Patient Centered Medicine
Professor George Lewith
The politics of care
Within the complementary and alternative medicine (CAM) literature we can easily identify poor science as well as academic excellence alongside extreme bias. One of the biggest issues that we face within CAM is the NHS debate. It seems vital to separate NHS provision from evidence. None of us would disagree that visiting the dentist is an excellent remedy for toothache. However the fact that there are no randomised clinical trials involving dental placebo procedures makes it impossible to separate dental surgery from patient expectancy. Nevertheless, most of us are intuitively accepting of the argument that dentists add value to our lives. Dentistry is becoming increasingly unavailable on the NHS thus separating an essential medical service, from any argument about evidence. This seems to be a good basis for thinking about how we might separate health provision and policy from evidence of clinical effect. Evidence is driven by clinical trials and academic excellence while health policy seems to be driven, in large part, by political expediency; thus, it would appear to be sensible not to confuse rigorous science with politics in the context of health care.
Defining professions
Thirty years ago it was possible to get struck off the medical register for referring a patient to a medical osteopath; osteopathy wasn’t called CAM then but ‘fringe medicine’. Things have changed, osteopaths are statutorily registered and now form part of the conventional ‘medical professions’; a political change which has little rigorous evidence to sustain it but a great deal of public support. Physiotherapists were unable to practice acupuncture in 1979, but over the last two decades acupuncture has become part of normal physiotherapy practice with between a quarter and a third of physiotherapists having been trained, some at undergraduate level. As Wonderling suggests 1, we now have the necessary evidence to sustain this practice, but initially the change came about based on the politics of expediency rather than clinical evidence or health economics 2. The idea that any government and much of the medical profession, has ever decided health policy solely based upon science seems to be unsustainable on present evidence from randomised placebo controlled studies , particularly in relation to surgical intervention 3 4.
Patient led
What has created this apparent patient centred enthusiasm for CAM? Patients know that CAM ‘works’ and seek treatment for many reasons, including the procurement of wellbeing and personal empowerment 5, but from the medical perspective it seems to involve a large amount of patient expenditure. Perhaps the medical profession has decided to take the issue of CAM seriously (particularly in the US) because they feel they may be ‘missing out’ on income? Current US estimates suggest that over $30 billion is spent each year ‘out of pocket’ on CAM 6 while over the last decade the salary of US physicians has fallen with the growth of healthcare provider organisations like Kaiser A similar situation exists in the UK 7. Although UK physician’s income is less influenced by patient choice, it appears that we may be institutionally threatened. Patients keep telling us that CAM ‘works’ but their definition of ‘works’ and the definition used by the more orthodox part of the medical profession is very different. Patients look for environments in which they feel comfortable and cared for as well as evidence of benefit in terms of safety and overall effect 5 and frequently base their treatment choices on the recommendation of friends and family 8.
Evidence of effect?
Clinical scientists look for evidence of effects that are greater than placebo (efficacy). The majority of physicians spend much of their time managing and prescribing for chronic illness. In these circumstances evidence-based treatment means an improvement of 10% over placebo with often a very substantial non-specific response. Eighty to ninety percent of depression improves with SSRIs, but probably only 10% of that is related to the specific pharmaceutical agent itself 9 a new bronchodilator could be licensed with a 7% improvement over placebo 10 with the vast proportion of the clinical effect size being related to the act of treatment rather than the specificity of the new drug. Much of clinical medicine seems to ‘work’ on patient expectancy, particularly in the treatment of chronic largely benign illness such as asthma, irritable bowel, headache, arthritis and mood disorders. Along with acute infections these conditions fill general practitioners surgeries and comprise the reasoning behind a large proportion of NHS prescriptions. We shouldn’t be surprised if many complementary medicines have similarly small specific effects in these common conditions 11 12. One of the big issues within CAM research has been the difficulty of developing placebos particularly for physical treatments such as acupuncture. Without a validated placebo’s the whole concept of the placebo-controlled trial becomes unsustainable. Recent rigorous trial data based on very large patient numbers suggests that acupuncture, whatever the site of needle placement provides a substantially superior clinical outcome when compared to standard conventional care and is apparently far safer 13. Implying that we have placebos for many of these interventions is not sustainable on available evidence. For example in pain caused by arthritis; it may not matter where an acupuncture needle is inserted, but that does not mean it isn’t more effective that the conventional drug therapy with NSAIDs. Perhaps our patients are correct in their intuitive assumptions about the effectiveness and safety of CAM. We must also remember that the absence of evidence is just that, and must not be interpreted as evidence of no effect 14.
It must be safe its natural
Patients perceive CAM as natural, safe and effective. There can be
little argument with the statements about overall effectiveness in chronic
illness; by and large CAM does work. While there may be interactions
between anticoagulants, the contraceptive pill and Hypericum acute medical
wards are not filled with patients suffering from adverse reactions to
herbs, acupuncture and homeopathy. However, safety is an issue and natural
does not mean safe, but it is an issue that is vastly overplayed by those
who may hold anti-CAM beliefs and is very rarely put in proportion in
relation to the potential and actual risks of conventional medicine.
It has been suggested that there are 784,000 deaths from adverse drug
reactions to conventional medicine in the US annually 15 16.
The wise physician looks at illness from the patients perspective and
allows the patient to believe that the physician ‘understands’ their
illness. I’ve never had a patient ask me for a placebo. They’ve
always implicitly asked my advice about treatments that might ‘work’ with
a degree of expectation that I might have an answer to their problems.
It seems that the perception of how a patient views ‘what works?’ and ‘what’s
safe?’ is different to the physicians. Telling a patient who obviously
improved with homeopathy that their treatment doesn’t work is usually
the way to close down communication in a consultation and indicates a
failure to understand the concepts that surround clinical improvement
for chronic benign illness. Homeopathy may or may not ‘work’ better
than placebo, but it may certainly be working for the patient in that
consultation; that is their truth and their perspective. To deny them
their view of their health and their wellbeing with an apparently ‘effective’ treatment
might be considered misplaced.
Will we ever know more?
It is quite surprising that CAM has any evidence base at all. In spite
of the fact that between 15 and 20% of UK citizens use complementary
medicine each year 7 17 only 0.008% of research expenditure is devoted
to it 18. This could be because: the quality of CAM research is of such
low quality that many university initiated research submissions are turned
down by grant-giving bodies; there may be no university research infrastructure;
there are no, or very few, research applications; funders don’t
understand CAM research, or perhaps they do not fund good applications
because they do not consider them a priority. The public certainly see
it as an important issue and a large proportion of research funding in
this country comes through public funding. There are almost no academic
departments for CAM in UK medical schools and universities as a whole,
an indication that the medical establishment has little real interest
in this area. This presents an interesting conundrum: we know it doesn’t
work so let’s not bother investigating it!
In view of this possible institutional bias it is surprising that the
quality of publications within CAM has been so high. Our recent response
to Derry et al’s review acupuncture is papered with rigorous and
high quality science from acupuncture research and includes articles
published in high impact journals 19-26. This seems to me a monumental
achievement considering the lack of structure and funding that exists
within acupuncture research. Similarly with homeopathy; the quality of
the articles in Shang et al’s, review was more rigorous for homeopathy
then for conventional medicine 27.
Even with the evidence base that currently does exist for CAM treatments,
there is little or no capacity for the NHS to implement evidenced-based
treatments that involve these types of interventions. There are no policies
that allow for the provision of acupuncture as an anti-emetic, either
post operatively or in conjunction with chemotherapy, in spite of the
good evidence available 28. It seems that even when evidence is available
and promoted by unbiased individuals 1 little is done to effect change
thus providing yet more evidence of systematic institutional bias.
Politics and medicine don’t mix
‘Top Docs Slam CAM’ 29 seems a wonderful example of how to not listen to patients and muddle science and public policy. These 13 individuals seem to have taken it upon themselves to speak for the medical profession, or so it appeared from the Times. All of us would support the provision of evidence-based medications such as Herceptin in the treatment of breast cancer. The essence of this debate, however, was around the provision of CAM through the NHS, for patients with cancer. It’s interesting to reflect that one of the biggest referrers to the Royal London Homeopathic hospital, the major ‘target for the ‘top docs’, are the oncologists from the same Trust. The expenditure, while important to the Homeopathic Hospital was a drop in the ocean when compared to the potential expenditure by the same trust for use of Herceptin. Saving on homeopathy would not result in the provision of appropriate funding for the evidence-based conventional treatment for cancer and there is no doubt that we all want the best available treatment for patients with life-threatening illness. The debate is really about provision of evidence-based treatments on the NHS, not CAM. Perhaps the oncologists in practice were listening to their patients who were requesting a quality and dimension of care for their cancer, with CAM, that they felt appropriate to their needs. This was then quite inappropriately being used as an attack on CAM without any real possibility of such policy changes making any significant impact on the provision of appropriate care for breast cancer patients. One can only assume that initiatives such as this are poorly thought through: at worst they create an environment where patients may feel that their doctors do not value their own views about health and well-being, particularly when it relates to the use of CAM. This could lead to two parallel systems of healthcare and continue to reinforce the idea ‘that one shouldn’t tell ones ordinary doctor about CAM’. Possibly as a consequence of this attitude, over half the cancer patients in this country do not tell their conventional physicians that they are taking Complementary Medicines 30. Therefore, we expose our patients to misunderstanding and the risk of drug interactions through a publicly stated negative view of CAM and the subsequent collision of different realities between patient and physician. If we approach CAM from patients’ perspective we may minimise such risks to their care and not blame them for ‘not telling us’. We should embrace increasing patient empowerment as it is only through such mechanisms that we will be able to tackle the enormous health problems that face us such as diabetes, drug addiction and obesity. We can only do this by helping patients to manage their own health and take responsibility for their own wellbeing, and as such, we in conventional healthcare could learn from those who use CAM.
Conclusion
If we assume that being patient centred means starting from our patient’s point of view and caring for them then on that basis then CAM seems to be succeeding well with a large self selected group of people who seem to be empowered and motivated to look after themselves. Conventional physicians can’t ‘force people’ to believe that CAM is useless if the evidence of the patients own experiences argues to the contrary. CAM offers a challenge clinically and within its research agenda. It questions implicit assumptions within medicine and may in the end tell us a great deal about how to manage patient expectation, empowerment, education and the process of self healing which in turn could be of enormous value in the management of chronic benign illness. Surely, for maximum patient benefit, we want the best of both worlds especially if they could be integrated to achieve a patient centred outcome which is greater than the sum of the individual parts.
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