In their now famous 1998 NEJM editorial about alternative medicine, Angell and Kassirer concluded that “It is time for the scientific community to stop giving alternative medicine a free ride. There cannot be two kinds of medicine — conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted. But assertions, speculation, and testimonials do not substitute for evidence. Alternative treatments should be subjected to scientific testing no less rigorous than that required for conventional treatments.”
Then and today, I entirely agree(d) with these sentiments. Years later, the comedian Tim Minchin brought it to the point: “You know what they call alternative medicine that’s been proved to work? – Medicine.” So, comedians have solved the terminology problem, but we, the experts, have not managed to get rid of the notion that there is another type of medicine. Almost 20 years after the above editorial, we still struggle to find the ideal name.
Despite their desperate demand ‘THERE CANNOT BE TWO KINDS OF MEDICINE’, Angell and Kassirer still used the word ALTERNATIVE MEDICINE. On this blog, I usually do the same. But there are many terms, and it is only fair to ask: which one is the most suitable?
- ALTERNATIVE MEDICINE is strictly speaking an umbrella term for modalities (therapy or diagnostic technique) employed as a replacement of conventional medicine; more commonly the term is used for all heterodox modalities.
- CHARLATANERY treatment by someone who professes to have expertise that he does not have.
- COMPLEMENTATY MEDICINE is an umbrella term for modalities usually employed as an adjunct to conventional healthcare.
- COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM) an umbrella term for both 1 and 3 often used because the same alternative modality can be employed either as a replacement of or an add-on to conventional medicine.
- COMPLEMENTARY AND INTEGRATIVE MEDICINE (CIM) a nonsensical term recently created by authors of an equally nonsensical BMJ review.
- DISPROVEN MEDICINE is an umbrella term for treatments that have been shown not to work (as proving a negative is usually impossible, there are not many such therapies).
- FRINGE MEDICINE is the term formerly used for alternative medicine.
- HETERODOX MEDICINE is the linguistically correct term for unorthodox medicine (this could be the most correct term but has the disadvantage that consumers are not familiar with it).
- HOLISTIC MEDICINE is healthcare that emphasises whole patient care (as all good medicine is by definition holistic, the term seems problematic).
- INTEGRATED MEDICINE describes the use of treatments that allegedly incorporate ‘the best of both worlds’, i.e. the best of alternative and conventional healthcare (integrated medicine can be shown to be little more than a smokescreen for adopting bogus treatments in conventional medicine).
- INTEGRATIVE MEDICINE is the same as 10 (10 is more common in the UK, 11 is more common in the US).
- NATURAL MEDICINE is healthcare exclusively employing the means provided by nature for treating disease.
- QUACKERY is the deliberate misinterpretation of the ability of a treatment or diagnostic technique to treat or diagnose disease (quackery exists in all types of healthcare).
- TRADITIONAL MEDICINE is healthcare that has been in use before the scientific era (the assumption is that such treatments have stood the test of time).
- UNCONVENTIONAL MEDICINE is healthcare not normally used in conventional medicine (this would include off-label use of drugs, for instance, and therefore does not differentiate well).
- UNORTHODOX MEDICINE the linguistically incorrect but often used term for healthcare that is not normally used in orthodox medicine.
- UNPROVEN MEDICINE is healthcare that lacks scientific proof (many conventional therapies fall in this category too).
These terms and explanations (mostly my own) are meant to bring out clearly that:
- none of them is perfect,
- none has ever been clearly defined,
- none describes the area completely,
- none is without considerable overlap to other terms,
- none is really useful.
My conclusion, after pondering about these terms for many years (it can be an intensely boring issue!), is that the best solution would be to abandon all umbrella terms (see Angell and Kassirer above). Alas, that hardly seems practical when running a blog on the subject. I think therefore that I will continue to (mostly) use the term ALTERNATIVE MEDICINE (consumers understand it best, in my experience) … unless, of course, someone has a better idea.
48 Responses to The “other medicine” … how shall we call it?
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How about “medicine” and “non-medicine”?
Is this a cue for that back-faffer from Sydney to pipe up about “reforms” in his branch of non-medicine (witchcraft)to make it legitimate? They always have an erroneous “answer” because none of them can think logically and critically.
speed-dating, canoeing, binge-eating, kite-flying plus a trillion other things are also ‘non-medicine’; hardly a very good term to differentiate, don’t you think.
No, because none of those make any claim to being medicine. Either something is part of medicine or it is not, in which case, chiro is equivalent to speed-dating for all of its medicinal benefit.
See what a bind these people have put us in with their silly beliefs. Now we’re having to waste our own precious time trying to think up a name for them. Although I suspect that they’ll continue to be happy with the existing ones, logical or not. Since logical thinking doesn’t seem to be their strong suit, I think it may be just as well. Inverted commas are always useful, as n ‘alternative’ medicine, or- perhaps better, alternativev’medicine’ or even the slightly longer ‘alternative’ ‘medicine’. All of which work less well when spoken, since they require something like a nudge in the ribs or a knowing wink, or sarcastic tone of voice.
I normally use ‘altmed’, but, as with the fuller ‘alternative medicine’, it can appear neutral, and appear non-critical, as if one approves of it. Or at least doesn’t mind it.
I too favour “alternative medicine” and its contraction AltMed, though I often use the term “pseudo-medicine”, which I feel has a lot to recommend it: I was disappointed not to see it in your list.
Richard Rawlins, in his excellent book Real Secrets of Alternative Medicine, coins the word “camistry” for AltMed. This is neat and sophisticated but probably not likely to catch on with the mainstream.
I like “pseudo-medicine”. It includes the essential judgement, whereas “alternative” is too neutral.
In a recent consultation response, I critiqued some of these terms as being pejorative as well as being misleading and suggested a term that was more neutral – it was important, I felt, for the organisation to be neutral and not pre-judge the evidence for any practice.
Also, I objected to the use of the term ‘medicine’ as many practices are not medicines and ‘therapies’ as this is also not neutral and presupposes the practice has a therapeutic effect. After some discussion of these issues, I suggested the use of ‘non-conventional practices’ (NCPs) – many are set up to be in opposition to what is widely understood as ‘conventional treatments’. I referred to those who provided these practices as practitioners, again avoiding more pejorative terms.
yes, I do like this term
In my book, ‘Real Secrets of Alternative Medicine’ (Amazon), I coin the term ‘Camistry’ to cover the domain represented by all ‘Complementary and Alternative Medicine’, and the associated philosophies and practices. And that would include the full list of terms given here by Professor Ernst.
Those who practice camistry are ‘camists’.
Some camists may, additionally, be qualified and practice regulated orthodox medicine.
Those patients who receive care at the hands of camists are ‘camees’ (as in trainee, interviewee, detainee etc).
I also coin ‘Condimentary Medicine’ as that practice which provides style but no substance, a pleasant flavour and nice to have, but no effect on any specific ailment. (Harriet Hall likes this one!)
From chapter 13:
Condimentary Medicine:
Condiments add flavour and pleasure to a recipe (Latin: condire, to season). By definition, ‘Complements’ as in ‘complementary medicine’, complete and make recipes whole. Complements are not needed for modern medical recipes – which are designed to be complete as they are. Use of the term ‘condimentary’ represents a more honest representation of what CAM is doing – providing pleasure but without significant effect on pathology.
What practitioners generally do not tell you is how CAM works. Patients do benefit from supplementary, complementary and alternative medicine products and practices. But unless and until plausible evidence is adduced, their role in health and well being would be clearer if they were referred to as ‘condimentary.’
The practitioner must be distinguished from the practice, the therapist from the therapy. Patients would then be better enabled to decide whether or not to spend time, trouble, and money on them – or whether to use available funds to obtain better conventional treatments and support from orthodox practitioners and placebists (those who openly use placebos).
I know!
nice term – except the public don’t know what it means.
Then tell ’em!
I first became seriously engaged with CAM/camistry when I was commissioned by the then President of the Royal College of Surgeons, Sir Rodney Sweetnam, to brief the College on ‘Non-Conventional Therapies’ (NCTs).
‘Therapies’ covers the concept that camistry’s non specific placebo effects are often (and temporarily), therapeutic.
That term did not take fire either.
Perhaps we should any of the terms as we wish adding ‘or such term conveying the sense of Ernst’s List 2017’.
How about “Health Care Fraud”?
It can remain in that category for so long as they persist in either making healthcare claims, or failing to follow the appropriate pipelines for establishing a new treatment.
If they want to go through the pathway to properly establish the treatment as valid, they have to follow ethical guidelines related to not abuse trials, or inappropriately subjecting patients to experimental procedures. If they fail to do so, we are right beck to health fraud.
I don’t think that all we categorise as alternative medicine is fraudulent.
Well , Charlatanism is certainly fraudulent by definition.
I like the term “faith based medicine”, as a descriptor . It encompasses the shamanistic , folkloric, ritualistic, mythological and metaphysical aspects of CAM
I use two terms: ‘alternology’ and ‘quackery’, with ‘alternology’ meaning ‘unproven’ and ‘quackery’ meaning ‘disproven’ or ‘generally no better than placebo’. I prefer ‘alternology’ because it keeps the ‘alternative’ part without using ‘medicine’, which it obviously isn’t, and lacks the pejorative meaning of ‘quackery’.
For starters, how are you defining ‘medicine’?
and how do you define ‘define’?
seriously, you can look up definitions as easily as I can:
1) the science and art dealing with the maintenance of health and the prevention, alleviation, or cure of disease.
2) the art or science of restoring or preserving health or due physical condition, as by means of drugs, surgical operations or appliances, or manipulations.
3) the science dealing with the preserving of health and with preventing and treating disease or injury.
ENOUGH?
That definition seems to be a good place to start. The next step is to offer your definition of ‘health.’
I see two mentions of ‘art.’ I’m not aware of any other arts whose validity is judged solely on the basis of double-blind placebo controlled trials, are you? In fact, because medicine is an art as well as a science, perhaps the over-reliance on these types of studies explains why conventional ‘medicine’ does so much harm to human health in actual practice, according to the data.
To put it simply, you’ve articulated a definition of medicine here with three components and yet you have an entire blog criticising interventions that completely ignore your own definition of medicine. And yet the most commonly used interventions in conventional ‘medicine’ spectacularly fail to meet this definition and lack biological plausibility for doing so, to boot!
If the purpose is to criticise interventions that fail this criteria of ‘medicine,’ why not start with those interventions that have the worst benefit to harm ratios and cause most damage to human health? That’s the obvious approach if your aim is to improve public health.
“That definition seems to be a good place to start.”
WHICH ONE?
AND YOU HAVE NOT DEFINED WHAT YOU MEAN BY ‘DEFINE’.
“why not start with those interventions that have the worst benefit to harm ratios and cause most damage to human health? That’s the obvious approach if your aim is to improve public health.” It’s usually risk to benefit ratios that can be measured. Since procedures such as sticking needles into people have zero definable benefit to health, any associated risk produces an infinitely high risk:benefit ratio. That’s the raison d’être of this blog.
And, BTW, the concept of medicine as an ‘art’ is a long outmoded concept the dictionaries still haven’t caught up with: it’s been dead for decades in the wake of algorithms and protocols for patient management. You seem to be fascinated by semantic arguments for your particular brand of pseudo-medical nonsense. Why not provide some objective evidence?
“it’s been dead for decades in the wake of algorithms and protocols for patient management.”
Not really, Frank. It just seems that way, because docs skilled in the art of medicine are becoming more and more rare. They are healers, not technicians – and are in high demand with full practices and long waiting lists.
@jm
There are still rare pilots who are skilled in the ‘art’ of flying aeroplanes. Curiously, they don’t seem to be in high demand, with waiting lists of people wanting to fly with them. I wonder why?
to jm: Alternative Health Imitators are not “Healers,” but rather magicians or con artists who practice fake medicine and get paid for it.
to S. Cox
We weren’t talking about Alternative Health Imitators, we were talking about modern med practitioners. MDs and such.
Mel He mentions ‘art’ because dealing with patients is something of an art and a skill, in much the same way that dealing with children is an “art” and a skill in education. That does not make the conclusion of medicine (or the lessons taught in education) any less rooted in evidence and reason.
You have claimed that conventional medicine”does so much harm to human health”
Could you please establish what level of harm you are talking about, in what context? Or if you are talking about a comparative level of harm, what alternatives are you comparing to? and compared to what benefit for the given therapies?
You say that commonly used intervention is conventional medicine “spectacularly fail… and lack biological plausibility”. Well that could be interesting if you had actually specified anything. What, pray tell, are you actually talking about?
As for targeting the interventions with the worst benefit to harm ratio; to do so is already standard practice in honest medicine. Not every is as good as it should be, but there is a continual effort to improve. On the other hand there are also therapies that do not promote themselves honestly, that deliberately avoid efforts to weed out the dud therapies and to keep using them regardless of evidence or logic. These modalities deserve special attention, even if their harm levels don’t make them the very worst things in the world.
Kurt, dealing with patients is something of an art and skill, but so is accurate diagnosis, assessment and patient management. In other words, the practice of medicine itself is both art and science, not just patient management.
In terms of establishing a level of harm to patients, one line of evidence comes from studies that point to an alarming rate of iatrogenicity as a cause of death in patients. While I’m aware that some studies have sparked much outrage for loose definitions of ‘medical error’ and ’cause’ leading to high estimates (such as Makary and Daniel’s study concluding that medical error is the 3rd leading cause of death in the United States), a more conservative and methodlogically sound estimate comes from James 2017 who estimates that of the 2.4 million Americans who die every year, approximately 400,000 or 1/6 of those die due to medical error. Even if one wants to quibble about the inclusion criteria, saying that conventional medicine causes considerable harm is firmly backed by peer-reviewed data driven reviews.
In terms of comparative level of risk:benefit ratios, one large clinical area that serves as a good example is that of pain management. The oft cited skeptic opinion piece ‘Acupuncture is a theatrical placebo’, offers the placebo effect as an explanation as to the ‘mechanism’ for why acupuncture is so effective and comparatively more effective than medication and usual care. That acupuncture works via non-specific effects alone is a hypothesis provided by skeptics, involves ignoring the basic science literature on acupuncture and has never been proven (and yes, it is disprovable). However, it is at the end of the day an explanation for acupuncture’s frequently demonstrated clinical effects in head to head comparisons to conventional treatments such as drugs, which themselves include large placebo effects and relatively more risk than acupuncture.
A review recently published in the journal Pain demonstrated that not only does acupuncture have a moderate treatment effect over usual care (medication, exercise, surgery), but the effects persist at 12 months (MacPherson 2017) and even Edzard himself has concluded that acupuncture is exceedingly safe when practiced by adequately trained practitioners. Meanwhile, not only are opioids frequently addictive and lethal, but a recent systematic review on opioids for low back pain, one of the most common clinical areas for which they are prescribed, found that they’re not even effective at recommended doses (Shaheed 2016). Targeting inteventions with the worst benefit to harm ratio would involve targeting a long ass list of interventions at which acupuncture would be at the bottom.
“You say that commonly used intervention is conventional medicine “spectacularly fail… and lack biological plausibility”. Well that could be interesting if you had actually specified anything. What, pray tell, are you actually talking about?” The definition of medicine above centered around healing and prevention. I can provide many examples of to what I refer but one example would be the use of SSRI’s in depression. SSRI’s supposedly ‘work’ by correcting a chemical imbalance in the brain resulting in low serotonin. However, it’s never been demonstrated that depression is caused by low serotonin or even by a chemical imbalance. Or another angle would be beta-blockers for hypertension. We could perhaps say that beta-blockers successfully prevent illness and death from CVD by lowering blood pressure. But they also cause depression and impotence and are required for life. I suppose I would refer to this as symptom management (a symptom most often caused by addressable lifestyle factors) but it does not meet the above definiton of ‘medicine’ as it relates to ‘healing’ nor does it have any biological plausibility for doing so.
“As for targeting the interventions with the worst benefit to harm ratio; to do so is already standard practice in honest medicine.” Can you provide a specific example of this for say low back pain? migraines? depression? I’m sure you’re right, but an example would help.
Mel, alternative and fake health care does not monitor results and side effects like real medicine does, and one would expect that placebo treatments to have less risks other than denying some from important interventions. How many real diseases and injuries do you really treat and benefit compared to real medicine? Negligible. When patients have serious illnesses they are often willing to accept more risks as long as they know them. I certainly have not seen iatrogenic deaths as common as you suggest, but know they are more likely to occur in the ICU and ER with more critical patients. Medicine monitors risks and benefits and appropriately continues to strive for improvements, whereas Alt care does not, but rather sells magic to many who are not even physically ill but have symptoms that respond to TLC and placebo. I would agree that any treatment that has inadequate benefits or excessive risks should not be used, and that includes many patients who take NSAIDS by rx or otc, unnecessary surgical procedures and just about all Alternative fake health practices.
but monitors criticism and continues to strive to “explain” it away instead.
I suppose “quack rites and ritual” would not work. I do like camistry. With a bit of publicity it should not be to difficult to make the general public aware of it.
I also think there’s a problem with both ‘alternative’ and ‘complementary’. I will publish my Charity Commission response in full later, but I wrote this:
I also highlight in a longer section how a number of trade bodies consider their practice to be a ‘complete system of medicine’, leading to the danger of it being considered solely ‘alternative’. I think this is borne out by what many, say, homeopaths, believe.
I then go on to lay out the argument for the use of the more neutral term I mentioned above: non-conventional practices (NCPs). Of course, it’s not always necessary to go to great lengths to identify neutral language (quackery is quackery, after all), but I think it is important for regulators, etc to be seen to be neutral – that cuts both ways: they shouldn’t be calling them quackery but neither should they be calling them therapies or medicines.
Hello Edzard,
Just a little typo in your second paragraph – it is Tim Minchin not Mitchin (albeit your link goes to the right place 🙂 ).
He is the son of a surgeon (local to me) so presumably does have some medical knowledge.
thanks
I suggest using “[evidence-based] medicine” for the real thing and “pseudo-medicine” or “not evidence-based treatments and medication” for the rest. Both terms communicate clearly that anything that isn’t based on actual evidence is not medicine.
Pseudo-medicine would be used for anything that tries to pass as medicine but isn’t (e.g. homeopathy), whereas not evidence-based treatments/medication can be anything, even promising methods or drugs that are being researched but haven’t reached the evidence-based status yet.
Does this distinction make sense?
“Make-believe medicine” has been a long time favourite.
My problem is that most options suggested, include the word ‘medicine’, which is not the business alternologists are in. They seem more akin to prostitutes (F/M) catering to the wishes and not the needs of the patient/victim, telling her/him essentially what he/she wants to hear, often accompanied by some form of physical fondling in exchange for some more or less hefty financial donation.
Hence my suggestion of non-conventional practices (NCPs) – it’s an attempt to make it entirely neutral and broad.
I seem to have missed this somehow in your reaction above mine, but I do like it.
I like it too!
but the public might not understand it and think it is an umbrella term for sexual perversions etc.
WHAT ABOUT ‘CO-CALLED ALTERNATIVE MEDICINE (SCAM)?
🙂
I’m sure that would go down well with the so-called BBC.
I have two main thoughts about that.
1. Many of these practices, could be considered sex-related or sexual perversions in and of themselves.
It may be a bit off-topic, but although I agree that the public might think it is such an umbrella terms, I am sick and tired of such thoughts. I think that reducing almost everything to either ‘terrorism’ or ‘sex’ is a perversion in and of itself. There are other crimes, which remain almost completely submerged because of this. For example, who still – or has ever – talked about the damage done by those who follow/followed the “spare the rod, spoil the child” claim of the Good Book?
2. Perhaps even more off-topic, where does it stop? This tendency to sue people who are in their 70s and 80s for deeds done decades ago, is beyond ridiculous in my opinion. In my own case, the damage done by my parents will never be repaired, but I am not about to sue them for things that happened half a century ago. I have more interesting things to do, even if it is only paying the rent. Mentality was different at the time, and however wrong we may now (or even then) consider it to be, it would change nothing. It all makes me think of the imaginary beneficial effects of the death penalty, which has long been shown to have just about as much effect as homœopathy.
While we should acknowledge and never forget the mistakes/misdeeds of the past, and while ‘to forgive’ is – I think – the wrong thing to do, revenge is not going to help anyone but the most primitive minds, and is never going to be enough, due to the unsatisfactory nature of revenge because one harm can hardly be undone by inflicting another.
I really like that term, but I fear that – due to the (un)fortunate acronym, it is just about as pejorative as ‘quackery’, and as you have pointed out to me several times, not all alternologists have a nefarious agenda and are often merely misinformed or don’t care, so I think it would be unfair to officially talk about the field this way, even though it is certainly a convenient and fun term not to be ignored during discussions.
I think I prefer the term ‘alternology’ in that case, because it still contains the ‘alternative’ bit without gracing it with the ‘medicine’ bit, which it obviously isn’t, and is therefore more neutral, even though there is ambiguity, since ‘alternology’ could also be understood as what you dedicated your life to: the study of such practices, rather than their actual practice.
I agree Bart. Alternatives are not trained physicians and do not practice medicine. They are not doctors but actors who may have some advanced training in mythology and pseudo health healing gimmickry. They appear to be “faith healers” and cons. The fact that non medical legislators are allowed to legitimize them for political kickbacks is unethical and wrong. Their evidence is weak and embarrassing.
I agree with finding a new word to replace ‘medicine’ in some cases, and I like the neutral term above – ‘non-conventional practices’, as a neutral term can better describe something like massage. A massage practitioner could be providing an honest service with no intention of making unsupported claims about having specific effects on any medical condition. Of course the massage might benefit someone with a medical condition, as might other enjoyable activities, individualised attention etc.
I’ve noticed the term ‘chiropractic care’ used by some chiropractors, which seems better than describing chiropractic as medicine, although not perfect. I’ve sometimes thought that perhaps if ‘Chinese medicine’ were to be renamed something like ‘Chinese care’ or ‘Chinese indulgence’ or ‘Chinese pampering’ it might better describe much of the typical daily practice, although these terms are also not perfect and might sound insulting to the patient. ‘Chinese non-conventional practices’ could be a better term.
basha said:
I think ‘care’ is still problematic in this context. It’s really no different to talking about homeopathic ‘remedies’: they don’t remedy anything, just as chiropractic care doesn’t care for anything. Equally worrying is ‘osteopathic medicine’, although that has different connotations in different countries.
Yes, the term ‘chiropractic care’ seems to be used by chiropractic ‘reformers’ who want to separate themselves from chiropractors who might claim that their practices are ‘medicine’. Of course, the goal of chiropractic reform can only ever be to make chiropractic ‘less-bad’, rather than to make chiropractic ‘good’. I think ‘chiropractic care’ is slightly less-bad than using the word ‘medicine’.
The point I wanted to make in the previous comment was that it could be helpful to avoid using the word ‘medicine’ in some cases, where the non-conventional practitioner is actually offering an honest service that would be more accurately described as ‘an enjoyable experience with individual attention’. e.g. we don’t say ‘going-to-a-nice-cafe medicine’ although going to a nice cafe might help relieve someone of their suffering due to their medical condition.
Hello Dr Ernst,
I follow your blog for some time, and really enjoy your sound conclusions.
As a non commercially involved pharmacist (since 1966), i like to think rationally, and to fight against bogus medicine (ans any other bogus, by extension).
Just one thougt I send to you, with my best wishes, inspired by actuality, feel free to use it if you like:
“Alternative medicine relates to medicine as alternative facts relate to facts”.
Unfortunately, I think, after the stome age and the iron age, we enter the liars age…
With all my sympathy.
Alain
thank you
unfortunately, there are many hints indicating that you might be only too correct.
Somewhat late, but what do you think about the term ALTERNEUTE for alternative therapeute? In my language (flemish/dutch), it sounds very good.
Well, I am Flemish/Dutch as well, and I agree that “alterneuten” sounds good in our language. In fact, my own “alternologists” was partly inspired by that. On the other hand, I find it disturbing that we are discussing naming this sorry phenomenon while uncounted numbers of people are suffering because of it.