Re: Alt/comp brochure

I am writing to comment on Dr Brian Dixon-Warren’s request, which appeared in the June 2002 issue [BCMJ 2002;44(5):234], asking for feedback on the brochure entitled “Complementary and Alternative Therapies.” Dr Dixon-Warren asked for feedback to be sent to the Alternative Therapies and Allied Health Committee. I am writing to the Journal because I feel this publication addresses broader issues than just complementary and alternative medicine (CAM), and issues of interest to the BCMA membership as a whole.

The complacency with which we physicians accept the sometimes horrendous complications of pharmaceutical drug use, but bridle fiercely at the real or imaginary potential for adverse effects from CAM, is sometimes nothing short of astonishing—especially to our patients. As a practitioner who employs, or refers patients to, a variety of CAM practices, in what I construe to be a rational manner (as well as employing conventional remedies where appropriate), I have come to accept as a fact of life that professional attitudes are often skewed in this manner. Unfortunately I feel now, as I felt in October 2001 when it was published, that the brochure from Dr Dixon-Warren’s committee does little to advance the cause of balance and reason in the historically contentious relationship between CAM and conventional practice.

Phraseology in the brochure like “may not be effective or safe,” “have not been scientifically tested for safety and effectiveness,” “even if a therapy is licensed and regulated, it is not necessarily effective or safe,” “can have serious side effects or interactions with other drugs,” “contaminated with poisons,” “some combinations may be dangerous,” “expensive, unproven products and therapies,” and “claims of miracle cures” are all pejorative, prejudicial, and negative. There are no balancing comments—even grudging ones—such as “can be helpful in certain circumstances,” “may have fewer side effects than regular medication,” or “has been used for many generations without evidence of serious toxicity.”

The brochure does not address the rather public and disgraceful news that emerges daily, in the front pages of the New York Times and the editorial columns of the NEJM and the BMJ, concerning the shenanigans of the pharmaceutical industry and its vaunted “research,” in which Dr Dixon-Warren clearly places so much trust (“thorough testing, similar to that being demanded of mainstream medical treatments”). Ironically, all of his negative phraseology about CAM could be equally well applied to many conventional drug therapies! And yet it is not. Consequently, this brochure only serves to strengthen the prejudices of those already biased against CAM, while offering patients sincerely interested in pursuing alternatives little incentive to be open with their physicians.

Let me close with some evidence. The Journal of the Royal Society of Medicine published, 2 years ago, a paper entitled “A randomized controlled study of reviewer bias against an unconventional therapy” (Resch KI, Ernst E, Garrow J. J R Soc Med 2000;93:164-167). The authors submitted identical papers, of a purported study of an agent to treat obesity, to 400 reviewers associated with the European Journal for Clinical Nutrition. Half the papers named the treatment as a homeopathic remedy. The other half named the therapeutic agent as a well-known, orthodox drug. All reviewers who responded agreed the methodology of the study was good and the findings valid. But those reviewing the version associated with the conventional drug were three times as likely to say it was a useful remedy as those reviewing the version associated with the homeopathic remedy.

It is difficult enough for patients to access useful therapy in these days of cutbacks, closures, closed practices, and down-sizing. I suggest that it is time for us as health professionals to foreclose on our biases and relax our ideologies, and incidentally avoid becoming, unwittingly or otherwise, the instruments of a patent-driven, money-mad corporate pharmaceutical industry.

Instead, let’s let cool heads, open minds, calm assessment, and the passage of time tell us which remedies, conventional or complementary/alternative, can stand the test of time.

—Warren Bell, MD
Salmon Arm

 Dr Dixon-Warren replies

Thank you for giving me the opportunity to respond to Dr Bell’s letter. I appreciate the critique which he has provided, and agree that the discussion involves very broad issues.

Much of Dr Warren’s letter is taken up with complaints about the relationship of physicians to the mainstream drug industry, “shenanigans” in that industry’s research, and reviewer bias in mainstream journals. Space constraints do not permit me to respond to these comments, except to say that it is the commitment to rigorous methodology in mainstream research and publication process that has made it possible for him to become aware of such shortcomings as they exist. This awareness also provides the stimulus to corrective action. Unfortunately, this rigor, so typical of good science, seems unusual in complementary and alternative medicine (CAM).

With regard to the brochure itself, I would like to make the following points:

• The brochure was written to assist BC doctors in counseling their patients and the general public. We know that many people are consulting non-physicians, both licensed and unlicensed, with medical complaints. In addition, many more are self-medicating with preparations from drugstores and health-food stores. Most doctors agree that there are risks in this, and the brochure says unashamedly caveat emptor, let the buyer beware

• The brochure implicitly acknowledges patient autonomy in the choice of health care. We would wish that this would be an informed choice, and consequently the brochure recommends consultation with the usual family physician for reliable information.

• Open two-way communication is important, so the brochure stresses the importance of advising the family doctor about all non-prescribed treatments being used, including vitamins, minerals, herbs, and other therapies.

• Evidence-based practice is central to good modern medicine. Since evidence is always limited, physician clinical judgment remains essential. The legitimacy of the use of CAM by an individual physician is a matter for the College of Physicians and Surgeons to decide. Our committee had the great benefit of input from the College, but does not presume to speak for the College.

—Brian Dixon-Warren, MD
Past Chair, Alternative Therapies and Allied Health Committee