It is said that medicine is both an art and a science. Various individuals may emphasize one aspect over the other, noting certain insufficiencies in the training and practice of physicians. However, neither should be emphasized at the expense of the other: physicians need to maximize the efficacy of both their scientific reasoning and their interpersonal skills. Both are brought into question on the subject of Complementary and Alternative Medicine (CAM).
Both the “art” and the “science” of medicine are criticized by individuals outside the profession. Patients complain about their interactions with physicians: the brevity, the impersonality, and sometimes the questions left unanswered. Scientists complain about physicians and their lack of rigor in their methods of deduction, their extensive use of anecdotal evidence to guide practice, and perhaps with a degree of jealousy and incredulity, their confusion as to why physicians benefit from higher salaries and the reception of more respect despite their inability to adhere as strongly to the fundamental principles of science. These are all important to consider, although never to the point of excessive and unwarranted self-doubt. More damaging to the integrity of medicine, however, are not affronts from the outside, but rather, those from within.
The medical sects grouped under the broad categorization of “alternative medicine” have existed as long, if not longer, than allopathic medicine, also known as “Medicine”, “Western Medicine”, or more recently taking on the latest moniker, “evidence-based medicine.” Allopathic medicine rose to dominance over health care in America during the 20th century as a result of the discovery and allopathy’s (begrudging) acceptance of Germ Theory, the rapid growth of the hospital-medical school complex as the center of allopathic training and health care delivery, and allopathy’s assimilation of rival sects (to some degree) or destruction of rival sects through the political manifestations of licensure and medical practice laws. From the time Europeans first set foot in America to the acceptance of Germ Theory (i.e. that diseases are often caused by microscopic organisms) in the late 1800s, medical care in the United States was decentralized and dispersed across a variety of competing disciplines: practitioners of allopathy, homeopathy, osteopathy, botanical medicine, surgical medicine, and more. In other words, medicine was heterogeneous, and no one knew which was “better” or “right.” The years after the discovery of Germ Theory, however, shifted the concept of disease from having an environmental basis to having a microorganismic basis, and this scientific finding gave allopathy a distinct advantage over other medical sects. Importantly, there was a shift in the focus on disease symptomotology to disease etiology (i.e. the mechanism by which a disease develops). Allopathic physicians were now able to more effectively treat and cure diseases. With the power of important scientific findings, political clout, and good strategy (i.e. pairing up with laboratories and hospitals, and absorbing other sects to varying degrees, including surgery and osteopathic medicine), allopathic medicine became just “medicine.”
Along the way, allopathic medicine developed many important scientific tools by which to improve the practice and efficacy of medicine. Among these are the randomized controlled trial (RCT), the gold standard of clinical research, and newfound emphasis on evidence-based medicine as a primary means to guide practice (as opposed to anecdotal or experiential evidence alone as overriding or primary guides). While responsible for much of the progress medicine has made in improving the effectiveness of health care, the efficacy of mainstream American health care is more questionable. That is, we have powerful tools to treat and cure diseases, but these tools, for many reasons, are not always producing the desired outcomes of maintained or better health.
I am not yet in a position to comment extensively on these reasons, but I can identify a few. First, there is great disparity in the delivery of health care technologies and services to all Americans. Secondly, failures in either the practice of the art or science of medicine may not achieve desired outcomes. In communicating with patients, we sometimes miss important details in their histories or their observations. In determining diagnoses and treatments, we sometimes make mistakes due to poor scientific reasoning. Finally, a third reason is that some patients (and their physicians) find that conventional medicine has little more that can be offered to them: they are told that “There is nothing more we can do for you.”
During the summer of 2004, I worked in the Editorial Offices of the New England Journal of Medicine, obtaining early critical thinking lessons from the Editors, some of the most talented and experienced minds in the realm of clinical research. That same summer, I spent a few weekends with an alternative medicine practitioner, a martial arts instructor who began applying his traditional Chinese physical therapy techniques to perform qi gong treatments on patients who found themselves left with no more options available from Western medicine. True to form, I approached these experiences with both curiosity and skeptical analysis. The practitioner, an American-trained physicist by training, became curious in alternative therapies when friends began to ask whether his qi gong exercises associated with his martial arts instruction could be applied to medical problems. Over the course of several years, word-of-mouth brought dozens of patients to his doorstep. To name a few: a woman who previously had encephalitis and subsequently developed epilepsy, a baby with an untreatable fever, and a patient with Parkinson’s disease. I saw the first two, and heard about the latter.
1. The woman with epilespy had seen the practitioner a few times, and each time, she and her husband attested that she appeared to be having fewer seizures. She had been taking antiseizure medications, but she claimed that there were no noticeable reductions in symptoms until she started seeing this alternative medicine practitioner a few months later. (Did the medications have a long latency period before becoming effective? Were the medications ineffective? Did the qi gong treatments reduce the seizures, or did they have a placebo or complementary effect?)
2. The parents of the baby were very concerned: their doctor had given them medications to reduce the baby’s fever, but the baby’s temperature was not going down. After seeing the alternative medicine practitioner, the baby’s fever immediately disappeared and did not return. (What happened here? Again, was latency of the medication the issue? Or did the qi gong pracititioner have some effect in reducing the fever? I think a placebo effect is somewhat less likely here, since the baby probably would not have known what was going on.)
3. The story of the Parkinson’s disease (a disease marked by the progressive degeneration of motor function or muscle use) patient was the most remarkable, though must be approached with sufficient skepticism. A patient was brought in by her family: she was almost completely immobile and couldn’t talk. The practitioner allowed her to stay at his house for daily treatment. After a few days, she was able to move her hands. After a week, she could sit up. After a month, she was able to stand on her own and have enough coordination and strength to play catch with the practitioner.
These are anecdotes, and should not be considered sufficient evidence to advocate this method of therapy. However, there is compelling evidence to suggest a closer examination of the scientific basis for these healing and restorative effects. The practitioner actively and assertively tried to find researchers in Boston to study these forms of therapy as well as to identify a scientific basis for the phenomenon of qi. However, to this date, he has not had substantial success in recruiting the interest of researchers: even if they are interested, they aren’t willing to spend their time and money or risk their credibility in studying a topic far outside the realm of conventional medicine.
I personally have no intention of seeking to practice or incorporate complementary and alternative medicine into my practice of medicine: the current proposed applications for these very diverse therapies are not yet in fields that interest me. However, I do believe that CAM will be an important part of my practice. Why? It’s not that I would bring it to my patients; rather, my patients would bring it to me. As much as $27 billion was spent by Americans on alternative medical therapies yearly in the late 1990s, and this number has likely grown since then. There are many ways that I, as a future physician, could choose to approach the topic of CAM therapies: I could ignore them, I could discourage them, I could encourage them, or I could try and work as closely as possible with the patient to see how conventional and alternative therapies could work together.
Many patients are afraid to bring up the topic of CAM therapies with their doctors: they’re afraid of being berated and made to look stupid for choosing something that isn’t based in hard scientific fact, even if their personal experiences suggest that they are garnering benefit from CAM treatments. This is a very serious problem. CAM therapies are very heterogenous: some may be harmful if used to the exclusion of conventional allopathic medical therapies or they may even produce undesired side effects used in conjunction with those prescribed by their doctors. How, then, is it helpful if physicians turn a blind eye to alternative medical treatments or make passionately blunt claims that only an idiot would consider to use CAM therapies? Only a very bad doctor would be so callous as to fail to consider the reasons why a patient would choose CAM therapies over the advice of their doctors. By failing to consider these reasons and motivations, by failing to be willing to talk to patients openly about CAM therapies, we as physicians would only appear to be protecting our own financial interests. Science, one of the two pillars guiding medical practice, is an imperfect and constantly evolving construct. This is, in fact, the reason why science is so powerful: because unlike unflexible dogma (often connected to religion and faith-based concepts of disease), it can change. There was fierce controversy and debate during the late 1800s when Germ Theory was introduced, and many allopathic physicians refused to believe that microorganisms could cause disease. There was uncertainty then, and there is still uncertainty now about many scientific issues in medicine. For example, scientists and physicians alike do not know the mechanism through which many anesthetic drugs function: we have a rough understanding of the areas of the brain that are affected and the corresponding effects, but not enough to be considered “well-understood.” However, the use of anesthetic drugs are a standard of practice (although many surgeons once discouraged the use of ether, one of the first anesthetics, because they believed that hearing the patient’s expressions of pain was an important tool for guiding surgical protocols).
Rather than be bigoted in our approach by tenuously upholding “science” as our only guide for medical practice, physicians need to be open to the discussion of the reasons behind patient decision-making. Physicians, for so long, have long assumed that they are always right: this paternalism has both upheld the professional integrity of medicine and fractured the doctor-patient relationship. In most cases, physicians are right with respect to the science, but this doesn’t always mean that what we advocate is right for the patient. Just as physicians cannot decide whether or not a patient should live or die in the Intensive Care Unit (ICU) (i.e. a patient has the right to withold life support if he/she would die otherwise), physicians cannot decide what treatments a patient should have: only the patient can decide whether or not to accept the advice of physicians (except under extenuating circumstances, such as in emergent situations). The sooner physicians admit this to themselves, the sooner we can better communciate with patients about the decisions they make. This is especially important on the topic of CAM therapies: while some may be useful and may someday become standard practices, some may be very unhelpful or even harmful. However, physicians have no true credibility in discouraging the use of a particular CAM treatment until they are willing to acknowledge its existence, the status of research into that therapy, and the reasons why patients might choose this alternative treatment. Science cannot be used as a singular end-all to all discussions, lest we lose the trust of our patients. It is important, perhaps the most important guiding principle, but we have more than science at our disposal to help us treat our patients. If we believe that we only have science as a tool for helping our patients, then we are no better than some scientists with their lack of the ability to apply science to the real world, and most importantly, to real people. Where some scientists lack sufficient ability to interface between abstraction and reality in matters of life-and-death, we have chosen this profession because we can. We can understand people: their fears, desires, and motivations. Accordingly, we must not give up a chance to understand and help our patients because of our arrogant belief that our science makes us right.