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Medicine's chasm: The wide gulf between conventional and alternative approaches

A recent White House commission report on unconventional medical therapies may have deepened the battle lines between advocates and skeptics.

By Stephanie Stapleton, amednews staff. June 3, 2002.

Long before the White House Commission on Complementary and Alternative Medicine Policy issued its final report, the dust-ups began.

There were letters to the surgeon general asking that the panel be disbanded and other criticisms -- public and private.

A blueprint for integration
Let science be the guide
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Then, in March, as the document was being transmitted to Health and Human Services Secretary Tommy Thompson, a news peg created momentum. Two commission members drafted a statement outlining the key elements they said were missing from the panel's findings. Their opinions were leaked to the press, and CAM skeptics sprang into action.

"We shaped the debate," said Stephen Barrett, MD, a retired Pennsylvania psychiatrist and founder of Quackwatch Inc. "It's the first time our network has been able to do that."

43% of Americans have used some form of alternative medicine.

This level of drama may seem unusual in response to nonbinding recommendations made by a White House commission. But controversy is no stranger to the notion of complementary and alternative therapies.

In fact, this recent episode provides an interesting look at how ideologically charged the debate has become regarding the integration of these approaches into mainstream medicine.

Many experts say that the strongest beliefs and harshest words come from a minority of players at each end of the spectrum and that substantive discussions about medicine's and CAM's future are ongoing. Ultimately, they say, science will provide the answers. But for now, practicing physicians -- who confront patient questions and patient care issues on a daily basis -- sometimes are left struggling to navigate a divided landscape.

Difficulty in defining terms

The popularity of alternative treatment has risen steadily in the last 30 years, and, according to some studies, an estimated 43% of Americans have used some form of it. This translates into big money. Americans spend as much as $40 billion on CAM treatments each year.

These figures, though, are sometimes called into question because of the ambiguous nature of what CAM actually entails.

In general, it has evolved into a catch-all phrase that refers to a range of healing practices -- from such commonly known therapies as acupuncture, meditation and herbal supplements to more exotic approaches, such as chelation therapy.

Americans spend $40 billion a year on complementary medicine.

Thus, even at this basic level, clarity is elusive.

CAM actually tries to combine two distinct concepts, said Robert S. Baratz, MD, PhD, a Braintree, Mass., internist and president of the National Council Against Health Care Fraud, a nonprofit organization that promotes reliable health information.

First are techniques that are truly complementary or adjuvant therapies used to make people feel better. This category includes massage therapy, physical therapy -- even prayer.

"These are not news. We've been doing these things for years," Dr. Baratz said. "They do not belong to the CAM movement. But CAM advocates are trying to co-opt them and mix them in with a bunch of other things."

And talk gets tougher when it's about those other things -- alternative practices.

"There is no alternative medicine," Dr. Baratz said. The term "alternative" suggests there is a viable treatment to use in lieu of standard medical practice.

Dr. Baratz uses this example to illustrate his point: To get to work, a person may be able to take the subway or the bus, drive a car or ride a bike -- all are forms of transportation. "But you can't ride a magic carpet. The notion of alternative medicine is like a magic carpet. It will get you nowhere."

Of course, not everyone embraces this characterization. The result is a polarity so intense that it seems that the two sides speak past each other.

"There are avid skeptics who remain convinced that no CAM practices work," said Stephen E. Straus, MD, director of the National Institutes of Health's National Center for Complementary and Alternative Medicine.

"At the opposite extreme, some advocates of alternative medicine continue to feel there is no benefit to subjecting CAM to scientific scrutiny because the methodology is inadequate and the investigators are too biased to conclude what has already been long known. There is very little common ground on which these diverse opinions can meet."

Diversity indeed

Wallace Sampson, MD, is a retired hematologist and oncologist who edits the Scientific Review of Alternative Medicine, a peer-reviewed journal devoted to objectively analyzing health claims that fall in this category. He maintains that the debate is not polarized -- "at least not among rational people." But this self-avowed skeptic also considers debunking the promise of alternative medicine to be a complicated task -- a fight pitting the scientific methods of proof against ideology. It's "a science war, a culture war," he said.

On the other end, James Gordon, MD, the psychiatrist who chaired the White House commission, does some debunking of his own. He cites the tone and language used by CAM opponents to question their motives. "That's the McCarthyite mindset. The inquisitor's mind, not the scientific mind. There's a lack of thoughtfulness in that approach -- knee-jerk is the right word."

With this level of controversy in the background, the 20-member White House panel, established in March 2000 by President Clinton, set out to develop public policy recommendations to maximize CAM's potential benefits.

The panel held four town hall meetings nationwide and 10 Washington, D.C., sessions; heard 700 testifying witnesses; gathered more than 1,000 written comments; and spent $2.6 million in the process. It offered its report in March.

Dr. Gordon, who also is director of the Center for Mind-Body Medicine in Washington, considers the most important suggestions to be those geared toward providing better scientific information about what is known about CAM practices' safety and efficacy.

He also emphasized the panel's request for establishing good manufacturing practices and improved product information for nutritional supplements.

Also key, he said, were repeated calls for more research of CAM practices -- an amount commensurate with usage and with an emphasis on complex interventions, rather than just single agents. In addition, he pointed to the creation of a central government office to coordinate CAM integration as critical.

These recommendations are just a sampling of those in the complete report. But they don't come without fallout. Opponents begin by criticizing the commission itself.

"Every member had a conflict of interest," Dr. Barrett said. He and other skeptics maintain that its membership was appointed because of their promotional or advocacy bent. There are also certain things the skeptics say are missing -- the same points they say are consistently not addressed by advocates.

They maintain that the report never defined complementary and alternative medicine, nor did it offer any conclusions about specific modalities that work and don't. And, they say, it never acknowledged that some of the methods under the CAM umbrella are simply irrational.

They also bristle at the fact that the report called for more money to teach CAM classes in medical school, pressed the government to promote CAM to insurance companies and proposed what Dr. Barrett called a "grand scheme" with a government office to advance the cause. In general, they view it as another episode in which CAM advocates dodged the hard questions.

Dr. Gordon takes exception to these assertions. "The accusations are not true," he said, adding that the report is focused on those approaches that will be proven safe and effective and that there is no assumption everything will gain this imprimatur. "I don't have that assumption. It's not there [in the report]," he said.

Dean Ornish, MD, the director of the Preventive Medicine Research Institute in California, who also served on the commission, agreed that these claims are misplaced. To him, the bottom line is that CAM needs more good science.

"The report is arguing for good science," he said. Much of what is included is very qualified and conservative, Dr. Ornish added. "I made sure that it was."

The good, the bad, the ugly

But even within the commission, some members were ultimately troubled -- a sentiment that led them to draft the additional statement that advances the same haunting questions that skeptics hammer home and advocates wish would be put to rest.

"It is essential to separate the effective from the ineffective, the safe from the unsafe, and to contextualize these practices against conventional modalities before any of them can be recommended for incorporation into the nation's health care system," wrote Tieraona Low Dog, MD, medical director of Tree House Center of Integrative Medicine in Albuquerque, N.M., and Joseph J. Fins, MD.

"If CAM is to be integrated and become part of the mainstream, its advocates need to distinguish the good, the bad, the ugly," said Dr. Fins, an internist and director of medical ethics at New York Weill Cornell Medical Center of New York-Presbyterian Hospital.

But this is no easy task.

Dr. Fins uses the analogy of a primary election. The candidate must cater to the true believers in an effort to shore up an electoral base. Moving to the center risks alienating this core group. In the case of CAM, though it would be viewed as scientifically responsible, such a move would come at a high political cost in this same manner -- pushing away some of the faithful.

Meanwhile, NCCAM's Dr. Straus said conventional medicine's protectors and CAM advocates simply hold "divergent world views."

"Scientists are inherently skeptical and do not accept claims based primarily on long-held and popular beliefs," he said. But CAM use is built on different levels of evidence than contemporary biomedicine. "Thus, there is a substantial difference in philosophy," he said.

As the CAM debate rages, physicians and patients are sometimes caught in the middle.

Timothy Gorski, MD, an ob-gyn in Arlington, Texas, who serves on the NCAHCF board, says the report did nothing to help doctors deal with challenges they face on a daily basis. "The government has not regulated this area as it ought to. That creates more of a physician responsibility to nurture the physician-patient relationship and notice those patients who are vulnerable."

And perhaps that taps into the one theme heard from both sides of the issue: It is more important than ever for physicians to know more -- about the reliable or unreliable information sources their patients may be reviewing, new developments in conventional and unconventional treatments, and even patients' behaviors.

After all, whether good or bad, proven or unproven, CAM is part of the health care reality.

"One of the major issues that needs to be recognized is that patients are utilizing these approaches," Dr. Fins said. "In [ our patients'] interest, we need to foster a dialogue."

ADDITIONAL INFORMATION:

A blueprint for integration

The White House Commission on Complementary and Alternative Medicine Policy offered these recommendations:

Increase funding for basic, clinical and health services research related to CAM.
Create an office within the Dept. of Health and Human Services to coordinate CAM research and other government activities.
Increase CAM educational opportunities for conventional health professionals, including medical school curricula development.
Make accurate information about CAM available to the public and ensure that modalities and products are safe.
Improve access and develop regulatory frameworks to ensure accountability.
Broaden insurance coverage for those practices shown to be safe and effective.

Let science be the guide

American Medical Association policy "encourages the Office of Alternative Medicine of the National Institutes of Health to determine by objective scientific evaluation the efficacy and safety of practices and procedures of unconventional medicine; and encourages its members to become better informed regarding the practices and techniques of alternative or unconventional medicine."

Weblink

Final report of the White House Commission on Complementary and Alternative Medicine Policy (http://www.whccamp.hhs.gov/)

Quackwatch's analysis of the White House Commission's report on complementary and alternative medicine policy (http://www.quackwatch.com/07PoliticalActivities/WHC/00.html)

NCCAM, National Center on Complementary and Alternative Medicine (http://nccam.nih.gov/)