eMJA: Lewith, Complementary and alternative medicine: an educational, attitudinal and research challenge

Editorials

Complementary and alternative medicine: an educational, attitudinal and research challenge
We need to understand more about these treatments, why they are being used, and what makes them effective
MJA 2000; 172: 102-103

Complementary and alternative medicine (CAM) has become increasingly popular over the past decade. Out-of-pocket expenditure in the United States has doubled between 1990 and 1997, from $US14 billion to $US28 billion,¹ a situation that is likely to be mirrored in Australia, both in the general population and among cancer patients.^2,3\

CAM is difficult to define. The British Medical Association (BMA) has suggested that it encompasses treatments not taught as part of the medical undergraduate curriculum.⁴ The major CAM treatments are usually considered to be acupuncture, homoeopathy, herbal medicine, manipulative medicine (osteopathy and chiropractic) and nutritional medicine, although this is based on patient and practitioner use rather than on definitive evidence.⁵ Further, the use of CAM treatments varies regionally. For example, while homoeopathy is particularly popular among general practitioners in the United Kingdom and Holland,^6,7 acupuncture seems to be the CAM treatment of choice in Australia.⁸ This is not necessarily related to evidence of efficacy, but correlates with a number of historical and cultural factors, including, in Australia, the enthusiasm of a small number of medically qualified acupuncturists in the late 1970s and early 1980s, which led to the reimbursement of acupuncture through Medicare.

Patients may...not be seeking proof of efficacy of particular treatments, but meaning and context for their illness...

In this issue of the Journal, articles by Pirotta and colleagues,⁹ and by Newell and Sanson-Fisher¹⁰ address doctors' knowledge and use of CAM in general practice and in cancer care. Both articles highlight extensive use of CAM among both doctors and patients. Pirotta et al found high levels of acceptance of acupuncture, hypnosis and meditation among GPs, and that considerable proportions of GPs had trained in, or expressed interest in training in, these and other CAM treatments, but that they still underestimate its use in the Australian population.⁹ Newell and Sanson-Fisher show that Australian oncologists have very variable knowledge of the therapies that are being used by 22% of their patients,^3,10 and that, while they appear to accept and understand meditation, acupuncture and chiropractic, they have very little knowledge of the widely available homoeopathic approaches used for cancer in Germany, such as Iscador. Newell and Sanson-Fisher suggest that Australian oncologists viewed this therapy as potentially dangerous,¹⁰ while preliminary evidence suggests that it may be both useful and safe.¹¹
In the UK, doctors who practise CAM are predominantly GPs, and a similar situation seems likely in Australia. As GPs act as mediators between the public demand for treatment and the evidence-based provision of medical services,¹² it is inevitable that economic and social pressures in a free market system such as Australia's will encourage the development of CAM in the general practice environment. Further, it is GPs who manage patients with chronic illnesses for which conventional medicine all too often offers inadequate solutions.

Disenchantment with conventional medicine is not necessarily the reason why patients turn to CAM.¹³ One suggestion is that patients are increasingly knowledgeable about CAM and seek a more egalitarian process within the consultation.¹⁴ It has been confirmed that patients seek CAM because of an intuitive feeling that it could offer them a more appropriate medical model for their illness.^15,16 Patients may therefore not be seeking proof of efficacy of particular treatments, but meaning and context for their illness, thus allowing them the freedom to benefit from therapeutic consultations within their chosen milieu.¹⁷ Why should we impose our medical model on patients? Their use of CAM may be their process of empowerment, which in turn allows them to contain and manage their chronic illness. It is perhaps difficult for those of us educated within the conventional medical system to allow our patients the freedom to make such journeys in a truly egalitarian manner.

As physicians, we do, of course, have statutory and moral responsibilities. We are obliged to attempt to design and conduct studies for evaluating CAM treatments so that they can be safely integrated into medicine, and so that patients can make informed choices about the risks and benefits of particular treatments. Clinical trial work within CAM presents enormous challenges. How do we evaluate physical therapies such as acupuncture and individualised approaches such as homoeopathy?¹⁸

CAM research, like the development of general practice research in the 1970s, needs specific skills and teamwork. It requires proactive policies and, as Bensoussan suggests, a collegiate approach,¹³ whereby those involved in CAM and in conventional medicine genuinely communicate with each other to develop a research agenda. Such a process has recently been completed in the United Kingdom with the support of the Foundation for Integrated Medicine. A research agenda looking specifically at the problems of priority setting, research methods, research capacity and support, potential funding streams and the dissemination of CAM research has been established.⁵ Core funding for centres of excellence was considered an essential part of developing a specific academic discipline for CAM. It was envisaged that, once established with relatively small amounts of funding, such centres could compete equally for specific project grants. Bensoussan's vision of cooperative ventures¹³ could then inform all practice, both through original research and through access to appropriate databases and systematic reviews.

The BMA has responded very clearly to the expansion of CAM by expressing a desire to expand both undergraduate and postgraduate CAM education.⁴ Over half the medical schools in the UK and nearly all those in the US now include some CAM familiarisation courses in their undergraduate curricula. The BMA, as well as Pirotta and Newell, indicate that such educational initiatives would also be of great value at the postgraduate level.

CAM is clearly popular among patients in Australia and throughout the Western world, but it may be a mistake to read too much into the use of any particular therapeutic intervention. Patients may be using CAM largely to empower themselves in the management of their chronic illnesses. We certainly need to understand more about CAM, why patients choose it, why doctors provide it, and what is it within CAM that seems to be effective. On the other hand, while it may be easier to answer these questions than to conduct large, randomised controlled trials into complex therapeutic interventions, such research may usefully challenge many of our preconceptions about conventional medicine. Without adequate research funding and the establishment of a high quality research network, as well as a critical and evaluative approach to education and practice, it will be impossible for us to answer these vital questions about the increased use of CAM and its individual or combined therapeutic efficacy. CAM may have much to teach us about the practice of medicine and the increasing desire for patients to play an active part in the management of their own illness.
George T Lewith
Honorary Senior Research Fellow and Honorary Consultant Physician
School of Medicine, University of Southampton, United Kingdom

Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997. JAMA 1998; 280: 1569-1575.
MacLennan A, Wilson D, Taylor A. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-573.
Begbie SD, Kerestes ZL, Bell DR. Patterns of alternative medicine use by cancer patients. Med J Aust 1996; 165: 545-547.
Integrated healthcare. A way forward for the next five years? Discussion document. The Foundation for Integrated Medicine on behalf of the Steering Committee for the Prince of Wales Initiative on Integrated Medicine, London: Foundation for Integrated Medicine, October 1997.
British Medical Association. Complementary medicine: new approaches to good practice. Oxford: Oxford University Press, 1993.
Lewith G, Reilly D. An examination of the effectiveness of complementary and alternative medicine in the UK NHS, with focus on homoeopathy. Health Matters in Prisons 1999; 6: 13-17.
Visser G, Peters L. Alternative medicine and general practitioners in The Netherlands: towards acceptance and integration. Family Practice 1990; 7: 227-232.
Easthope G, Gill GF, Beilby JJ, Tranter BK. Acupuncture in Australian general practice: patient characteristics. Med J Aust 1999; 170: 259-262.
Pirotta MV, Cohen MM, Kotsirilos V, Farish SJ. Complementary therapies: have they become accepted in general practice? Med J Aust 2000; 172: 105-109.
Newell S, Sanson-Fisher RW. Australian oncologists' self-reported knowledge and attitudes regarding non-traditional therapies used by cancer patients. Med J Aust 2000; 172: 110-113.
Kiene H. Klinische Studien zur Misteltherapie karzinomatoser Erkrankungen. Eine Ubersicht. Therapeuticon 1989; 3: 347-353.
Wharton R, Lewith G. Complementary medicine and the general practitioner. BMJ 1986; 292: 1498-1500.
Bensoussan A. Complementary medicine -- where lies its appeal? Med J Aust 1999; 170: 247-248.
Vincent C, Furnham A. Complementary medicine. A research perspective. Chichester, UK: John Wiley & Sons Ltd, 1997.
Moore J, Phipps K, Marcer D, Lewith G. Why do people seek treatment by alternative medicine? BMJ 1985; 290: 28-29.
Astin JA. Why patients use alternative medicine. JAMA 1998; 279: 1548-1553.
Mitchell A, Cormack M. The therapeutic relationship in complementary health care. Edinburgh: Churchill Livingstone, 1998: 149-159.
Lewith G, Vincent C. The evaluation of the clinical effects of acupuncture. A problem reassessed and a framework for future research. Pain Forum 1995; 4: 29-39.

©MJA 2000

Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company.
Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>".
<URL: http://www.mja.com.au/> © 2000 Medical Journal of Australia

	Complementary and alternative medicine (CAM) has become increasingly popular over the past decade. Out-of-pocket expenditure in the United States has doubled between 1990 and 1997, from $US14 billion to $US28 billion,¹ a situation that is likely to be mirrored in Australia, both in the general population and among cancer patients.^2,3\ CAM is difficult to define. The British Medical Association (BMA) has suggested that it encompasses treatments not taught as part of the medical undergraduate curriculum.⁴ The major CAM treatments are usually considered to be acupuncture, homoeopathy, herbal medicine, manipulative medicine (osteopathy and chiropractic) and nutritional medicine, although this is based on patient and practitioner use rather than on definitive evidence.⁵ Further, the use of CAM treatments varies regionally. For example, while homoeopathy is particularly popular among general practitioners in the United Kingdom and Holland,^6,7 acupuncture seems to be the CAM treatment of choice in Australia.⁸ This is not necessarily related to evidence of efficacy, but correlates with a number of historical and cultural factors, including, in Australia, the enthusiasm of a small number of medically qualified acupuncturists in the late 1970s and early 1980s, which led to the reimbursement of acupuncture through Medicare.

	Patients may...not be seeking proof of efficacy of particular treatments, but meaning and context for their illness...

	In this issue of the Journal, articles by Pirotta and colleagues,⁹ and by Newell and Sanson-Fisher¹⁰ address doctors' knowledge and use of CAM in general practice and in cancer care. Both articles highlight extensive use of CAM among both doctors and patients. Pirotta et al found high levels of acceptance of acupuncture, hypnosis and meditation among GPs, and that considerable proportions of GPs had trained in, or expressed interest in training in, these and other CAM treatments, but that they still underestimate its use in the Australian population.⁹ Newell and Sanson-Fisher show that Australian oncologists have very variable knowledge of the therapies that are being used by 22% of their patients,^3,10 and that, while they appear to accept and understand meditation, acupuncture and chiropractic, they have very little knowledge of the widely available homoeopathic approaches used for cancer in Germany, such as Iscador. Newell and Sanson-Fisher suggest that Australian oncologists viewed this therapy as potentially dangerous,¹⁰ while preliminary evidence suggests that it may be both useful and safe.¹¹ In the UK, doctors who practise CAM are predominantly GPs, and a similar situation seems likely in Australia. As GPs act as mediators between the public demand for treatment and the evidence-based provision of medical services,¹² it is inevitable that economic and social pressures in a free market system such as Australia's will encourage the development of CAM in the general practice environment. Further, it is GPs who manage patients with chronic illnesses for which conventional medicine all too often offers inadequate solutions. Disenchantment with conventional medicine is not necessarily the reason why patients turn to CAM.¹³ One suggestion is that patients are increasingly knowledgeable about CAM and seek a more egalitarian process within the consultation.¹⁴ It has been confirmed that patients seek CAM because of an intuitive feeling that it could offer them a more appropriate medical model for their illness.^15,16 Patients may therefore not be seeking proof of efficacy of particular treatments, but meaning and context for their illness, thus allowing them the freedom to benefit from therapeutic consultations within their chosen milieu.¹⁷ Why should we impose our medical model on patients? Their use of CAM may be their process of empowerment, which in turn allows them to contain and manage their chronic illness. It is perhaps difficult for those of us educated within the conventional medical system to allow our patients the freedom to make such journeys in a truly egalitarian manner. As physicians, we do, of course, have statutory and moral responsibilities. We are obliged to attempt to design and conduct studies for evaluating CAM treatments so that they can be safely integrated into medicine, and so that patients can make informed choices about the risks and benefits of particular treatments. Clinical trial work within CAM presents enormous challenges. How do we evaluate physical therapies such as acupuncture and individualised approaches such as homoeopathy?¹⁸ CAM research, like the development of general practice research in the 1970s, needs specific skills and teamwork. It requires proactive policies and, as Bensoussan suggests, a collegiate approach,¹³ whereby those involved in CAM and in conventional medicine genuinely communicate with each other to develop a research agenda. Such a process has recently been completed in the United Kingdom with the support of the Foundation for Integrated Medicine. A research agenda looking specifically at the problems of priority setting, research methods, research capacity and support, potential funding streams and the dissemination of CAM research has been established.⁵ Core funding for centres of excellence was considered an essential part of developing a specific academic discipline for CAM. It was envisaged that, once established with relatively small amounts of funding, such centres could compete equally for specific project grants. Bensoussan's vision of cooperative ventures¹³ could then inform all practice, both through original research and through access to appropriate databases and systematic reviews. The BMA has responded very clearly to the expansion of CAM by expressing a desire to expand both undergraduate and postgraduate CAM education.⁴ Over half the medical schools in the UK and nearly all those in the US now include some CAM familiarisation courses in their undergraduate curricula. The BMA, as well as Pirotta and Newell, indicate that such educational initiatives would also be of great value at the postgraduate level. CAM is clearly popular among patients in Australia and throughout the Western world, but it may be a mistake to read too much into the use of any particular therapeutic intervention. Patients may be using CAM largely to empower themselves in the management of their chronic illnesses. We certainly need to understand more about CAM, why patients choose it, why doctors provide it, and what is it within CAM that seems to be effective. On the other hand, while it may be easier to answer these questions than to conduct large, randomised controlled trials into complex therapeutic interventions, such research may usefully challenge many of our preconceptions about conventional medicine. Without adequate research funding and the establishment of a high quality research network, as well as a critical and evaluative approach to education and practice, it will be impossible for us to answer these vital questions about the increased use of CAM and its individual or combined therapeutic efficacy. CAM may have much to teach us about the practice of medicine and the increasing desire for patients to play an active part in the management of their own illness. George T Lewith Honorary Senior Research Fellow and Honorary Consultant Physician School of Medicine, University of Southampton, United Kingdom Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997. JAMA 1998; 280: 1569-1575. MacLennan A, Wilson D, Taylor A. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-573. Begbie SD, Kerestes ZL, Bell DR. Patterns of alternative medicine use by cancer patients. Med J Aust 1996; 165: 545-547. Integrated healthcare. A way forward for the next five years? Discussion document. The Foundation for Integrated Medicine on behalf of the Steering Committee for the Prince of Wales Initiative on Integrated Medicine, London: Foundation for Integrated Medicine, October 1997. British Medical Association. Complementary medicine: new approaches to good practice. Oxford: Oxford University Press, 1993. Lewith G, Reilly D. An examination of the effectiveness of complementary and alternative medicine in the UK NHS, with focus on homoeopathy. Health Matters in Prisons 1999; 6: 13-17. Visser G, Peters L. Alternative medicine and general practitioners in The Netherlands: towards acceptance and integration. Family Practice 1990; 7: 227-232. Easthope G, Gill GF, Beilby JJ, Tranter BK. Acupuncture in Australian general practice: patient characteristics. Med J Aust 1999; 170: 259-262. Pirotta MV, Cohen MM, Kotsirilos V, Farish SJ. Complementary therapies: have they become accepted in general practice? Med J Aust 2000; 172: 105-109. Newell S, Sanson-Fisher RW. Australian oncologists' self-reported knowledge and attitudes regarding non-traditional therapies used by cancer patients. Med J Aust 2000; 172: 110-113. Kiene H. Klinische Studien zur Misteltherapie karzinomatoser Erkrankungen. Eine Ubersicht. Therapeuticon 1989; 3: 347-353. Wharton R, Lewith G. Complementary medicine and the general practitioner. BMJ 1986; 292: 1498-1500. Bensoussan A. Complementary medicine -- where lies its appeal? Med J Aust 1999; 170: 247-248. Vincent C, Furnham A. Complementary medicine. A research perspective. Chichester, UK: John Wiley & Sons Ltd, 1997. Moore J, Phipps K, Marcer D, Lewith G. Why do people seek treatment by alternative medicine? BMJ 1985; 290: 28-29. Astin JA. Why patients use alternative medicine. JAMA 1998; 279: 1548-1553. Mitchell A, Cormack M. The therapeutic relationship in complementary health care. Edinburgh: Churchill Livingstone, 1998: 149-159. Lewith G, Vincent C. The evaluation of the clinical effects of acupuncture. A problem reassessed and a framework for future research. Pain Forum 1995; 4: 29-39. *©MJA* 2000 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists** are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 2000 Medical Journal of Australia