Advocates of complementary and alternative medicine (CAM), including naturopaths and functional medicine practitioners, constantly criticize mainstream medicine. The recurrent themes are:
- Doctors don’t do prevention
- They only prescribe drugs and surgery and don’t consider non-drug treatments
- They don’t treat the underlying causes of disease
- They don’t treat the whole person
- They don’t know anything about nutrition
- When they criticize CAM, they’re only trying to protect their turf and increase their income
And of course, CAM advocates present themselves as prioritizing prevention, using non-drug treatments, finding the underlying cause, treating the whole person, being experts in nutrition, and apparently implying that they are not financially motivated (!).
I’ve been catching up on my CME (Continuing Medical Education) and I currently have four recent biweekly issues of American Family Physician on my desk – the flagship journal of the American Academy of Family Physicians. Family physicians rely on it to keep up to date; there is a quiz in each issue that allows members to earn CME credits. It arguably represents the best in current clinical practice, the standards primary care physicians should aspire to (even though some may not measure up in practice). I thought it would be interesting to review those four recent issues looking for evidence for or against the accusations of CAM advocates. I found plenty of evidence that those accusations are wrong.
August 15th
- Preventing Falls in Older Persons (a comprehensive review addressing the whole patient and recommending many non-drug approaches – see details below)
- Putting Prevention into Practice (discourages routine pelvic exams, which would tend to reduce physician income)
- Health Literacy Tools in the Outpatient Setting (a sensitive approach to making sure patients are able to understand medical information)
- Accepting Family Care in Chronic Illness (a patient’s perspective, intended to improve physician empathy and understanding of patients’ nonmedical needs)
- Pregabalin Does Not Decrease the Pain of Sciatica (a recommendation against using the drug Lyrica)
- TOP POEMS [Patient-Oriented Evidence that Matters] of 2016 Consistent with the Principles of the Choosing Wisely Campaign (including numerous recommendations to avoid using pharmaceuticals or surgery for specific conditions)
September 1st
- Aseptic and Bacterial Meningitis: Evaluation, Treatment and Prevention (yes, prevention, with vaccines and chemoprophylaxis for close contacts, preventive measures that have been proven effective)
- Vitamin D for the Management of Asthma (reports a Cochrane review evaluating a “natural treatment”)
- Noninvasive Treatments for Low Back Pain (including exercise, spinal manipulation, heat, massage, tai chi, yoga, and advice)
- Varenicline for Smoking Cessation (a drug treatment, but an effective way to help patients prevent smoking-related morbidity and mortality; no non-drug treatment is as effective)
- Combination of Resistance and Aerobic Exercise Best for Older Persons with Obesity (combination of exercise and weight loss better at improving function than either alone; specific advice about what kind of exercise is best)
September 15th
- Diabetes Self-Management: Facilitating Lifestyle Change (a comprehensive review of lifestyle changes and how to achieve patient compliance – see details below)
- Vitamin B12 Deficiency: Recognition and Management (recognizing a nutritional deficiency and treating it appropriately)
- Screening for Syphilis Infection in Nonpregnant Adults and Adolescents, in the Putting Prevention into Practice series (early detection can prevent late-stage disease and transmission to others)
- Low Back Pain: American College of Physicians Practice Guideline on Noninvasive Treatments (recommends 13 interventions, from exercise to yoga, that should be tried before prescribing medications)
October 1st
- Recurrent Ischemic Stroke: Strategies for Prevention (lifestyle modifications like exercise, smoking cessation, and decreased alcohol are covered before discussing anti-clotting drugs)
- Secondary Hypertension: Discovering the Underlying Cause
- Pet Therapy: Helping Patients Cope
- Yoga for Cancer-Related Symptoms in Women with Breast Cancer (recommended for depression and other symptoms)
Preventing falls in older persons
This comprehensive article covers prevention, addresses the whole person, and recommends non-drug interventions that have been proven effective. It recommends screening older patients for a history of falls or balance impairment, looking for underlying causes (everything from cancer to inappropriate footwear), evaluating home safety, exercise to improve strength and balance, review of medications, vision correction, foot care, and a vitamin (D). They recommend multifactorial interventions that address every aspect of the whole person.
How does this differ from the approach of a naturopath? It doesn’t, except that naturopaths add a few things like silica, strontium, Curcumin-Boswellia blend, or other supplements that were not included in the American Family Physician article because they are not supported by good evidence. I know of no evidence that naturopaths are any better at preventing falls than MDs.
In a YouTube interview, a naturopath fails to mention most of the things in the American Family Physician and focuses on diet. She recommends assessing for malnutrition and correcting or preventing sarcopenia by increasing protein intake and taking leucine. She recommends evaluating gut health to ensure nutrients are absorbed, and checking for low magnesium levels. I know of no evidence that that approach reduces the incidence of falls.
Diabetes: Facilitating lifestyle change
Mainstream medicine agrees with alternative medicine that lifestyle changes (weight loss, exercise, healthy diet, etc.) are indicated to treat (and help prevent) diabetes and pre-diabetes. And of course, these measures are good advice for anyone wanting to stay healthy and reduce the risk of chronic diseases. But it has been notoriously difficult to get patients to make those lifestyle changes. The article in American Family Physician provides all kinds of techniques for improving compliance, techniques that are equally applicable to achieving compliance with any treatment for any health conditions. They recommend inquiring into patient expectations, attitudes, and preferences, and addressing psychosocial factors (i.e., treating the whole person). They address effective timing of interventions, assessing a patient’s readiness to change, setting clear goals, individualizing the plan, encouragement, empowerment, dealing with slips and relapses, teaching coping mechanisms, controlling cues, providing social support, etc. There is a wealth of wisdom here that any health care provider could benefit from.
What passes for prevention in the world of CAM
CAM claims to stress prevention, but they are arguably not as good at prevention as mainstream providers. Patients of CAM providers are less likely to get vaccinated or to get evidence-based screenings like mammograms.
Some chiropractors recommend routine maintenance adjustments and claim that keeping the spine properly aligned will prevent most or all illnesses. This view is not supported by evidence.
Acupuncturists claim to provide preventive care. There is no evidence that regular acupuncture treatments prevent anything.
Homeopaths also claim to offer prevention; and as a substitute for effective vaccines, they offer homeopathic remedies that contain no active ingredient.
Some people believe that if you just eat right, you won’t ever get sick. That’s demonstrably not true, and recommendations about how to eat right vary widely.
Mainstream medicine invented prevention. It developed proven preventive measures like the vaccines that have saved untold lives. CAM has contributed nothing of substance.
Conclusion: CAM is unnecessary
It is clear from the examples above that mainstream medicine does not do all the bad things CAM criticizes it for. And that it does do all the good things CAM claims to do.
CAM’s criticisms of mainstream medicine are misguided. Good mainstream clinicians do at least as good a job as CAM providers when it comes to prevention, using science-based non-drug treatments, treating the (real) underlying causes of disease, treating the whole person, understanding the principles of nutrition, and achieving good health outcomes for their patients. All these things fall squarely in the province of good science-based medicine. Science-based medicine offers a wide range of proven treatments, while CAM offers treatments that have not been proven to work (if they had, they would be “medicine,” not “alternative medicine.”)
When mainstream doctors criticize CAM, it is not to protect their turf. They routinely follow the evidence and stop using treatments or tests that are lucrative when they are found to be ineffective. Their goal is not to maximize income, but to do what is best for their patients. They want patients to be able to give informed consent, to have accurate information about treatments that are ineffective, untested or inadequately tested, scientifically implausible, or hyped way beyond any all-too-meager evidence.
CAM has tried to appropriate things like prevention and exercise from mainstream medicine. They talk as if they discovered those things. They didn’t. They borrowed freely from mainstream medicine without acknowledgement, and they haven’t added anything of significant value.
Mainstream medicine is far from perfect. One big problem is the limited time doctors have with patients, and CAM has capitalized on that flaw; they often spend more time with patients, but they don’t make as good use of that time as doctors could. It makes sense to concentrate on improving mainstream medicine. It makes no sense to replace it with even more imperfect substitutes. We don’t need CAM.