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Special Theme: Complementary, Alternative, and Integrative Medicine: SPECIAL THEME COMMENTARIES: FIVE SPECIAL THEME COMMENTARIES

From Dr. Marcus

Marcus, Donald M., MD

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Many advocates of complementary and alternative medicine (CAM) present a caricature version of traditional medical education and practice as “reductionistic and materialistic,” and as unaware of mind—body interactions. In my article1 I provided evidence that this accusation is false, and that medical education is based on a biopsychosocial model. Astin2 acknowledges that medical educators do teach the biopyschosocial model, but he questions how effectively these teachings are integrated into medical practice. He cites studies that demonstrate shortcomings in physician—patient interactions. It is well known that some physicians fail to follow educational standards and guidelines, e.g., in prescribing antibiotics or treating hypertension. The real significance of the studies that Astin cites is that they are evidence of a commitment of medical educators to continually evaluate and improve medical education and practice.

The concerns of medical educators are in contrast to the lack of evidence supporting the claims that CAM is effective, gentle, and safe. Astin's call for “evidence-based criticism” does not seem to extend to CAM. What evidence supports the assertions that CAM practitioners provide sensitive, compassionate, and competent care? Where are the videotaped analyses of the encounters of herbalists, chiropractors, or acupuncturists with patients, and, of greater importance, analyses of the standards of care that they provide? It is important to distinguish between patient satisfaction, which may be based on personality and salesmanship, and objective measures of treatment outcomes.

In citing data that support the efficacy of herbs and other CAM modalities, neither Astin nor Sierpina and Philips3 cite the substantial number of systematic reviews and meta-analyses of recent years that point out the basic flaws in methods and interpretation of this body of literature.4,5,6 The best that can be said for most herbal therapies is that they are “promising,” but lack clear evidence of efficacy.7 Moreover, Astin and Sierpina and Philips fail to address the critical issue of the safety of herbs. As noted by Robbers and Tyler,8 “herbs are crude drugs of vegetable origin.” Their active ingredients are chemical compounds that are similar to those in prescription medications, and they are capable of causing the same adverse effects. The belief that herbal medications are safe is not based on careful clinical studies that include monitoring of hepatic, renal, and hematologic function. Despite the marked inadequacy of current procedures for reporting adverse events associated with dietary supplements,9 there are many reports of adverse effects of herbs, including herb—drug interactions. Many people who were treated with an herbal preparation to promote weight loss developed renal failure and carcinomas of the kidney and ureter10 because of the substitution of the herb A. fangchi for S. tetranda in this preparation. Years after the initial report of this problem11 the FDA is still struggling to identify herbal products that contain A. fangchi and to prevent their sale in the United States.12 As noted by Goldman13 in his review of herbal medicines, “Current knowledge about the safety and effectiveness of herbs now on the market is clearly inadequate and not likely to improve under current regulations.”

Astin asks what accounts for the skepticism about CAM and the powerful resistance to it? The answer is that after 50 years of remarkable progress in understanding the pathophysiology of disease and in developing effective treatments, it is dismaying to see people revert to the beliefs and practices of previous eras. Sierpina and Philips state their belief in “the need to be familiar with historically and culturally defined practices that have not been and probably never can be evaluated by the scientific method.” One can be familiar with these practices and appreciate their historical value without endorsing their use in the 21st century.

REFERENCES

1. Marcus DM. How should alternative medicine be taught to medical students and physicians? Acad Med. 2001;76:224–9.
2. Astin JA. Complementary and alternative medicine and the need for “evidence-based” criticism. Acad Med. 2002;77:864–8.
3. Sierpina VS, Philips B. Need for scholarly, objective inquiry into alternative therapies. Acad Med. 2002;76:863–4.
4. Ernst E. Complementary treatments for back pain—the facts. Focus on Alternative and Complementary Therapies. 1999;4:3–5.
5. Fugh-Berman A. Herb—drug interactions. Lancet. 2000;355:134–8.
6. Ernst E. Harmless herbs? A review of the recent literature. Am J Med. 1998;104:170–8.
7. Ernst E, White A, Pittler MH, Stevinson C, Huntley AL, Long L. Opinion versus evidence: creative tension or uneasy coexistence? Focus on Alternative and Complementary Therapies. 2001;5:1–2.
8. Robbers JE, Tyler VE. Tyler's Herbs of Choice. The Therapeutic Use of Phytomedicinals. New York: Haworth Press, 1999.
9. Office of Inspector General, Department of Health and Human Services. Adverse Event Reporting for Dietary Supplements. An Inadequate Safety Valve. OEI-01-00-00180. Washington, DC: 2001:1-110. 〈www.dhhs.gov/oig/oei〉. Accessed 6/6/02.
10. Nortier JL, Martinez MM, Schmeiser HH, et al. Urothelial carcinoma associated with the use of a Chinese herb (Aristolochia fangchi). N Engl J Med. 2000;342:1686–92.
11. Vanhaelen M, Vanhaelen-Fastre R, Vanherweghem J-L. Identrification of aristocholic acid in Chinese herbs. Lancet. 1994;343:174.
12. Dietary supplements: aristolochic acid. 〈http://www.cfsan.fda.gov/-dms/ds-bot.html〉. Accessed 5/12/02.
13. Goldman P. Herbal medicines today and the roots of modern pharmacology. Ann Intern Med. 2001;135:594–600.
© 2002 Association of American Medical Colleges