EDITORIALS
Weighing the Alternatives:
Lessons from the Paradoxes
of Alternative MedicineAnnals of Internal Medicine, 15 December 1998. 129:1068-1070.
The realization that at least 25% to 50% of adults in industrialized nations, including the United States, consult alternative medicine practitioners (1, 2) has prompted serious exploration of what makes alternative practices so attractive to patients (3). In this issue, Kaptchuk and Eisenberg (4) contribute importantly to our understanding of that attraction.
Many conventional practitioners have responded to the emergence of alternative medicine by acquiring a new understanding of practices that they had previously considered to be "on the fringe" (5). Others have incorporated "alternative" concepts and practices directly into their own daily patient care. Medical schools have opened their curricula to this previously forbidden area (6); books, journals, and courses on the topic proliferate. But despite all this casting about, the simple fact that our patients are turning to alternative medicine remains baffling and disturbing, if only because it tells us that they need something that our much-vaunted scientific health-care system currently doesn't provide. Our distress echoes the feelings of parents whose children reject their advice and values: How can it be that alternative practices, shrouded in mystery, grow and flourish, while a century and half of effort by scientific medicine to demystify disease and its treatment—our spectacular success in defining pathophysiology, standardizing tests and treatments, and purifying drugs—is seen as inadequate, even dangerous? Where did we go wrong?
Alternative medicine is not, of course, a single coherent body of theory and practice, although, as Kaptchuk and Eisenberg point out, certain features are common to almost all of its many "schools." As if the transcendent nature of many of these features were not paradoxical enough from the perspective of reductionist science, alternative medicine's "alternative" approach to several pragmatic issues—including the taking of responsibility, telling the truth, self-scrutiny, and commerce—are distinctly paradoxical from the conventional medicine point of view. At the same time, their very attractiveness to patients suggests that these alternative approaches can provide important clues to ways in which scientific medicine is seen to be falling short.
The Responsibility Paradox
Scientific medicine asserts that factors outside patients, rather than within, are largely responsible for disease. Many alternative care systems, in contrast, are characterized by their intense conviction that the root cause and, hence, the remedy for most illness lies deep within the patient, primarily in mind and spirit. Consequently, alternative therapists see themselves very much as facilitators of patient self-healing (4, 7, 8), in contrast with conventional medicine's strongly physician-centered sense of responsibility, for both therapeutic success and failure.
As long as the patient is doing well, this shift of responsibility from physician to patient under alternative care clearly gives patients a much-needed sense of control, a clear expression of the "patient-centering" that is now asserting itself in many spheres (9). Therapeutic failure under alternative care is altogether another matter, however, because like success, therapeutic failure in alternative systems also belongs primarily to the patient. It is the patient's failure to believe deeply enough or failure to eliminate negative thinking that is at fault when the disease gets worse (4). The paradox here is that alternative medicine, while sometimes empowering for patients (including many with life-threatening illness [1] The responsibility paradox teaches at least two important lessons for conventional practice. First, the autonomy needs of patients are powerful, and patient empowerment can be a crucial therapeutic tool (3, 4); patient-centering is serious medicine (9). And second, conventional medicine must never fall into the abandonment trap; that is, deciding there is nothing more that we can "do" for a patient. The most important, challenging, and rewarding care is often precisely the caring done when there is the least we can do for a patient in the usual biomedical sense.
The Truth-Telling Paradox
Conventional medicine has struggled long and hard to confront the biological, epidemiologic, and statistical realities of disease. Prowess, fortitude, and fatalism are among conventional medicine's deepest moral precepts (10). As conventional medicine has increasingly succeeded in confronting these biological and existential realities, it has slowly overcome the ancient practice of skewing the truth in a positive direction: that is, withholding information, particularly bad news, for the "benefit" of patients, in part because our patients now expect us to be open and honest with them (9).
In contrast, alternative medicine insists on taking the most optimistic possible view of clinical reality (4). Thus, alternative care teaches patients to "believe the diagnosis, but not the prognosis," to focus on the small number of patients who outlive the average prognosis rather than on those with the usual or worst outcomes; it also teaches that giving bad news has enormous potential for mental, spiritual, even physical harm—the "negative placebo" or "nocebo" effect. The flip side of these messages, implicit or explicit, is that conventional medicine's efforts at truth-telling are hope-destroying and worse.
The inescapable paradox that emerges here is that the truth about serious disease is both essential and devastating. Although it is important to give bad news, it is unforgivable to give bad news badly. At the extreme are undesirable practices like "hanging crepe," that is, deliberately skewing the truth in certain situations in a negative direction (11). Even more problematic is the practice of blurting out bad news, then walking away without providing the human connection and support patients need at such times, a practice Eric Cassell calls "dropping truth fragmentation bombs." It should never happen, but unfortunately sometimes still does. And although hiding diagnostic and prognostic truths is generally unacceptable, excessive precision about "the truth" is equally unjustified. Thus, telling patients exactly what chance they have of cure or exactly how long they have to live is not only morally reprehensible but also statistically insupportable. All prognostications have confidence intervals as well as point estimates (12), and patients have the right to know as much about the uncertainties of their situation as they do about the established facts.
The Self-Scrutiny Paradox
It is in the very nature of scientific medicine to study itself: to scrutinize, measure, assemble the evidence about what it is doing and why. True, hard surveillance really only began with the studies of Pierre Louis a mere 165 years ago (13); the methods of self-scrutiny are still relatively crude; much foot-dragging has occurred along the way; and outcome studies have been among the last to appear. But self-scrutiny there is, not just in clinical trials and practice report cards but also in national accreditation and licensing standards, specialty certification and recertification, self-assessment programs, editorial peer review, audits, studies of practice performance, quality improvement programs, and the like.
Conventional medicine has now, unfortunately, become known as much for its inefficiencies and its dangers as for its benefits (14-16). Although conventional medicine's willingness to take on "heroic" interventions undoubtedly accounts in part for its unsavory reputation, the paradox here is arguably that it has developed this reputation precisely because its self-scrutiny has become so intense and far-reaching. Alternative medicine generally takes the position that the efficacy of its therapies is intrinsically unmeasurable because therapy for every individual patient is, by definition, unique, an assumption that makes it difficult if not impossible to assemble meaningful study cohorts (17). Indeed, self-scrutiny in alternative medicine has consisted largely of anecdotal reports and testimonials, although that situation has begun to change (18). It should come as no surprise, then, that alternative medicine is widely perceived as the kinder, gentler, safer system of care.
The lesson from this paradox is that the willingness and the ability to scrutinize itself are among conventional medicine's proudest achievements. Such obscure and unlikely techniques as intention-to-treat analysis, accounting for dropouts in clinical trials, measurement of toxicities and risks, and documentation of publication bias—in short, a full and honest accounting in our diagnostic and therapeutic balance sheets—turn out to be vital instruments in this effort. Indeed, the heritage of self-scrutiny is a crucial distinguishing characteristic of scientific medicine, and we should continue to bind it to us with hoops of steel.
The Commercial Paradox
At roughly $1 trillion, the mainstream health care system is one of the largest segments of the U.S. economy. By comparison, alternative medicine is a gnat on an elephant: Patients spent a mere $13.7 billion on visits to alternative practitioners (plus dietary supplements and megavitamins) in 1993, roughly 1.5% as much as they spent on mainstream medicine (2). But those estimates do not include expenditures for herbal therapies or medical equipment, devices, books, and other materials, and spending for alternative care has undoubtedly increased substantially since those numbers were obtained. The alternative medicine enterprise may not be so small after all; a business that involves more than one third of the adult population, already consumes tens of billions of dollars, is increasingly protected by legislation, and is growing rapidly is decidedly a business to be reckoned with.
The paradox here is not, however, the amount that patients pay for alternative medicine but the spirit in which they pay it. The simple fact is that after paying for conventional care, about which they have little choice, patients are still willing to go out and pay, voluntarily and out of pocket, for alternative care; indeed, they spend more altogether for it than they do out-of-pocket for conventional care (2). (It can hardly be an accident that alternative care seems to be used more by persons with larger incomes [2].)
What are the lessons here? Are patients willing to put their money down because alternative medicine takes everyday problems, like allergies, headache, insomnia, and back pain, and less strictly biomedical problems, like palliative care (1), more seriously than conventional medicine does? Is it because alternative medicine is perceived as health promoting more than disease treating? Because alternative practitioners take more time with patients (19)? Because alternative medicine markets itself so effectively through books and the media? We badly need to understand these lessons in view of the enormous and grim economic realities facing all of health care.
How conventional medicine responds to these and related paradoxes will be an important reflection of our professional maturity. We could decide, for example, that alternative medicine, as an antirational, quasi-religious movement, is retrogressive and as such a direct threat to scientific medicine. We could then resort to strategies like those of the past in which conventional medicine, organized or otherwise, drew battle lines between itself and the alternatives. (Recall that there were no clear victors.) We could decide that alternative medicine is a passing phase (fueled by "millennium anxiety," perhaps?) and hence offers little real threat to the hard-won scientific knowledge, clinical progress, and dominant social position of scientific medicine. We could then simply live and let live.
Or we could recognize that these paradoxes reflect legitimate cries for help from our patients, dowsing rods, so to speak, that point to important gaps—not giving patients enough of our time (19) or enough information (20), for example—deeply embedded in our present system of conventional care. Changing our practices in recognition of those gaps may be painful, but, if done carefully, there is no reason to believe that such changes would compromise scientific care. The real issue for conventional medicine here is not how to manage our patients' involvement in alternative care; it is rather, in T.S. Eliot's phrase, how to learn from alternative practices in an effort to regain the knowledge we have lost in information.
Frank Davidoff, MD
Editor
Ann Intern Med. 1998;129:1068-1070. Annals of Internal Medicine is published twice monthly and copyrighted © 1998 by the American College of Physicians-American Society of Internal Medicine.
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