosicrucians: "What sets alternative medicine apart, in our view, is that it has not been scientifically tested and its advocates largely deny the need for such testing." Elsewhere, this paper suggests that the case reports of conventional medicine are categorically different from those of CAM because they are "well-documented ... in a defined setting." Finally, the authors stress that "with the increased interest in alternative medicine, we see a reversion to irrational approaches to medical practice," and that "it is time for the scientific community to stop giving alternative medicine a free ride."14
Free ride? For openers, let's do the math. The current annual budget of the Office of Complementary and Alternative Medicine (OCAM) is $20 million, while that of the NIH as a whole is $11 billion. The fraction of the NIH budget devoted to CAM is therefore less than two-tenths of one percent. As a former director of the OCAM suggested, obviously the government must believe in CAM research because they have provided homeopathic doses of money to work with. If this is a free ride, it is a journey on a solitary roller skate.
Well-documented? Consider that mainstream medicine at one time embraced such practices as leeches and laughing gas. Consider that just a few months ago, JAMA published the results of a study conducted by a sixth-grade girl, rewritten by her parents, co-authored by the former director of the National Council Against Health Fraud (renamed Quackwatch, Inc.), lacking any primary physician input, prone to negative bias due to emotional cues provided by the untrained experimenters and lacking any meaningful literature and statistical analyses.
An editor of Alternative Therapies in Health and Medicine points out that this paper would not have made even the first level of review in their journal.16 In an eloquent and thorough rebuttal of the study, Eric Leskowitz points out that even when standard medical practices are shown in rigorous clinical trials to be no more effective than placebos (e.g., the use of amoxicillin for treating pediatric otitis media), they do not draw the fire from medical journals to discontinue coverage from insurers17 -- while JAMA unconditionally cries out in even the abstract of its article that "the claims of TT (therapeutic touch) are groundless and that further professional use is unjustified."15
What does this all have to do with chiropractic? Simply that the future of the profession, as with any health care intervention, clearly lies with research and documentation -- and that to categorically equate mainstream medicine as scientific and alternative practices as unscientific is folly. It is easy to forget that only 15 percent of medical practices are supported by any evidence at all,18 and that only one percent has been deemed to be scientifically rigorous.19 It is simply a knee-jerk statement to suggest that the only meaningful evidence is provided by randomized clinical trials, since the latter are subject to problems of proper interpretation and generalization.
No less an authority than David Sackett has argued: "External clinical evidence can inform, but never replace individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all, and, if so, how it should be integrated into a clinical decision."20
These flawed and desperate attacks upon alternative medicine should be accepted as a call for conducting further research and not as a warning to abandon our interest in alternatives to orthodox medicine. As the editors of NEJM have pointed out, standards should not vary between alternative and conventional medicine -- which are of the same fabric.14 Whether or not alternative medicine exists at all is the subject of another argument beyond the scope of this discussion.
What needs to be taken home is the fact that future chiropractic research and practice interests in such areas as asthma, otitis media, carpal tunnel syndrome, scoliosis and heart rate variability must not be sacrificed to what appear to be the rather poorly disguised political interests of conventional medicine.
- Eisenberg DM, Kessler RC, Foster C, Norlac FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. New England Journal of Medicine 1993;328(4):246-252.
- Spiegelblatt L, Laine-Ammara G, Pless IB, Guyver A. The use of alternative medicine by children. Pediatrics 1994;94(6):811-814.
- Borkan J, Neher JO, Anson O, Smoker B. Referrals for alternative therapies. Journal of Family Practice 1994;39(6):545-550.
- Kronenberg F, Mallory B, Downey JA. Rehabilitation medicine and alternative therapies: new words, old practices. Archives of Physical Medicine and Rehabilitation 1994;75:928-929.
- Fisher P, Ward A. Complementary medicine in Europe. British Medical Journal 1994;309:107-111.
- Blumberg DL, Grant WD, Hendricks SR, Kamps CA, Dewan MJ. The physician and unconventional medicine. Alternative Therapies in Health and Medicine 1995;1(3):31-35.
- Gordon JS. Alternative medicine and the family physician. American Family Physician 1996;54(7):2205-2211.
- Chung MK. Why alternative medicine? American Family Physician 1996;54(7):2184-2187.
- The Landmark Report on Public Perceptions of Alternative Care. Sacramento, CA: Landmark Healthcare, Inc., 1998.
- Astin JA. Why patients use alternative medicine. Results of a national study. Journal of the American Medical Association 1998;279(19):1548-1553.
- Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysician clinicians. Journal of the American Medical Association 1998;280(9):788-794.
- Complementary, alternative, unconventional and integrative medicine: call for papers for the annual coordinated theme issues of the AMA journals. Journal of the American Medical Association 1997;278(23):2111-2112.
- Enhancing the Accountability of Alternative Medicine. New York, NY: Millbank Memorial Fund, 1998.
- Angell M, Kassirer JP. Editorial: alternative medicine -- the risks of untested and unregulated remedies. New England Journal of Medicine 1998;339(11):839-841.
- Rosa L, Rosa E, Sarner L, Barrett S. A close look at therapeutic touch. Journal of the American Medical Association 1998;279(13):1005-1010.
- Achterberg J. Clearing the air in the therapeutic touch controversy. Alternative Therapies in Health and Medicine 1998;4(4):100-101.
- Leskowitz E. Un-debunking therapeutic touch. Alternative Therapies in Health and Medicine 1998;4(4):101-102.
- Smith R. Where is the wisdom? The poverty of medical evidence. British Medical Journal 1991;303:798-799.
- Rachlis N, Kuschner C. Second Opinion: What's Wrong with Canada's Health Care System and How to Fix it. Toronto: Collins, 1989.
- Sackett DL. Editorial: evidence-based medicine. Spine 1998;23(10):1085-1086.
Anthony L. Rosner, PhD
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