The letter from Dr Bell, et al. in the July/August edition of the BCMJ (2006;48:255-256) contains some important misconceptions that require urgent rebuttal.
Dr Bell states that there is a “considerable volume of high-quality research” that supports the effectiveness of complementary and alternative medicine (CAM). In point of fact, this is true. The problem is that there is a far greater quantity of even higher-quality evidence that tells the opposite story. A case in point is homeopathy, invoked by Dr Bell as an example of a scientifically sound practice. Those physicians who recall high school chemistry will be interested to note that a typical homeopathic remedy is diluted vastly beyond the point where a single atom of the allegedly active substance could be present (so much so that one would have to consume a sphere many kilometres in diameter to get even a single atom). Furthermore, even though one can find positive trials of homeopathy in the published literature, the best quality trials are overwhelmingly negative and we have yet to see consistent positive RCTs conducted by non-proponents.[1,2] Under such circumstances, one might wonder if disciples of homeopathy are concerned about scientific quality or are simply suffering from “dilutions of grandeur.”
Why Dr Bell presents acupuncture as the other CAM poster child is somewhat puzzling. To be sure, most of the over 800 clinical trials of acupuncture have declared it to be positive, yet systematic reviews that have taken the quality of the trials into account have found that the alleged effects are almost universally illusory, particularly when sham acupuncture is used as a control.[3-29] As more research is being done, the number of diseases for which acupuncture seems to be promising appears to be shrinking. To date, it appears that the only conditions for which acupuncture enjoys anything near consistent positive RCTs are post-operative nausea and vomiting and some (oddly, not all) types of musculoskeletal pain,[10,30-32] and even these trials are fraught with heterogeneity. Critical thinkers, however, will recognize that it really would be remarkable if a treatment used for thousands of years and touted as a cure-all were only good for a couple of conditions, some of which didn’t even exist when the therapy was invented.
The authors also assert that the public is “choosing CAM in droves.” It is worth noting that CAM encompasses a huge array of practices that range from the bizarre to the somewhat plausible but unproven. The studies that have measured public use of CAM (e.g., Eisenberg et al.) have typically included items such as prayer, self-help groups, meditation, and lifestyle change as CAM modalities. Small wonder then that such surveys might indicate that many citizens have used at least one form of CAM in their lifetime.
Dr Bell rightly criticizes the undue influence of vested interests on medical information. But the solution to this problem isn’t to turn back the clock on standards of safety and effectiveness. The solution is to continue to demand higher standards of validity, transparency, and disclosure in the conduct of clinical trials so that we reduce bias in our estimates of the value of medical therapies.
The authors call for open-mindedness with respect to CAM and link this to patient-centred care. One can only hope that Dr Bell is not confusing open-mindedness with gullibility. Modern medicine has been very quick to adopt any therapy proven beneficial. Open-mindedness doesn’t mean low standards of evidence, and it is a problem when unproven ideas are promoted as bona fide therapies, and it is particularly worrisome when practitioners continue to promulgate misconceptions that have long been debunked.
—Lloyd Oppel, MD
Chair, Alternative Health and Therapeutics Committee, COHP
Dr Bell and colleagues’ letter was in response to an article by Dr James E. Miles published earlier in the year. Sadly, Dr Miles died in November, but he would have been pleased to see the debate he started continue on in the pages of the journal to which he was a friend and frequent contributor. We will miss his strong opinions and dry, irreverent humor.—Ed
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