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Alternative Medicine Dictionary

Bringing complementary and alternative medicine (CAM) into mainstream is not integration

EDITOR--Vickers's review is another example of how complementary and alternative medicine (CAM) is being brought into the mainstream rather than integrated.[1] Times are indeed changing, but what to?

The dictionary defines integration as "the incorporation of equals into society."[2] Let's be honest: there is no equality in medicine; there never was and probably never will be. The recent approval of acupuncture by the BMA is by no means an overarching endorsement of Chinese medicine as a legitimate alternative system.[3] It is simply an acknowledgement of the accumulation over time of good enough evidence that shows the effectiveness of acupuncture in some conditions. This is, to borrow a metaphor from the word processing world, a cut and paste approach. It results in the assimilation, and not creation, of a new emergent property. Combination medicine is not integrated medicine.

Two other important aspects related to the future of CAM deserve discussion. Health services research--Currently, much of the research effort in CAM is in the form of treatment x for disease y. Almost no systematic research is taking place on the delivery, organisation, and financing of different integrative healthcare models or on the appropriateness, quality, availability, and cost of CAM modalities in the current healthcare system. At a time when there is much interest in marketing, to ignore this line of research would undoubtedly be counterproductive in the long run simply because money is easier to measure and relate to than healing. Only by combining both types of research--biomedical that looks mainly at mechanisms of effect, and health services that looks mainly at modes of delivery--will true integration beyond the mere expansion of therapeutic tools be possible.

Medical education--Tallying the number of CAM courses given in medical schools is probably the most misleading indicator of integration. It may create an illusion that CAM has already made inroads into the temples of the medical establishment. The truth is that CAM education is currently an optional dessert rather than a main course. True integration will not be feasible without shifting the medical education paradigm from disease to humanism, from cure to healing, from knowing to not knowing. Education is the key to change.[4]

By their nature, review articles deal with the past. People, however, ought to look at the future: what will follow the current trend of mainstreaming? Integrative medicine, in its true sense, has the potential to expand the horizons of medicine beyond therapeutics.

Opher Caspi research assistant professor Program in Integrative Medicine, Department of Medicine, University of Arizona, Arizona Health Sciences Center, PO Box 245153, Tucson, AZ 85724-5153, USA ocaspi@ahsc.arizona.edu

[1] Vickers A. Recent advances: Complementary medicine. BMJ 2000;321:683-6. (16 September.)

[2] Merriam-Webster's collegiate dictionary. 10th ed. Springfield, MA: Merriam-Webster, 1993.

[3] Board of Science and Education, British Medical Association. Acupuncture: efficacy, safety and practice. Amsterdam: Harwood Academic, 2000.

[4] Caspi O, Bell IR, Rychener D, Gaudet TW, Weil AT. The tower of Babel: communication and medicine. An essay on medical education and complementary-alternative medicine. Arch Intern MM 2000;160:3193-5.

Challenge of making holism work

EDITOR--Treating the patient as a whole is a perennial issue in medicine. As doctors, we have the necessary skills to deal with some of the factors entailed. Other factors, such as financial status and education, fall outside the scope of our training and skills. Wanting to engage with the whole patient is one thing. Being able to do so is quite another. To consider tackling the physiological, psychological, social, epidemiological, and spiritual aspects of a person all at the same time is a pretty tall order. Maybe even this is not possible. Our complex and rapidly changing environment challenges the understanding of anyone. Why should we be any better equipped than other human beings to make sense of this fragmented world or of someone in it?

Doctors often complain that patients' expectations are unrealistically high, without seeing that the medical profession has played a large part in creating these expectations. If we really want to engage with the needs of the person in front of us, a constructive first step is to admit that this is an intractably difficult task rather than continuing to persuade ourselves that scientific medicine has the answers to everything. Adopting convenient politically correct modes of practice dictated by others merely enables us to sidestep the uncomfortable nature of this truth.

As doctors, we are very privileged. Technology has given us some powerful tools. Furthermore, our patients often share information with us that they cannot discuss with other people. If we can accept our position with a little humility, we may be able to begin to get a larger and more accurate picture of the person in front of us.

Tony Woolfson family doctor Medical Centre, Arcadas S Joao Fracc CH, Areias S Joao, 8200-260 Albufeica, Portugal tw@propadox.com

Dr Woolfson has set up a website, the Proper Doctors' Club (www.propadox.com), to act as the focal point for an informal network of doctors who are interested in addressing the issues raised in this letter and want to improve the quality of their work.

Integrated medicine is not new

EDITOR--Ancient medicine was always integrated--a mind-body medicine rooted in a social and religious matrix of a culturally defined people with a definite belief system. Ancient medical beliefs differed radically from those of modern medicine. When Milton wrote: "Of Man's first disobedience, and the fruit/Of that forbidden tree, whose mortal taste first/Brought death into the world and all our woe ..."[1] he expressed a Christian sentiment that disease was contamination caused by sin and a punishment from God; physicians were priestly servants of Christ.

By the end of the 17th century beliefs and superstitions began to be replaced by more practical methods. This entailed the systematic removal of metaphysical elements such as the life force. Mesmer's magnetism is akin to Hahnemann's vital force, the Qi energy of Chinese medicine, and the vis medicatrix naturae of Paracelsus--an elan vital. Observation based and explanatory, the concept of a life force is dismissed by modern physicians. Most integrated medical systems see disease as an imbalance of natural energies, and cure as a retuning of the whole organism--concepts long ignored by modern clinicians.

If ancient physicians were to view a clinical life dominated today by specific drugs and diseases, would they understand conditions to be distinct from the patient or regard them as constructs of the observer's mind, visible only "through the spectacles of their own hypothetical conceits"?[2] Such a viewpoint persists in most holistic therapies, a patient being regarded as a multidimensional living continuum subject to myriad influences. Stahl (1660-17341, Mesmer (1734-18151, and Hahnemann (1755-1843) were the last great vitalists.

Sundered from theology, so medicine has become secularised. Imbued with materialism, the modern view of the world has wholly displaced the ancient view. As diseases have become defined strictly in chemical or physical terms, so the spiritual side of medicine has been lost. Koch and Pasteur caused germs and vaccines to eclipse vitalism. Molecules and infectious agents are all that interest modern physicians; other possible causes of disease have been ignored or sidelined.

Much of the metaphysical element that was ejected from medicine centuries ago now queues at modern medicine's back door. A path of disintegration has separated medicine from its spiritual roots. The holistic therapies might lead medicine back towards the holism of the ancient systems. In some senses the disintegrative force of reductionism has run its course. Integration seems likely to entail retrieving some theology.

Peter Morrell honorary research associate, history of medicine

Department of Sociology, Staffordshire University, Stoke-on-Trent ST4 2DE Peter.Morrell@tesco.net

[1] Milton J. Paradise lost. London, 1667.

[2] Hahnemann S. Aesculapius in the balance, 1805. In: Dudgeon RE, ed. Lesser writings of Samuel Hahnemann. London: Homoeopathic Publishing Company, 1851: 423-6.

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