Complementary medicine – A Clinician’s Tale of Pride and Prejudice

GP ST1, Dr Cornelia Junghans discusses her experience during an open day at the Hospital for Integrated Medicine.

I frequently get asked by patients about homeopathy, acupuncture and reflexology and find myself admitting that I don’t know much about it. As a result, I recently attended an open day at the Hospital for Integrated Medicine in London to find out more about complementary medicine in order to have a better answer for patients who ask about it.

The day covered the use of a range of complementary medicine such as homeopathy, herbalism, acupuncture and hypnosis. I learnt that complementary medicine places a strong emphasis on restoring balance, focuses on the patient’s own healing powers and considers that mind and body are intrinsically linked. It made me realise that we as doctors learn about the concept of balance or homeostasis in pre-clinical years, but seem to forget about it to some degree in clinical practice. We also routinely separate body and mind for neatness of diagnosis. I was reminded of the importance of good communication: to work with the patient’s beliefs and wishes in order to encourage self-care and healing beyond treating symptoms. The concept of ‘symptom shift’, the phenomenon that when we 'fix' one illness, another may develop in its place, is understood by most clinicians in Germany, but not so commonly in the UK.

Incorporating some of the thinking behind complementary medicine in our history-taking and joint therapy decisions must surely make us more holistic doctors. I feel that it behoves us to know a little about these options, as patients often want to hear more about them and can be referred to the Integrated Medicine hospital under ‘choose and book’. I, for one, would like to learn more about homeopathy, acupuncture, autogenic training and hypnosis as additional therapy options to complement, or offer an alternative to, ‘school’ medicine.

I confess to having had the prejudice of thinking that complementary medicine attracts the ‘worried well’, but was surprised to find that the majority of patients there were what they call TEETH patients (Tried Everything Else, Try Homeopathy). They are the ‘heart sink’ patients we see in practice with multiple comorbidities, chronic pain, hard to fix problems and polypharmacy who are at the end of their tether. Learning about complementary medicine encouraged me to think more about the power of belief (homeopathy is said to be maximising the placebo effect) and reminded me of how awe-inspiring our bodies are. In my view, the concept of welfare, self-care and ‘staying in balance’ needs to be something that is taught to our children and to adults more than we do now. And, as doctors, we must promote self-care and wellbeing more than we do now. The five-year forward review for General Practice places a heavy emphasis on prevention. A wider view on how to foster self-care and encourage patient engagement may be helped by adopting some of the principles and practices of complementary medicine.

Having had a few of my prejudices and assumptions challenged, I discussed this with a doctor colleague, who is an anaesthetist. What started off as a general discussion about treatment options turned into a bit of an argument, in which my colleague pointed out that there was little evidence to support the benefit of complementary therapies. It made me realise how entrenched our views often are on the medicine we practice. It is with good intention that we seek to practice only things that do no harm and benefit the patient, and that we seek 'hard' and irrefutable evidence to support it.

I went to have a closer look at the evidence published around two areas of complementary medicine that we discussed: homeopathy and acupuncture. One study, which was published in the Lancet (and often gets cited as evidence that homeopathy doesn’t work) nevertheless showed that, in certain areas (such as upper respiratory tract infections) homeopathy had a substantive clinically and statistically significant positive effect compared to placebo OR 0·36 [95% CI 0·26–0·50]. The authors of the paper point out that context effects were not looked at in this meta-analysis, but context in itself may have a powerful effect in therapies, which rely heavily on a good doctor-patient relationship.¹ With regards to acupuncture, there is growing scientific consensus that it is safe and effective for pain², particularly back pain³ and headaches.⁴

On the flip side, what we practise under the umbrella of evidence-based medicine is sometimes more of a collection of perceived wisdom or acceptable practice with the stamp of approval of standard medical practice and is not always rooted in robust evidence. Randomised controlled trials, hailed as the gold standard in medicine, routinely exclude everyone of child-bearing age, with any comorbidity and of a certain age, yet we happily apply the findings to all our patients.

As Jane Austen famously writes: “It is a truth universally acknowledged that a single man in possession of a good fortune must be in want of a wife. However little known the feelings or views of such a man may be on his first entering a neighbourhood, this truth is so well fixed in the minds of the surrounding families, that he is considered as the rightful property of someone or other of their daughters”. Are we as clinicians so busy trying to pair-up patients with their correct evidence based medication (often with the tenacity of Mrs Bennet) that perhaps we do not always, due to our own ignorance, allow patients to explore alternatives?

Does the lack of good evidence on a therapy give us clinicians the appearance of having the patient’s interest at heart, but is actually a boast to our sometimes well-intentioned but paternalistic attitudes? Or, in the words of Mr Darcy, “Nothing is more deceitful than the appearance of humility. It is often only carelessness of opinion, and sometimes an indirect boast”.

The term ‘alternative’ medicine is often unhelpfully used in the context of complementary medicine. I wonder whether we, as clinicians, have contributed to the alienation of these therapies and, in so doing, unintentionally fostered an unregulated and sometimes dangerous practice, which demonises ‘school’ medicine and promotes complementary or ‘natural’ therapies in its stead. By carefully scrutinising how these complementary therapies can be safely used, either as an adjunct or as additional therapy option when all else has failed, we will help them be better regulated and accepted.   

Are we collectively so afraid to venture into the less-accepted that we'd rather see the patient muddle on through without any options than try something that might actually improve their health and well-being? I'm determined to be a bit braver in my practice and centre it around the patient, working with the patient, informing myself of the evidence, but also working out how to integrate complementary medicine safely.

References:

1 Shang A, Huwiler-Müntener K, Nartey L, Jüni P, Dörig S, Sterne JA, Pewsner D, Egger M. Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy. Lancet. 2005 Aug 27-Sep 2;366(9487):726-32.

 2 Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Archives of Internal Medicine. 2012;172(19):1444–1453.

      

3 Berman BM, Langevin HM, Witt CM, et al. Acupuncture for chronic low back pain. New England Journal of Medicine. 2010;363(5):454–461.

                        

4 Linde K, Allais G, Brinkhaus B, et al. Acupuncture for tension-type headache. Cochrane Database of Systematic Reviews. 2009;(1):CD007587. Accessed at www.thecochranelibrary.com on July 2, 2014.

      

Acknowledgments: Many thanks to Maham Stanyon and Drew for brilliant editing and helpful suggestions