Monday, February 4, 2008

What's the point of rigorous research on complementary/alternative medicine?

Towards understanding the need for evidence based medicine

This oldie but goody by Edward Ernst PhD (ed) (well known CAM researcher of the Department of Complementary Medicine, School of Sport and Health Sciences, University of Exetor) is a very nice summary of the more typical excuses CAM and CAVM practitioners put forward when arguing against objectively evaluating alternative therapies. Ernst seems to be one of the few CAM researchers dedicated to a more open and honest approach to evaluating the merit of alternative therapies for effectiveness.

Though none of these eight points hold up in the face of critical consideration, three of them tend to stand out in my own experience as a veterinarian (of course, all of them are worth looking at). This is my take on them:

Argument No. 1

‘If it helps my patients, I don't need science to tell me that it works’.

This is a tired argument that belies the narrow perceptual scope from where many CAM and CAVM practitioners work. It is legitimate to ask them; how do you know it helps your patients? As noted through out this blog, it is critical to have a system where clinicians can coolly and dispassionately evaluate their practices. We need to separate personal testimonial-like assessments that are invariably replete with bias and subjective experience- a world of illusions and placebos. Though, humanity benefits from the “gentle touch”, psychological gratification needs to be fused with effective treatments- bedside manner and evidence are but two sides of the same coin. Practitioners can not afford to be fooled by the foibles of their own imaginations.

Argument No. 4

‘The clinical trial is inadequate, being based on the assumption that individuals can be put in diagnostic categories whereas CAM sees each as unique’.

This claim suggests that CAM and CAVM -because they are “holistic”- take into account all aspects of a patient’s condition and therefore are in a position to offer a unique and individualistic approach to their illness. In fact, most of these therapies are devoid of efficient problem solving techniques and tend to offer diffuse and difficult to pin down diagnosis and treatments (i.e.; changing the flow of “Qi” using needling and meridians).

On the other hand, evidence-based medicine is truly holistic taking into account a myriad of systems, subsystems, and normal versus abnormal to name just a few. This methodology truly allows for a better and continual fine tuning from populations down to a patients own particular circumstance. The uses of different types of statistical analysis are essential tools for wading through masses of information in search of meaningful relationships. To claim clinical trials are inadequate means for evaluating efficacy reveals an ignorance of an important knowledge base- one that eventually leads to a reasonable body of reliable evidence for any therapy.

Argument No. 5

‘For my therapy no credible placebo exists and blinding is impossible; clinical trials can therefore not be performed’.

The “evidence wedge”used in evidence-based medicine includes a body of different types of evidence that taken as a whole gives us a template by which many (not all) modalities can be evaluated. Though some trails may be difficult to implement researchers should strive to complete the most rigorous trials possible. It is the body of accumulated data; from plausibility to objectively observable benefits that contribute to developing a scientific consensus regarding the therapy in question.

This interesting article helps shed light on why medicine needs to be evidenced based. Any modalities from CAM and CAVM that pass muster would then become part of one medicine. Those therapies that don’t meet the test need to be set aside.*

*A more candid approach would be for some modalities to admit a belief base and act appropriately (i.e. “our therapy has no real effect but using it might distract you a little” or “we don’t cure anything, but we can help you relax”)

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