We read with great interest Sierpina and Philips' letter in the September issue of Academic Medicine,1 Grollman's reply in that issue,2 and Astin's article in this issue,3 all relating to the set of articles on alternative medicine that appeared in this journal in March 2001. We tend to agree with Sierpina, Philips, and Astin that several of the March 2001 articles went beyond healthy skepticism and showed a strong bias toward how to reveal the “quacks,” and that looking for the evidence supporting complementary and alternative medicine (CAM) is a failure or misconception, since “it is diametrically opposed to the development of evidence-based medical practice.”4, p. 227
On the other hand, it is true that Sierpina and Philips are biased toward CAM, and they do not hide their bias. But we tend to agree with them and Astin that there is a need for a more balanced presentation of viewpoints and evidence. When dealing with the evidence relating to CAM, one cannot ignore that in the past few years there has been an increase in quality and quantity of research in this area. The Cochrane Library lists over 5,300 reports of randomized controlled trials and over 60 systematic reviews on CAM. A Medline search using the terms “alternative medicine” or “complementary medicine” reveals over 45,000 citations. Although much of the research has failed to show effects, there is an increasing number of studies that support the use of some CAM modalities for particular indications, and Astin mentions a few. This positive evidence can not be ignored.
However, it is necessary to acknowledge that when one deals with CAM, the importance of evidence in medicine is only one part of the picture that needs to be addressed. We have to understand that the majority of those who use CAM do so because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life.5 Evidence-based medicine (EBM) does not respect these patients' autonomy to choose between reasonable options; instead it forces everyone to march in lockstep with “the evidence.” The clinician gathers information from the patient and integrates it with evidence reported in the medical literature. But the clinical course of action cannot be taken until the patient's own values and preferences and unique physiologic and other characteristics inform the decision. Too often, the physician assumes—naively or autocratically—that the patient shares the physician's values and preferences. Patients vary remarkably in their attitudes about their choices of treatments, their willingness to take risks, and their perceptions about the relative values of longevity and quality of life.6
A basic tenet of EBM is that the clinician gathers and presents the evidence, but ideally the final decision requires input from the patient. This principle was completely ignored in some of the March articles, as well as in Dr. Grollman's foreword to the set of articles and his reply to Sierpina and Philips.
Astin mentions a very important and neglected point about the value of the mind—body interactions and the value of addressing psychosocial factors in relation to CAM and medical education. This topic continues to be overlooked in clinical encounters and underemphasized in medical education. This has a direct effect on the patient—doctor relationship. That relationship is becoming a major issue that needs to be addressed when dealing with CAM. We should not forget that most patients do not disclose CAM use to their physicians. Why is that? Clearly, it's the attitude of the physician that prevents the patient from making the appropriate and needed disclosure of his or her CAM use. Adopting the closed attitude toward CAM that some of the authors in the March set of articles recommend would not improve the situation but instead would worsen it. Patients value their physicians' respect and understanding regarding treatment choices even when there are times that physicians do not agree with those choices.
Discussing the issue of CAM brings us to basic issues of the science of medicine, compassion, and the art of medicine. There has always been a need to strive for a balanced tension between the science and the art of medicine. By putting the stress only on the importance of evidence in medicine and medical education, we threaten this balance by failing to understand the limitations of the science and the power of the art.7
1. Sierpina VS, Philips B. Need for scholarly, objective inquiry into alternative therapies. Acad Med. 2001;76:863–4.
2. Grollman AP. In reply. Acad Med. 2001;76:864–5.
3. Astin JA. Complementary and alternative medicine and the need for “evidence-based” criticism. Acad Med. 2002;77:864–8.
4. Marcus DM. How should alternative medicine be taught to medical students and physicians? Acad Med. 2001;76:224–9.
5. Astin JA. Why patients use alternative medicine: results of a national study. JAMA. 1998;279:1548–53.
6. Reilly BM, Hart A, Evans AT. Part II. Evidence-based medicine: a passing fancy or the future of primary care? Dis Month. 1998 Aug; 44(8):370–99.
7. Fischer PM. Evidentiary medicine lacks humility. J Fam Pract. 1999;48:345–6.