MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

When I retired a few months ago, I began to sort out hundreds of old files and, in the course of doing so, I stumbled across my inauguration lecture given at Exeter in late 1993. Because so many people have been puzzled, bewildered or annoyed by my post, my attitude, my remit, my writings, my errors, my perceived lack of support for CM or my alleged inconsistencies, I have now decided to reproduce the most important sections of this publication here (unfortunately, the article is not available on line but I will send a PDF to anyone who asks for it). For clarity, the original text is in italics; where i needed to add something, I put it in square brackets so that there can be no misunderstandings.

… there are some common denominators [for all different types of CM]: an all encompassing theory (sometimes more a philosophy than a theory) the view of health as a balance of forces within the body and healing as the restoration of this balance, the holistic approach, and the emphasis on each individual’s own responsibility for health. It is noteworthy that the latter two characteristics are, of course, an integral part of (good) orthodox medicine.

…[CM] often lacks an adequate theoretical basis, its diagnoses are usually not in line with science, and it has failed to demonstrate clinical effectiveness convincingly. CM may thus be defined as those branches of the art and science of health care that are not in accordance with current medical thought, scientific knowledge or university teaching…

… no one doubts that today’s modern, orthodox medicine is more successful than any of its predecessors in diagnosing, treating and preventing disease. Yet the public chooses complementary medicine in vast numbers. Why? There must be many reasons, ranging from dissatisfaction with high-tech medicine to a fascination with mysticism, from grabbing ‘the last straw’ to looking for more empathy, to falling victim to the Barnum-Effect or the Health Information Fatigue Phenomenon. Whatever the reasons are (and no doubt they need to be researched in much more detail), they represent a severe criticism to the content and style of today’s medicine. Orthodoxy might be well advised to try and learn a lesson from the apparent success and obvious popularity of CM…

CM also accepts more and more its own limitations, the fact that it may also do harm and the urgent need for much more scientific proof – a remarkable change considering that the scientific method was formerly said to be nothing short of naive reductionism representing an over-simplified mechanistic philosophy, which does injustice to the complexities of the human being.

… the medical establishment is gradually becoming more open-minded and prepared to look into the matter seriously. It realises that it must abandon old prejudice and differentiate between various approaches – maybe not everything in CM is bad after all! A wry and useful classification is the schematic listing of CM in 3 categories: the frankly fraudulent, the foolishly harmless, and the possibly useful. It is clear that only rigorous research will be able to differentiate one from the other.

…why do we need controlled trials, some proponents of CM would argue, when everyday experience shows us that our treatments work? The answer is disarmingly simple: clinical experience can be totally and repeatedly misleading. Medical history abounds with examples. Blood-letting, the panacea of the middle-ages, killed probably more people than it ever helped. Yet clinicians thought to witness its benefit for centuries. Every time in the past, present and future, when a patient’s cure is solely attributed to a treatment, two important factors are neglected: the natural history of the disease, and the placebo effect. There is only one way to be sure, and that is to conduct randomised controlled trials. The notion that they are not feasible, desirable or conclusive is blatantly wrong; not to believe in controlled trials is not to care about the effectiveness of one’s doings and to adopt a quasi-religious attitude towards medicine.

I find some of the points I made back in 1993 remarkable. To be honest, I could not stop smiling when I re-read my text after almost 20 years. Rather than discussing the messages of my own lecture, I will leave the critical assessment of these points to the probably lively comment section that will follow this post. In closing, I do, however, want to briefly highlight two aspects.

1) Many CM proponents have attacked me because they feel that I am too critical and  some even assume that I am in the pockets of BIG PHARMA and got the Exeter job under false pretences. The University of Exeter should have employed an outspoken champion of CM, they argue. I think my inaugural lecture shows beyond any doubt that they always knew who they were getting and it suggests that, at least initially (before Prince Charles intervened), they wanted me because universities need scientists, not promoters.

2) Since 1993, about 10 000 articles have been published on the subject of CM (my estimate), and yet we do not seem to have advanced all that much. The title “changing attitudes” might thus have been more than a little optimistic on my part!

21 Responses to Complementary medicine [CM]: changing attitudes [?]

  • I think that the main reason for attitudes not having changed much in the last 20 years is that CAM proponents know that their customers want to feel cared for at a level their GPs can’t deliver, so it’s now Big Business. IOW, more people (especially in the current economic climate) are jumping on the bandwagon because of the financial rewards.

    Another reason for CAM’s ongoing popularity might be related to education and politics – i.e. those who train in CAM therapies attain their career status a lot faster than MDs and they normally don’t require impressive entry qualifications (if any) to study their preferred subject. Further, once qualified, regulatory requirements are tame to non-existent.

    CAM is also likely to be a particularly attractive livelihood for those who enjoy being a figure of (perceived) knowledge and authority in others’ lives.

    But there seem to be many other reasons for the popularity of CAM, many of which are discussed in this excellent essay by the late psychology academic, Barry Beyerstein:
    http://web.archive.org/web/20110723060336/http://www.crhp.net/article1.html

    Note that he ends the essay with a pertient quote from Goethe:

    “Nothing is more dangerous than active ignorance.”

    So true.

    • It’s so much easier to make one’s “customers” feel cared for when not burdened by the competence to make a clinical diagnosis. Warm words are easier when not saddled with the reality of actual illness.

      I agree very much with the notion that CAM is attractive to those who are drawn to “being a figure of (perceived) knowledge and authority in others’ lives.” This is just one of the very many remarkable similarities between CAM and organized religion. In complete contrast to evidence-based medicine the single-most undesirable ability for a CAM practitioner (if he or she isn’t a complete fraud) is critical thinking.

  • I think its a matter of cost. Alternative medical proactioners can give people more time than most doctors can, at a reasonable cost. That said, this itself will strengthen the placebo effect. Perhaps the solution is to have more nurse lead clinics, or something on those lines.

    Peter, its quite insulting to equate organised religion and CM. My religion allows people to doubt, and we do not get upset if people think we are wrong. We do not get upset if people change their minds (as I did for some years) and decide are wrong. I think some CM practitioners (like some religious people) are simple fanatics, other are agressive because they no deep down that they are buiding without foundations.

    • cost???
      is alt med cheap???
      even if it were, if you pay little for something that does not work, it is still a rip-off!

      • I did a bit of Googling for prices.

        A private GP will charge £60+ (and it can be quite a lot plus) for 15 minutes. A homeopath will charge £60+ an HOUR.

        People who go to a homeopath feel reassured and looked after, and they get a pill that makes them feel better.

        So it is a cheap way of giving people placebos and making them feel better. It does work because placebos work (a real medicine may work better, of course!).

        That still leaves the danger that people will rely on homeopathy for serious sciknesses, and that homeopaths will fail to recognise early symptoms of a serious problem – I am thinking of the sort of situation where a doctor says “it looks like nothing to worry about but will do some tests/keep an eye on it to be sure”.

    • Nurse led clinics? Please please no no no!!!! God I would prefer CAM!!! Araragh!

  • I, for one, was excited by your appointment… and in so far as you sought to research CAM in a manner appropriate to the current scientific model, and to the model of clinical trials as it stands for pharmaceutical medicine, you have been thorough. However what if the current scientific paradigm is erroneous, and its error is magnified for CAM?! What then of all these clinical trials?!!

    I personally believe you could have used your tenure far more productively by interrogating the current paradigm of research for science and medicine to discover WHY it is – EXACTLY – that what we experience in the application (both in terms of efficacy and utility) of CAM does not properly correlate with what we see from all these (paradigm-defective) clinical trials that you mention. Sometimes, when common sense and experience tells you that, at least for some people – and in some instances many people – there is some (and sometimes great) individual benefit from the utilisation of certain procedures, you need to ask the question as to whether science is properly investigating what we are asking it to test!

    I definitely want to see CAM practices that are dilutionary and ACTUALLY ineffective sidelined, and certainly do not advocate wishy washy science. However if the paradigm is erroneus, all this lovely clinical research has done little to properly inform us which practices are worthy of inclusion into a system of medicine and which aren’t, who can benefit most from what and why, and how mainstream medicine/individuals can fully benefit from the adjunctive use of CAM alongside the conventional… or in place of it, in certain circumstances.

    Over the past 25 years I , in conjunction with colleagues, have developed a wholly different paradigm of medicine… and the really interesting revelation is that not only is CAM extremely effective, on a case-by-case basis, in certain circumstances and in certain individuals, when applied in accordance with clear principles about the hows, whys, whats and wherefors of its utility… BUT also pharma, applied in accordance with similar principles, has the potential to be used to a much higher level of efficacy (and that potentially includes the application of moities for which clinical trials have not currently demonstrated value). The converse is also true – there are ways of determining when CAM pracitices are most unlikely to work, or unlikely to work at a particular stage of treatment, or in combination with other applications… as there are ways of predicting when pharma is unlikley to work in a given individual (when side effects may far outweigh benefits).

    All in all therefore I conclude that the paradigm of medicine is not only erroneus for CAM but simply erroneus. And having, accordingly, spent the last five years studying different sciences that use different research methods, it is evident historically and operationally how we get to be where we are… with all this science, all this pharma research, and especially all this great potential for CAM sitting dormant. I really think it is time to get a little more sophisticated in our approach to research, so that people can start to informedly benefit from all this redundant knowledge theyve invested in in charitable donations and taxes!

    Given the historic nature of your position, I had rather hoped that you would lead the way forward with a change of THINKING… because what we really need is not more clinical trials consuming limited resources to yield yet more debatable results because the manner in which the research is conducted is simply inadequate or inappropriate for the questions we seek to answer… but a whole new mindedness.

    I appreciate that all the criticism that you attracted in your position must have been really challenging, but regrettably that is what happens when people in leadership positions keep on following a counterproductive path which people common-sensically know is wrong. It happens with politicians also. In science it really is difficult for people wholly immersed in an academic situation to stand back and see that something just does not add up, and we should encourage people to ask these big questions when things just don’t tally. However your appointment in itself created some small inroads at least, and I applaud the level of your output over the tenure… and most sincerely wish you the very best in your retirement.

    • a paradigm-shift makes sense when scientists encounter anomalies that cannot be explained by the universally accepted paradigm within which scientific progress has been made. we can very easily explain the phenomena you describe with the current paradigm. in my view, there is no need to shift anything and the talk about paradigm shift in relation to alt med is hollow, nonsensical waffle.

      • I am grateful for your response – which is both interesting and, if I may say, indicative (and really no nastiness intended).

        There are anomalies that relate both to pharmaceutical and complementary medicine that cannot be readily explained as things stand. So I would happily counter you on your assertion, but clearly there is no great value in doing so here. However even though you are adamant on the paradigm issue, I would hope that you could contemplate that there could minimally be far more insight and sophistication in the application of any medicine on an individual basis.

        I hope that we can pick up this conversation again at some point in the future, and in so doing benefit from your extensive experience in your professorship position, in your particular way of thinking about science and CAM, and your personal views on how progress may be attained (or barriers to progress thwarted).

        As I say, best wishes to you for your retirement.

        • Dr Alex Concorde BSc MBBS PhD MBA said:

          There are anomalies that relate both to pharmaceutical and complementary medicine that cannot be readily explained as things stand.

          For instance?

          • For instance, for pharmaceutical medicines, the relatively low level of efficacy relative to the fact that the products are extremely highly targetted. For instance, the relatively high level of side effects. If we are all just beautifully standardized human beings, sitting neatly under the dome of every bell-curve, this would not hold true.

            But the true problem is the extraordinarily combative nature of the way people are discussing these rather important issues. I have many conversations with people, including professors, in the USA, who have rather different opinions from the rather narrow views that are held in the UK. People in Pharma, in CAM, in Functional medicine and Naturopathic Medicine have proper grown up debates about these issues without all this ‘oh yeah?!! show me!’ attitude. Some of the things that might be possible havent be established conclusively yet AND THAT IS BECAUSE THEY HAVE NOT YET BEEN RESEARCHED (sorry about the caps, I dont have bold or italics). But they are still POSSIBLE.

            In the UK it seems to me that the field of ‘discussion’ has been led by rather closed-minded individuals, some of whom appear to have an agenda to prove themselves ‘right’ in the first place, and at every juncture thereon. NO progress happens that way. My point is that we should encourage a far more open-minded approach and not just slam doors shut making our rather tedious points and shouting from our rather too entrenched positions.

            NOTHING but nothing is more important than health and healthcare. It SHOULD be the arena in which we encourage the greatest level of innovation and least unprofessional debates, in and across all approaches and all modalities. Saying things like ‘hot air or worse’ and ‘hollow non-sensical waffle’ is really a little poor. In my view.

            I am neither pro-CAM, or pro-pharma, or anti-CAM, or anti-pharma. I am interested in seeing people get the best of what is available, absolutely without overstatements and without falsifications. And that can only come from educated grown-up discussions, including in response to assertions. Inevitably, if we cannot have a grown up debate here, I’m not going to spend my time writing here. Obviously.

            But for the record I never mentioned a paradigm *shift, which started the focus on anomalies… and again I feel that is indicative (openminded people usually don’t feel the need to lunge forward with their already-established argument, making somewhat combative comments – rather they tend to explore what it is that someone is seeking to convey with a fresh view, from a new or properly-informed perspective). I mentioned a *new *paradigm.

            Which means that I am rather more interested in what is POSSIBLE from what we already know from established SCIENCE about how the human body works (and/or what is not working well enough when there is functional or medical disability). Not from what we’ve gleaned from CLINICAL TRIALS, which are an altogether different thing, bundling all individuals into one pot in accordance with some assumed common standard, which clearly we cannot all have, not at least to the extent that it would be convenient for us to have.

            It is crucial in medicine that we have some domain to target to start the ball rolling when treating someone’s illness because that is efficient and helps secure patient safety. But if only a relatively small part of many people’s presentation will overlap with most other people in that pot – will be ‘true’ to that common standard – that doesn’t address the myriad of other things that are or maybe affected in a given illness, condition or persentation, that don’t fit the common standard. That is all. And of those OTHER dimensions/pathways/systems, Im interested to know which, if any, can be addressed via properly targetted CAM.

            And it is the fact that you were not able to establish what those targets – if any – might be, during your tenure, that I was lamenting in what I wrote above.

            Back to wishing you well in your retirement.

        • “There are anomalies that relate both to pharmaceutical and complementary medicine that cannot be readily explained as things stand.”
          OH YES???
          as long as you do not provide examples, this is just hot air…or worse.

          • Prof, wouldn’t it be more polite to ask a new contributor to the blog for examples rather than gruffly claim they are bluffing or BSing?
            Hardly makes for constructive debate and hardly scientific.

            I’m intrigued as to what the doctor claims cannot be readily explained by the current paradigm, but talk like that may discourage them from continuing the discourse.

  • Hi Prof Ernst,

    I was wondering i could if you look at the following link, it would be interesting to hear your thoughts on the topic:

    https://www.youtube.com/watch?feature=player_embedded&v=HI4zQJqtYso

    Many thanks

  • Congratulations to Dr.Concorde for her most perceptive input,a voice of real reason in a yah-booh infested blog site. Unfortunately most of the contributors seem to be nihilistic ‘activists’ who thrive on anatgonism and not on the sort of constructive debate she proposes and which might ultimately make patients lives better.

  • “why do we need controlled trials, some proponents of CM would argue, when everyday experience shows us that our treatments work? The answer is disarmingly simple: clinical experience can be totally and repeatedly misleading.”

    Clinical experience, whilst it has the ability to be misleading, should not be completely discarded though, correct?

    “Every time in the past, present and future, when a patient’s cure is solely attributed to a treatment, two important factors are neglected: the natural history of the disease, and the placebo effect.”

    This is why in a clinical setting it is important not to be guided solely by subjective things like “how do you feel?” or “the pain is less now”, is it not? Objective measures, where valid, are important tools to measure improvement.

    “There is only one way to be sure, and that is to conduct randomised controlled trials. The notion that they are not feasible, desirable or conclusive is blatantly wrong; not to believe in controlled trials is not to care about the effectiveness of one’s doings and to adopt a quasi-religious attitude towards medicine.”

    RCTs are imperfect for conditions such as back pain – where there are any number of causes of pain and any number of possible interventions to study. The difficult part here is study design. Asking the right questions and then testing the right intervention (or combination of interventions).
    I think CAM practitioners (myself, a chiropractor) need to be more active participants in asking the right questions rather than criticise anyone who devotes enough of their time to research (far less profitable) and at least have a go at applying scientific method.

    The ultimate goal should be about providing patients with the best tools at our disposal. If the tool we have is completely ineffective, then upgrade the skillset and move on.

  • @ Prof Ernst,

    Also have a read of this blog posting – could be an interesting point of discussion!

    http://rogerkerry.posterous.com/scientific-error-and-the-real-world

  • “1) Many CM proponents have attacked me because they feel that I am too critical and some even assume that I am in the pockets of BIG PHARMA”

    How do they respond when it’s suggested that they are in the pocket of Big Supplement? (a multi-billion dollar industry in itself)

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