Fairly early on during my time at Exeter, I had felt that it would be relevant, interesting and important to familiarise general practitioners with alternative medicine. At the time, we decided that we would start to run regular courses specifically for these health care professionals. Back in the mid 1990s, this was a remarkable thing to do, so much so that we even published our experience after the first such event. Recently I came across the article that resulted from this endeavour; here is an except from the abstract:
The delegates started with a positive but questioning attitude toward complementary medicine (CM) and acknowledged that they gained useful information, leading to increased confidence in discussing CM with patients. The course to a large extent met their needs and expectations. Benefits and draw-backs of integrating CM within general practice were explored. The main advantage of CM, apart from the potential intrinsic value of the techniques themselves, was identified as the time to establish a good therapeutic relationship with the patient. The particular concerns about CM that were expressed by the doctors included poor dialogue with CM practitioners, doubts about competence, and lack of readily identifiable and recognized qualifications. The risk of holding out unrealistic hope of cure was their greatest concern, however, especially if patients were thereby denied an effective orthodox treatment.
What strikes me as particularly remarkable is the fact that, even then, so many doubts were voiced by our GPs about alternative practitioners, their therapeutic claims and their doubtful medical competence. It was then that it occured to me for the first time that these therapists might systematically misinform their patients. This suspicion was strengthened on numerous occasions in the years to come; but it was not until much later that we decided to look into this subject (which is rather difficult to research) more systematically. What we found shocked us. Here are the conclusions of some of our investigations:
The most popular websites on complementary and alternative medicine for cancer offer information of extremely variable quality. Many endorse unproven therapies and some are outright dangerous. The link to the article is here.
Some complementary and alternative medicine (CAM) providers have a negative attitude towards immunisation and means of changing this should be considered. The link is here.
Advice about herbal medicine is readily available over the Internet. The advice offered is misleading at best and dangerous at worst. Potential Internet users should be made aware of these problems and ways of minimizing the risk should be found. The link is here.
The majority of chiropractors and their associations in the English-speaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue. The link is here.
In another study, we found that advice given by alternative practitioners to diabetic patients had the potential to kill them. A similarly scary conclusion emerged when we evaluated the advice chiropractors provide to asthma patients. Other research found that anthroposophic doctors often advise against measles vaccinations and are thus causing measles outbreaks.
The totality of this evidence, I believe, begs the question: DO ALTERNATIVE PRACTITIONERS SYSTEMATICALLY MISINFORM THEIR PATIENTS? I look forward to a lively discussion of it.
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Surely a rhetorical question.
depends who you ask, perhaps.
My experience with a plethora of alternative practitioners over the last three decades has shown me very clearly the ways in which they systematically misinformed me as a client.
I am sometimes tempted to write many paragraphs answering the frequently raised question “But, what’s the harm (of CAM)?”. I have two choices: either rise above my past and put it down to a fantastic learning experience or become bitter and twisted over the fact that I was duped.
I’d much rather have lively discussion than write about my negative anecdotal evidence!
Here’s a handy guide to misinforming patients and undermining pediatricians, written by two chiropractors:
http://www.chirobase.org/20PB/top7.html
The bracketed comments offer explanatory counter-points.
Good morning Professor,
You use the terms complimentary medicine and alternative medicine interchangeably where as I would imagine they are separate approaches?
The concerns of the GP’s (in 1996) seem to be more linked to them not having an understanding of what CM is. (The fault of CM practitioners not GPs)
The concern of CM practitioners denying patients orthodox treatment should be more directed at alternative therapists as, by definition, they offer an alternative rather then something that compliments orthodox treatment. Again this maybe down to poor understanding of CM practitioner remit.
The title of your piece is about alternative practitioners where as the excerpt of the abstract is about CM? – Also I cant help thinking that the title would be more accurate as Do some alternative practitioners……..etc? Otherwise it is a rather sweeping generalisation.
Thanks in advance for entertaining my rambling.
the distinction between COMPLEMENTARY and ALTERNATIVE medicine is theoretically very clear, as you say. but in practice the two are indistinguishable. take homeopathy, for instance; it is sometimes used as AM and sometimes as CM; some homeopaths use it as both depending on the case or even in the same case/patient. this is why i have more or less given up making this distinction and use mostly AM as this is the term everyone knows. in discussions like this, the distinction is often used by practitioners as an ‘escape route’ for situations when they are cornered.
after ~20 years of discussing terminology like this ad nauseam, i have arrived at the conclusion that this will never lead anywhere.
I think it is important to continue to use the terms as they are intended. Yes there will be over lap in some disciplines although I’m not sure how homeopathy can compliment anything orthodox due to the very nature that it doesn’t appear to do anything! To blur the lines of the definitons is unhelpful to patients and could lead to further misinformation. Patients are better informed if they know whether the intervention is designed to replace existing interventions or to be used in conjunction with them.
I am genuinely unsure what you mean by practitioners using distinctions as ‘an escape route’ ?
Thanks once again.
Can you say what CAM you believe are designed to replace existing interventions and which to ‘complement’ them?
“To blur the lines of the definitons is unhelpful to patients and could lead to further misinformation. Patients are better informed if they know whether the intervention is designed to replace existing interventions or to be used in conjunction with them”
the lines are blurred and none of these interventions is “designed” to be either alt nor comp. i am all for good info for patients – but if we tell them that a distinction exists in practice THIS WOULD AMOUNT TO MISINFORMATION, I am afraid.
I don’t know enough about all the individual CAM treatments to be able to list them accuratley as either CM or AM however my guess at examples would be – CM – someone suffering from non specific low back pain may be instructed to take paracetamol as an orthodox treatment and some form of CM ie massage/osteopathy to compliment it. This seems reasonable to me?
Where as someone who is told that chiropractic is an alternative treatment for their inhaler to treat their asthma does not seem reasonable.
That’s why distinctions should be made between AM and CM.
that’s what i am trying to tell you: there is no such thing as an alternative or a complementary therapy. all of them are both at the same time.
Professor Ernst,
I’m not sure what you mean by none of these interventions are designed to be AM or CM? I am struggling to grasp your point about informing patients that there is a difference between AM an CM is misinformation? Surely it is key information that patients require to make their own choices.
patients need to know that, if they go to see a homeopath, chiropractor, naturopath, reflexologist, healer etc, they might receive their treatments both as alternative or as complementary interventions. an example might make this clearer: a diabetic patient might see a practitioner, receive several sessions of therapy and eventually become convinced by the practitioner that he does no longer need his anti-diabetic medication. thus an initially complementary treatment gradually becomes an alternative one. in case you think this is far-fetched, let me assure you that plenty of such instances have been reported.
interested reader
Surely the only distinction between them is what is claimed for them, rather than what they were ‘designed’ for? But most CAM is claimed to be complementary by some practitioners yet alternative by others. It’s not a particularly useful categorisation for any specific therapy.
Alan Henness – ok that makes it a bit clearer. I can see how difficulties could arise in making distinctions if some practitioners of a discipline claim to be CM whilst others of the same discipline claim to be AM.
The example I gave is perhaps a little too black and white. However tarring all CAM with the same brush (the one that says all CAM practitioners misinform their patients) means that patients may not go for that massage/osteopathy/exercise that compliments what the GP has prescribed. The flip side of that is the patient is protected from extreme versions of CAM.
Not sure there is an easy to implement answer here. I am sure there are some good unscrupulous CM practitioners who despite their training have decided to persue the CM route (example given). But I am sure there as many who have chosen the more AM route (definition of alternative being “mutually exclusive” ……although the definition of complimentary was “free” and we all know that’s not true!)
I meant scrupulous!
the evidence i linked to in my post suggests otherwise, i think.
Your evidence you linked to I was only able to access the abstract of.
hardly my fault, don’t you think?
Not suggesting it is.
interested reader said:
They are tarred with the same brush of lack of good evidence! Even the robust evidence for osteopathy is lacking to say the least and very difficult to tease out any specific effects of osteopathic treatment from the non-specific effects.
The unifying characteristic of all CAM is their lack of good evidence they are even a treatment, never mind whether they are complementary or alternative. That’s why many/most practitioners misinform their customers: do you think they tell their customers about the lack of good evidence and lack of a plausible mechanism of action that doesn’t contravene much of what we already know about physics/chemistry/biology?
But I do wonder if you are confusing ‘complementary’ and ‘complimentary’? As you say, CAM is rarely free.
Am I right then in thinking that the NICE guidleines for NSLBP are incorrect?
?
Quite possibly.
NICE falls for Bait and Switch by acupuncturists and chiropractors: it has let down the public and itself
NICE fiasco, part 2. Rawlins should withdraw guidance and start again
The NICE fiasco, Part 3. Too many vested interests, not enough honesty
Complementary and complimentary have two very different meanings and it is always a good idea to know the difference.
Yes my mistake on the spellings point taken. So it would seem that the article of Professors Ernsts blog could have read – NICE and CAM practitioners misinforming patients/each other. The articles you have posted are very interesting and do seem to show that not only is CAM slightly/very (in some cases)misleading/ill informed but so are the people who give out advice to patients via NICE.
There is another example of CAM being “alternative” rather than “complementary” cunningly hidden in this comment: exercise is not “complementary” to medicine – it will be recommended by any competent doctor. Proponents of CAM often use this sort of “bait and switch” approach (“exercise is good; exercise is complementary; therefore CAM is good”), tied up with the implied claim that medicine is not holistic, as a means of denigrating medicine.
very true, in my experience.
Professor Ernst,
Yes I see your point from the example you have given. Surely that is the exception to the rule? (Please tell me it is!) what you’re suggesting is that CM is fine as long as it stays CM? and AM should be avoided at all costs!!!
my example is extreme perhaps but not the exception in the sense that the investigations cited in my post shoe that MANY OR EVEN MOST practitioners behave irresponsibly.
“CM is fine as long as it stays CM?” no, it depends on the evidence not on the name you give it!
The name CM should strictly be given to therapies that can be complimentary to the orthodox treatments they are being used alongside. Therefore my point of ‘CM is fine as long as it stays CM’ is valid.
The research you have chosen to represent your argument is, in my humble opinion, all AM.
interested reader
That still leaves the most fundamental question unanswered: how do we know what therapy is complementary? We’ve already established that many practitioners deem their therapy to be either or both, so how can we differentiate?
you are like a broken record…and even spell COMPLEMENTARY consistently wrong.
Now Professor my spelling is not always the best I agree but I am not sure that it merits pointing out? Not sure what it proves? and as for sounding like a broken record your life’s work seems to be have been dedicated to proving one point only!
I came onto this blog to try and further my understanding of AM/CM/CAM whatever it is you/we/anyone wants to call. This blog promotes a very distinct opinion of certain an all I was trying to do was see what the other side of the argument was. I can see that this is perhaps not the place to do it.
Last question then I will leave you to it:
Is Physiotherapy a CAM/AM/CM ?
thank you for showing your true colours.
Sorry Professor it was meant as a ‘light hearted’ dig at your stand point and I felt your broken record jibe was best met with a response highlighting it.
Spelling point stands though as you will find there are many spelling mistakes in your own responses that I felt were unnecessary to mention.
spelling mistakes, grammatical errors etc are never an issue on this blog, particularly as english is not my first language; however, if you make a long, repetitive argument about one particular term and fail to spell it correctly, one has the right to worry whether you know what you are talking about, don’t you think?
I have never claimed to know what I am talking about and am here to learn more about CAM. I am just trying to have a debate with you and others. The blog would be pretty dull if all the responses just said “good point Professor”
The people who know what you know probably don’t need to visit your blog where as people who are uncertain of CAM and want further information ie me are likely to get more from it.
The people who really need to read this blog are CAM practitioners who are making misleading claims.
interested reader
Any thoughts yet on how you would differentiate?
Not sure I have an answer. I am still wondering what category physiotherapy comes under? CM/AM etc.
I suppose the governing bodies of CAM need to decide what it is the treatment claims are of the discipline they represent and set about testing these in a more rigorous fashion. My limited reading of these matters has mainly been through searches on the Cochrane library. What seems to happen in the systematic reviews is that most of the papers are not included in their reviews as they are extremely flawed in methodology. Therefore the conclusions tend to read there is no/little evidence to support the claims of etc etc…..
Looking at number of members for certain governing bodies and the money the members pay I can’t see why this research isn’t now carried out at the levels deemed acceptable by the SBM/EBM community.
Would be interested on your views on that and whether or not you think that there are any CAM treatments you agree with and dare I say use?!
here is a long list of AMs which, according to our evaluations, are evidence-based http://www.ncbi.nlm.nih.gov/pubmed/18318982.
is physio conventional? yes
interested reader said:
CAM regulators aren’t interested in curbing the claims of their members. If they were to start now, they’d need to go on the current robust evidence and that would stop claims on just about everything – their members (who pay their salaries) would not be well pleased.
The people who should be doing the rigorous trials (if any are needed) are those who want to make the claims. How they do it is entirely up to them, but the will never seems to be there. For some reason, they never seem that interested in backing up the claims of their therapy with solid evidence.
As it should be. Some practitioners (particularly homeopaths) like to simply add up the positive trials and add up the negative trials and declare victory if there are more positive ones. However, that’s not how it’s done, because, as you rightly mention, many CAM trials are extremely poor quality – laughably so in many cases.
Indeed. the money is there, but not the willingess.
Hi Alan , sorry I respectfully disagree, the people who need to read this blog are the patients who are attracted to CAM – so they can get the information they need to give Informed consent. sure as hell they won’t get it from practitioners.
By the way, my interpretation of Interested reader is that he is indulging in a form of tolling known as jac-ing off (just asking questions) you are extremely patient with him
Duh! Jaq-ing off ! Not jac…also my comment was meant to come in earlier….
actually, i am writing this blog for anyone who is interested in alt med. i would hope patients might benefit as much as practitioners.
the INTERESTED READER is rather amusing: he/she wants to debate but admits having no idea about the subject. this reminds me of endless debates with alt med proponents about the value of randomised trials…only to find out an hour later that they did not know what randomisation was nor what purpose it serves.
you can educate practitioners with this blog but you can also save the lives of patients ( and their bank balance) There’s no sense for me in defining who benefits most – I just think it’s a terrific place
the point of jaq trolls is they pretend ignorance to derail a thread and get an angry response. I would suspect IR is a CAM practitioner and from the undertones of anger very likely a regular commentator 🙂
Sue – I think you maybe reading a little too much into my questions and subsequent comments. I’m not sure where you got the notion from that there is anger in my responses? and I can assure you that I am not a CAM practitioner. I have been a patient of CAM and had good and bad experiences with the treatments I have received. I am sure that if Alan Henness wasn’t happy to answer my questions and discuss my thoughts then he would have said so your thanks to him for being patient is perhaps unnecessary. Your suspicions about me (you seem quite suspicisus) being a regular commentator are also unfounded. I have only ever commented on this post and one other.
Professor Ernst – my lack of knowledge about some of the topics discussed here should be welcomed and not exclude me from trying to learn more and therefore add more to the discussion? Until recently I had little understanding of how/why gold standard trials were so necessary but Mr Goldacre’s book put pay to that. So I am defiantly playing catch up and hope to be able to add more in the future.
Sue
Yes, very true – users of CAM should be reading Edzard’s blog to find out what CAM practitioners don’t tell them.
Of course interested reader is trolling! But I don’t reply for his/her edification…
Not sure I fulfill the definition of troll/trolling however if that’s how it’s been seen then I shall take this opportunity to thank you for your time and leave it there.
IR is all thin skinned – but not when distributing insults like “your life’s work seems to be have been dedicated to proving one point only! “
Another excellent website for CAM users is EBM-First.com – What alternative health practitioners might not tell you
your opinion is not only humble, it also is wrong
Some of the comments by “interested reader” have made me delve a little deeper into a serious question I was asked a few months ago by a young shop worker: “How can we tell if the information we read is correct?”
I’ve just looked up homeopathy in the online Encyclopaedia Britannica, which ought to be a definitive source of reference. The “Kids” area of the website states “Homeopathy is a form of medical care.” and does not go on to state that it lacks robust evidence for efficacy thereby leaving the reader with the impression that it is viable medical care. My initial reaction was shock soon followed by horror.
It is becoming increasingly difficult to delineate fact from fiction in the modern world. Fortunately, Edzard very kindly provides us with this invaluable website as a means for us to learn about and discuss the truth.
According to Ernst ‘Physio is conventional’. So the 6000 members of the Acupuncture Association of Chartered Physiotherapy use a conventional treatment method. Really? Whats conventional about acupuncture?
Bill, whatever your point is, you have failed to make it. Try again.
yes, physio is conventional, legal, regulated etc,etc
yes, physio is conventional, legal, regulated etc,etc
My understanding is that Physiotherapists use acupuncture techniques for pain relief, not as traditional Chinese medicine. There are various studies that show both TCM acupuncture and “sham” accupuncture having pain relieving effects. It’s the stuff about meridians and Qi, and the use of TCM to treat underlying illness that has no evidence base.
I seem to recall Professor Ernst telling me that a quack is a quack regardless of his/her professional background.
yes, a pysio who does something other than physiotherapy might well be a quack, if she does something illegal, she would be outside the law, etc, etc. are these concepts difficult to grasp for you bill?
“Complementary medicine” was really a rebranding exercise.* 30 years ago we had “alternative medicine”. It was rebranded as “complementary” because of the obvious issues involved in promoting ineffective treatments as alternative to medicine. The rebranding didn’t really work because practitioners carried on practising and promoting treatments in the same way, and the acronym “CAM” was too convenient. Now we have “integrative medicine”.
*cf Windscale and Sellafield.
Septickat- the point is plain to see!
Bill, I didn’t understand you comments at all.
I detest missing that which is in plain sight therefore I hope you will take the time to explain to me “the point”.
The argument you expressed above amounts to this:
1. If physio is supposedly ‘conventional’
2. And some physios use acupuncture
3. Therefore we have to say acupuncture is conventional.
The flaw is plain to see.
Pete: my point is quite simple. Professor Ernst has repeatedly pointed out that there is little evidence that acupuncture is efficacious for anything except perhaps for pain management and is essentially quackery. Physiotherapists use acupuncture routinely for a wide variety of disorders -not just pain- and also use craniosacral therapy,moxibustion and cupping etc etc and yet Professor Ernst deems them to be conventional. How so?
for heaven sakes, bill!!! how difficult is this? a physio, doctor, midwife etc who uses quackery is a quack. quackery is not drfined by your job title but by the methods you use. and you are wrong: not all physios use acupuncture and those who do use it employ it mostly for pain.
Bill: many thanks for answering my question. With great respect, I feel that you may have fallen into the same logical trap that I frequently fall into.
Forgive this silly example… Suppose I discover that many fully accredited installers of domestic appliances are also into at least one branch of pseudoscience. If I then recommend to you that it would be best to use the services an accredited installer am I therefore also promoting pseudoscience? No, I am not.
Professionals should perform their primary role with due diligence and set aside their pseudoscientific beliefs. However, it can be most disconcerting (even devastating) for a client who one day discovers that their trusted practitioner also charges for treatments which have zero or negative evidence for efficacy.
You said “Physiotherapists use acupuncture routinely…” and I have no counter-argument other than: the physiotherapists who do not also use quackery are the ones demonstrating due diligence in their primary role.
Sadly, the quacks far outnumber the experts making it very difficult for clients to choose a suitable health practitioner.
I didnt say ‘ALL’ physios use acupuncture! For heavens sake why dont you do some reseacrh yourself and check out their websites!! The profession is loaded to the brim with quackery and you have the audacity to say they are conventional. Currently physiotherapy utilises anything it can lay its hands on whether it is conventional or CAM/ALT and has no clear identity. So how can you possibly say it is CONVENTIONAL. No dammit, there is nothing clear.
…and there are 1000s of doctors who practice nonsense, yet medicine is considered mainsteam/conventional…JUST LIKE PHYSIOTHERAPY!!!
Bill
Perhaps you could try to re-write your argument in the form of a syllogism so we can see if you understand it?
Here you’ve changed the argument to:
‘Some physios use quackery, therefore physiotherapy can’t be called conventional.’
Again, the flaw is plain to see and EE has already pointed it out. Can you perhaps use acupuncture to pin all the parts of your brain together so they are working as a team?
Ernst: ‘and there are 1000’s of doctors….’
At what point, what concentration of quackery in the mix, will you say that conventional is quackery? If CAM/ALT is eradicated in it’s entirety and replaced by ‘conventional’ utilising quackery will that be acceptable. I would hope not. But currently under the umbrella of ‘conventional’ quackery is prescribed, even in the NHS, and seems immune from the scrutiny of the likes of skeptikat and the nightingale crew. Physical therapy in all it’s forms requires re-modelling using an eclectic approach to incorporate the best of all disciplines and the eradication of bullshit whether it be from physios, chiropractors, osteopaths, physiatrists etc etc. Currently physiotherapy is simply evolving and incorporating into it’s scope anything and everything, including CAM, and under this aegis acquiring a credibility which CAM/ALT has failed miserably to achieve. I am simply asking why this is acceptable.
i fear that you have still not grasped my point. i and the “nightingale crew” do protest against quackery regardless under which umbrella it occurs – ask, for instance, the conventional doctors in the ROYAL LONDON HOSPITAL FOR INTEGRATED MEDICINE [or whatever name they are currently using] or read some of my previous posts here, or ask profs lewith, witt etc. if you are correct, and physiotherapy [or any other health care profession] adopts quackery, this would not be acceptable to me or anyone else who is able to think critically.
It’s really very simple: therapies should be judged according to whether there is evidence they work, not who practises them. Quackery is quackery, no matter who is practising it or what qualifications they have; a therapy that works will not cease to work in the hands of a practitioner who also practises quackery.
Pete: thank you for your polie response.
I agree, the quacks outnumber the experts…but in the world of MSK therapy I believe the physiotherapists outnumber the quacks.
Pete: my apologies, that should have read ‘polite’.
Not only chiropractors in the English-speaking world: here’s an interview with one who’s set up practice in Spain and very characteristic answers we have, too: these answers and definitions can be found in all the Spanish-speaking practices, too.
http://www.mumabroad.com/catalunya/Russell_Dean_Chiropractor-10681