MD, PhD, FMedSci, FSB, FRCP, FRCPEd

critical thinking

One of the most gratifying aspect of my work in Exeter was being able to offer posts to visiting researchers from across the world. Some of these co-workers, after returning to their home countries, became prominent scientists in their own right, and quite a few remained in contact and continued to collaborate with me or with members of my team. In one of these collaborative projects, we wanted to investigate adverse events attributed to traditional medical treatments in the Republic of Korea.

For this purpose, we reviewed adverse events recorded in the Republic of Korea, between 1999 and 2010, by the Food and Drug Administration, the Consumer Agency or the Association of Traditional Korean Medicine. Records of adverse events attributed to the use of traditional medical practices, including reports of medicinal accidents and consumers’ complaints, were evaluated.

Overall, 9624 records of adverse events were identified. Liver problems after the administration of herbal medicines were the most frequently reported adverse events. Only eight of the adverse events were recorded by the pharmacovigilance system run by the Food and Drug Administration. Of the 9624 events, 1389 – mostly infections, cases of pneumothorax and burns – were linked to physical therapies (n = 285) or acupuncture/moxibustion (n = 1104).

We concluded that traditional medical practices often appear to have adverse effects, yet almost all of the adverse events attributed to such practices between 1999 and 2010 were missed by the national pharmacovigilance system. The Consumer Agency and the Association of Traditional Korean Medicine should be included in the national pharmacovigilance system.

The assumption that alternative treatments are entirely harmless is widespread, not least because it is incessantly promoted via millions of web-site, thousands of books, newspaper articles, VIPs like Prince Charles etc. etc. Consumers are incessantly being told that NATURAL = SAFE. Yet, if we look closely, most alternative treatments are not natural and, as this investigation demonstrates, they are certainly not devoid of risks.

I already see the apologists preparing to comment that, compared to conventional therapies, alternative treatments are very safe. So let me pre-empt this fallacy by pointing out (yet again) that 1) in the absence of adequate surveillance systems, nobody can say how frequent adverse-effects of alternative treatments really are, and that 2) even severe adverse effects can normally be tolerated, if the treatment in question has been shown to be efficacious.

So, instead of commenting on my repeated reports about the risks of alternative medicine, I invite, in fact, I challenge my critics to answer this simple question: For how many alternative therapies is there a well-documented positive risk/benefit balance?

If one spends a lot of time, as I presently do, sorting out old files, books, journals etc., one is bound to come across plenty of weird and unusual things. I for one, am slow at making progress with this task, mainly because I often start reading the material that is in front of me. It was one of those occasions that I had begun studying a book written by one of the more fanatic proponent of alternative medicine and stumbled over the term THE PROOF OF EXPERIENCE. It made me think, and I began to realise that the notion behind these four words is quite characteristic of the field of alternative health care.

When I studied medicine, in the 1970s, we were told by our peers what to do, which treatments worked for which conditions and why. They had all the experience and we, by definition, had none. Experience seemed synonymous with proof. Nobody dared to doubt the word of ‘the boss’. We were educated, I now realise, in the age of EMINENCE-BASED MEDICINE.

All of this gradually changed when the concepts of EVIDENCE-BASED MEDICINE became appreciated and generally adopted by responsible health care professionals. If now the woman or man on top of the medical ‘pecking order’ claims something that is doubtful in view of the published evidence, it is possible (sometimes even desirable) to say so – no matter how junior the doubter happened to be. As a result, medicine has thus changed for ever: progress is no longer made funeral by funeral [of the bosses] but new evidence is much more swiftly translated into clinical practice.

Don’t get me wrong, EVIDENCE-BASED MEDICINE does not does not imply disrespect EXPERIENCE; it merely takes it for what it is. And when EVIDENCE and EXPERIENCE fail to agree with each other, we have to take a deep breath, think hard and try to do something about it. Depending on the specific situation, this might involve further study or at least an acknowledgement of a degree of uncertainty. The tension between EXPERIENCE and EVIDENCE often is the impetus for making progress. The winner in this often complex story is the patient: she will receive a therapy which, according to the best available EVIDENCE and careful consideration of the EXPERIENCE, is best for her.

NOT SO IN ALTERNATIVE MEDICINE!!! Here EXPERIENCE still trumps EVIDENCE any time, and there is no need for acknowledging uncertainty: EXPERIENCE = proof!!!

In case you think I am exaggerating, I recommend thumbing through a few books on the subject. As I already stated, I have done this quite a bit in recent months, and I can assure you that there is very little evidence in these volumes to suggest that data, research, science, etc.. matter a hoot. No critical thinking is required, as long as we have EXPERIENCE on our side!

‘THE PROOF OF EXPERIENCE’ is still a motto that seems to be everywhere in alternative medicine. In many ways, it seems to me, this motto symbolises much of what is wrong with alternative medicine and the mind-set of its proponents. Often, the EXPERIENCE is in sharp contrast to the EVIDENCE. But this little detail does not seem to irritate anyone. Apologists of alternative medicine stubbornly ignore such contradictions. In the rare case where they do comment at all, the gist of their response normally is that EXPERIENCE is much more relevant than EVIDENCE. After all, EXPERIENCE is based on hundreds of years and thousands of ‘real-life’ cases, while EVIDENCE is artificial and based on just a few patients.

As far as I can see, nobody in alternative medicine pays more than a lip service to the fact that EXPERIENCE can be [and often is] grossly misleading. Little or no acknowledgement exists of the fact that, in clinical routine, there are simply far too many factors that interfere with our memories, impressions, observations and conclusions. If a patient gets better after receiving a therapy, she might have improved for a dozen reasons which are unrelated to the treatment per se. And if a patient does not get better, she might not come back at all, and the practitioner’s memory will therefore fail register such events as therapeutic failures. Whatever EXPERIENCE is, in health care, it rarely constitutes proof!

The notion of THE PROOF OF EXPERIENCE, it thus turns out, is little more than self-serving, wishful thinking which characterises the backward attitude that seems to be so remarkably prevalent in alternative medicine. No tension between EXPERIENCE and EVIDENCE is noticeable because the EVIDENCE is being ignored; as a result, there is no progress. The looser is, of course, the patient: she will receive a treatment based on criteria which are less than reliable.

Isn’t it time to burry the fallacy of THE PROOF OF EXPERIENCE once and for all?

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