For clarification, when I use the term ‘CAM’ in this post I am talking about Complimentary and Alternative Medicine
‘EBM’ on the other hand refers to Evidence Based Medicine
Evidence Based Medicine is hugely influential in the implementation of modern healthcare and is becoming increasingly important in the integration of complimentary therapies such as Acupuncture into the mainstream. This subject can get a bit controversial so I thought it would be a good idea to explain a little bit about it and to present my general position on the subject.
Evidence based medicine is used by policy makers (like the NHS) to help inform decisions on how healthcare should be administered. Clinical trials are carried out on a given treatment method to try to establish if it is providing benefit or causing harm. Several clinical trials are then analysed together using established methodology such as Systematic Reviews and Meta Analysis. Conclusions drawn from this are then used to help inform decisions of if / how the treatment method in question should be used in practice by healthcare providers.
Clinical trials themselves come in various different forms. Placebo controlled triple blind randomised controlled trials (RCT’s) for example, attempt to tightly control the number of variables that are present to examine specific details about the effect that the treatment in question is having. Pragmatic trials at the other end of the scale collect information on the use of a treatment in the ‘real world’ setting of routine clinical practice. Each of these and everything in between can tell us something slightly different and provide useful points of view.
One thing that springs to a lot of peoples minds when they think about research is that when you look at one study in isolation, the conclusions drawn are rarely definitive and universally agreed upon. For example, one week you will see a headline in a news paper saying that if we prescribe Drug-X to everyone once they reach middle age, we will all live until we are 150, then a few months later there is another headline saying that if you were to merely walk past a chemist which has Drug-X on it’s shelves, you are soon to meet a sticky end. This type of scenario demonstrates that our knowledge of these subjects is often a developing process and that there are few occasions where you can completely hang your hat on one position or another.
The reliability of media reports on scientific studies and indeed the studies themselves can also be compromised by various factors. So, if you are reading an article about a particular piece of research, it is useful to maintain a critical mind. Here are some examples questions that can be asked:
In my opinion, debates surrounding alternative healthcare topics can often become way too polarised and this can sometimes inhibit peoples ability to make informed and reasoned decisions. Here are two exaggerated example of opposing perspectives:
CAM Fundamentalist: “I have been bitten by a snake, my leg has gone black and two of my toes have fallen off. I am going to turn to Alternative therapy XXXX as it will cure any ailment. I know this because I read about it in a book written by a wise looking old man. All modern health care methods and drugs are bad and will give me horrible side effects.”
Skeptic Fundamentalist: “I’ve been up all night on internet forums debunking stuff and now I have a head ache. I will only use conventional therapies as the have a strong evidence base so I am going to head down to my G.P to get some pain killers. I would never be gullible enough to waste my money on an alternative health practitioner as there is no evidence whatsoever that the treatments that they use are effective. I know this because Richard Dawkins said so. Any other opinion has no scientific basis and is completely irrational.”
Chances are that the first persons toes probably aren’t going to grow back any time soon and the evidence base for the bottle of pills that the second guy walks out with may not actually be half as strong as he assumes it is.
Again, i’m exaggerating to make a point and not to patronise or offend, but people who fall into these categories to varying degrees are always getting into arguments with one another and often, neither party has actually bothered to seek out and examine the information that is out there on both sides of the debate with an open mind. This inhibits constructive discussion and efficient development.
Fortunately there are also many people out there with backgrounds in conventional or complementary therapies who are working hard to use science to increase our understanding of how CAM medicine works in a fair and unbiased manner. It is these individuals who will produce real progress which will lead to improvements in health and the way that CAM therapies are practiced.
According to this article from BMJ – Clinical Evidence only 11% of conventional treatments offered on the NHS have strong support of efficacy based on randomised controlled trials while 46% are of unknown effectiveness and 4% are likely to be ineffective or harmful.
This does not mean that all of the interventions that do not fall into the 11% will not work, but it does mean that many of them are yet to reach the ‘gold standard criteria’ of evidence which some people assume has been applied to all aspects of mainstream healthcare. Many of the treatments we accept as gospel have been found to work over years of observation and experience and not just through clinical trials. The article also discusses the difficulty and complexity of compiling and categorising this data as there are many challenges associated with using statistics to measure human health which we are striving to overcome.
Most scientific research which claims to prove or disprove something can be picked apart and brought into question by someone who is inclined to do so. This is a good thing and highlights the fact that there are not as many certainties in life as we would sometimes like and that balanced and open minded debate and experimentation is essential for human progression.
I support the use of evidence based medicine and clinical trials to dictate treatment decisions in complementary health care and I feel that this can have a positive influence on the way that we use therapies like acupuncture. This will mean that we can continually refine the way that we welcome patients who have conditions that we feel we have a good chance of helping and turn away those who don’t. These developments may also help us evolve they way that we administer treatment and improve upon the techniques that we use and I fully embrace this.
Before this can happen though, there are some significant hurdles to overcome. CAM therapies are not backed by large corporations and generally have limited resources to devote to carrying out clinical research, especially when compared to pharmaceutical companies who are able to fund studies into the products that they sell at will. This means that developments in CAM research generally occur at a relatively slow pace. It is also difficult to develop effective study designs and placebo controls for CAM therapies due to their complex nature and the wide range of variables that are present in clinical practice. This means that debate around the trials often ends up being more focused on how they were carried out than on the results themselves.
In spite of these challenges, I feel confident that the evidence base for CAM therapies will grow and I will follow this progression with interest and an open mind. In the meantime time, I hope that free choice, open mindedness and reason prevail.