Second thoughts on integrative medicine

Journal of Family Practice, Feb, 2005 by Edzard Ernst

Integrative medicine is a new concept of healthcare.(1,2) Confusingly, the term has 2 definitions. The first definition is a healthcare system "that selectively incorporates elements of complementary and alternative medicine (CAM) into comprehensive treatment plans...." (1) The second definition is an approach that emphasizes "health and healing rather than disease and treatment. It views patients as whole people with minds and spirits as well as bodies...." (1)

I would argue that the whole-person concept has always been at the core of good medicine, particularly primary care, and that coining a new name for an old value is counterproductive. If we can agree that the whole-person concept needs no other name, we can greatly simplify matters by letting integrative medicine stand for just one thing--incorporating elements of CAM into routine health care. Let's consider the implications of this thinking.

The arguments for integrative medicine

Proponents of integrating CAM into routine medical care point to its increasing popularity (3) and to the satisfaction of most CAM users. (4) They also argue that CAM has largely been a privilege of the affluent class, (3) and, to achieve equity in health care, we should integrate CAM across all of society. This line of argument seems logical and well intentioned. But is it convincing?

Just because the affluent are the primary recipients of CAM does not necessarily recommend it to everyone. Their lifestyle choices also put them at greater risk for cancer and gout, and they undergo liposuction more often. That the affluent can afford to pay for CAM does not mean it's good for them.

The evidence for benefits vs risks

The assumption we should really mistrust is that satisfaction with CAM services is the same as a demonstration of efficacy. The missing link in the logic of integrated medicine is the evidence that CAM does more good than harm. Integrating therapies with uncertain risk-benefit profiles (eg, upper spinal manipulation) or modalities that are pleasant but of dubious value (eg, aromatherapy) would render health care less evidence-based and more expensive but not necessarily more effective.

Of course, not all CAM is ineffective or unsafe. (5) CAM interventions that demonstrably do more good than harm should be integrated; those that don't should not be. Research into CAM is in its infancy, and the area of uncertainty remains huge. For most forms of CAM, we simply cannot be sure about the balance of risk and benefit. To integrate such CAM would be counterproductive. To integrate those therapies that are supported by good data is not integrative medicine but simply evidence-based medicine.

Patient choice and responsible decisions

And what about patient choice? This concept is well-founded in our legal system. As physicians, we are just advisors trying to guide patient choice. Creating a new type of medicine that stands for incorporation of unproven practices into medical routine would, however, be a violation of our duty to be responsible advisors to patients. Responsible advice has to be based on evidence, not on ideology. Decision-makers rightly insist on data, not anecdote. (6)

In conclusion, the term integrative medicine is superfluous since it stands either for whole-person medicine (a concept already a part of primary care) or for the promotion of integrating well-documented CAM modalities (already being done with evidence-based medicine). The danger of integrative medicine lies in creating a smokescreen behind which dubious practices are pushed into routine healthcare. I believe this would be a serious disservice to all involved--not least, to our patients.

REFERENCES

(1.) Rees L, Well A. Integrated medicine. BMJ 2001; 322:119-120.

(2.) Caspi O, Bell IR, Rychener D, Gandet TW, Weil A. The tower of Babel: communication and medicine an essay on medical education and complementary/alternative medicine. Arch Intern Med 2000; 160:3193-3195.

(3.) Eisenberg DM, David RB, Ettner SL, et al. Trends in alternative medicine use in the United States. JAMA 1998; 280:1569-1575.

(4.) Mahady GB, Parrot J, Lee C, Yun GS, Dan A. Botanical dietary supplement use in peri- and post-menopausal women. Menopause 2003; 10:65-72.

(5.) Ernst E, Pittler MH, Stevinson C, White AR. The Desktop Guide to Complementary and Alternative Medicine. Edinburgh: Mosby; 2001.

(6.) Van Haselen R, Fisher P Evidence influencing British Health Authorities decisions in purchasing complementary medicine. JAMA 1998; 290:1564.

Edzard Ernst, MD, PhD, FRCP, FRCPEd, Peninsula Medical School, Universities of Exeter and Plymouth, Exeter, UK

Correspondence: Edzard Ernst, MD, PhD, FRCP, FRCPEd, Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter EX2 4NT UK. E-mail: Edzard.Ernst@pms.ac.uk.