Complementary And Alternative Medicine (CAM)

Complementary And Alternative Medicine (CAM)
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Complementary And Alternative Medicine (CAM)

  • What is it?
  • What treatments?
  • Why would anyone use these treatments!
  • How should I plan my patient’s treatment?
  • Pseudoscience? Quackery? Phony treatments?

What Is Complementary Medicine?

  • It is a group of treatment methods that are not taught in conventional medical faculties or outside conventional medicine. There are 2 main features in CAM: treatments whose effectiveness has not been proven and treatments whose effectiveness can hardly be scientifically demonstrated in clinical trials and other scientific studies.

According to the National Institutes of Health (NIH) definition:

  • Alternative includes treatments that involve the substitution of treatment for conventional medicine. In other words, it includes a holistic approach that focuses on treating the whole body and mind.
  • When we say complementary, it includes treatments that are applied in addition to the patient’s current accepted treatment. For example, massage therapy with a medication prescribed for anxiety.
  • When we say integrative treatment, it is the applications made with the coordinated use of conventional and complementary medicine practices together.
  • In the USA, 38% of adults and 12% of children use complementary and/or alternative medicine methods.

Basic headings of complementary and alternative therapies

    • The National Centre for Complementary and Alternative Medicine (NCCAM) classifies these treatments under four sub-headings
  1. Manipulative and body-based applications
  2. Energy therapies
  3. Mind-body medicine
  4. Biologically based applications

Who Is A Physical Medicine And Rehabilitation Specialist?

In order to become a specialist in Physical Medicine and Rehabilitation (Physiatrist) in our country, after graduating from medical school, a 4-year speciality training is started by winning the speciality exam.

At the end of four years, the assistant who successfully completes the specialisation exam is entitled to become a specialist in Physical Medicine and Rehabilitation. Physiatrist is the physician who diagnoses and plans the treatment of the patient in musculoskeletal and neurological diseases.

Physiatry focuses on the prevention, diagnosis and treatment of diseases related to the musculoskeletal system and nervous system. The goal in the field of Physical Medicine and Rehabilitation is to improve the medical, social, emotional and occupational quality of life after diseases or injuries.

We work as a team in the organisation of the patient’s treatment. This treatment team may include many professions such as doctors, nurses, physiotherapists, psychologists, orthotists, social workers, occupational therapists, and vocational counsellors according to the needs of the patient. The patient’s condition is assessed and the areas that need support in development are determined and plans are made for these areas.

As the leader of the team, the physiotherapist guides all medical and therapeutic treatments.

Where Can I Find Out About These Treatments?

  • http://getatportal.saglik.gov.tr/
  • https://www.mevzuat.gov.tr/mevzuat?MevzuatNo=20164&MevzuatTur=7&MevzuatTertip=5

Why Do I Have To Learn These Subjects?

  • You have a patient asking questions about CAM, how do you answer?
  • Patient scenarios: What can you recommend to which patient?
    • A patient presenting with a new onset of back pain
    • Patient with back pain for three months, who has tried almost all treatments but has been unable to find a cure for his back pain
    • Patient for whom you cannot administer any medical treatment due to drug allergy
    • A patient who wants to continue her cancer treatment but is unable to continue despite all medication due to severe nausea
    • There is nothing more that can be done in medical treatment.
  • Good practice in medical prescribing and treatment states: You should prescribe medicines if you have sufficient knowledge about the patient’s health and you are satisfied that the medicines you are prescribing are in the best interests of the patient.

Before prescribing a medicine, you should assess the patient’s condition with the patient.

What Is The Patient's Expectation From The Physician On CAM In The World?

Why do patients prefer CAM?

  • They believe in the combination of CAM and conventional treatment
  • Preference for alternatives to conventional medicines
  • No further progress with conventional treatment
  • They want to be treated from a different perspective
  • Positive feelings about the CAM treatment/practitioner
  • Adverse consequences with conventional treatment
  • Willing to discuss the situation with another professional
  • Referral by the family doctor 7

What Do Patients Expect From Physicians?

Patients prefer a physician who listens to them, who is knowledgeable about CAM, who informs the patient about possible CAM treatments, who refers the patient to a CAM physician when necessary, or who works together.

The proportion of patients requesting a physician who is not interested in CAM, has no knowledge and does not refer to CAM is 9

Patient’s approach to integrative treatment

Role Of The Physician

  • Take TAT research seriously
  • Empathic listening
  • Discuss and initiate CAM use with the patient
  • Liaise with CAM practitioners
  • Question and note patients’ use of CAM

What Is Conventional Medicine?

The system by which medical doctors and other health professionals use treatments such as drugs, radiation or surgery to treat complaints and diseases

  • Other terms:

Allopathy

  • Allopathic medicine
  • Western medicine
  • Orthodox medicine
  • Regular medicine
  • Biomedicine

Conventional medical tests and treatments undergo a series of scientific examinations. If they pass these examinations, they become part of conventional medical treatment.

However, there are always exceptions. Some new treatments offer such dramatic and obvious benefits that their acceptance is rapid and justified.The recommendation of evidence-based decision-making is not very old.

Many conventional treatments today have not gone through these accepted methods. This is because these methods were in practical use before they were accepted.

What Is Evidence Based Medicine?

It is to choose the treatment of the patient based on the best evidence level research as a guide in the clinical decision-making process.

It is a systematic approach determined for physicians to make treatment decisions in the diagnosis and treatment process of diseases in the light of the best and current evidence available, combining their own experiences with the patient’s characteristics and preferences.

It started in the second half of the 19th century. It refers to the conscious and judicious use of the best available evidence in the treatment of each patient. The evidence pyramid visualises both the quality of evidence and the value of evidence.

Systematic reviews are at the top of the pyramid: the strongest evidence and the rarest studies. At the bottom of the pyramid, the number of studies increases and the value of evidence decreases.

Is Evidence Based Medicine Valuable?

  • Evidence is growing very fast
  • Advances in trial design, clinical measurements and methods of analysing data are enabling better design of valid clinical trials
  • Despite these advances in research methods, many published studies report inaccurate or misleading results
  • Many clinicians, including those with reputations, do not apply the best available research findings in medicine

Why Do I Need To Know About TAT?

  • There is a clear trend towards CAM treatments
  • Hospitals offer CAM treatments, Health organisations cover some treatments
  • More and more physicians are applying CAM treatments in their practice
  • Insurances started to cover more TAT treatments
  • Why does everyone use these treatments?
  • Many patients assume that CAM is natural and therefore safe. However, there are risks in the use of CAM. There is often insufficient research on a clear benefit/harm ratio.

Patients May Not Realise That

Lower standards are applied to the alternative treatment industry, both in testing safety and efficacy during the pre-market testing phase and in reporting side effects after market launch

TAT Evidence

  • If any complementary medicine method provides sufficient evidence with accepted scientific standards, this treatment will become part of conventional medical practice.
  • Studies investigating the effects of CAM are increasing day by day.
  • The normal standards required as evidence of efficacy are not suitable for evaluating the effectiveness of CAM.
  • CAM does not work in the same way as conventional medicine.
  • Failure in randomised controlled trials (RCTs) does not mean that CAM treatments are ineffective
  • Is RCT the best study design to evaluate the efficacy of CAM?
  • RCT is considered to be the most powerful study design and the gold standard for evaluating the efficacy of conventional treatments. However, RCT may not be the best method for evaluating CAM efficacy. Because CAM treatments are individualised, multifaceted and double-blind studies are difficult.

Is It Fair To Require Evidence Based Use Of CAM?

  • Is it fair to require such high standards for CAM when only 20-25% of conventional treatments are evidence-based? There is not enough budget to support CAM research.

Ethics/Medical Ethics

  • Ethics/Moral philosophy
  • Medical Ethics “What is ethically good? What is bad?” is the discipline that examines the question.
  • Ethical judgement should be made in medical decision making.
  • The basic ethical principles are the principles of “autonomy, usefulness, non-harm, justice”.

What Are The Ethical Reservations About CAM?

Reservations about patient autonomy and consent

  • Doctors respect patients’ wishes and decisions about their own treatment. Doctors should discuss their treatment and care with their patients, listen to their patients and respect their views on their health. If their preference is for the use of CAM, they should be enabled to access the use of CAM. Doctors should provide adequate information to their patients about the possible effects of the recommended treatment. The efficacy and safety of CAM are currently still controversial. It is impossible/difficult for doctors and other health professionals to ensure that their patients are informed about the benefits and harms in accordance with guidelines
  • If parents request CAM treatment for their child who lacks capacity, how will the decision be made? Parents or other decision-makers on behalf of their child who lacks capacity should act in their best interests when making decisions. It can be difficult for the practitioner to make an informed judgement about whether CAM treatment is clinically appropriate.
  • Similar criticisms can be made of conventional medicine. We do not fully understand the full effects of many of the medicines we use. Doctors may be concerned that their patients tend to be less informed about CAM. This raises questions about the ability of patients to give valid consent for CAM.

Do good, do no harm, autonomy and paternalism

  • The practitioner must act in the best interest of the patient. If he/she believes that there is evidence that CAM will not fully benefit his/her patient, he/she can argue that these treatments should not be applied, prescribed or referred to CAM treatments. Doctors cannot act in a way that harms their patients. Without sufficient evidence of what the risks associated with CAM use might be, the practitioner is not confident.

Honesty, deception and doctor-patient relationship

What If The Use Of CAM Only Offers An Efficacy Equivalent To Placebo?

Ethical reservations about CAM

  • Risks associated with discontinuing the practice of conventional medicine: life-threatening diseases such as cancer, children, infectious diseases. Outbreaks due to lack of vaccination. Harm may affect people who choose not to practise these treatments
  • Fairness and use of public resources: those who can afford it can access it, those who cannot afford it cannot benefit from it. Costs may be greater than the benefits
  • Relationship of interest: the fact that the physician earns money

Recommendations

Autonomy: the obligation to respect the patient’s free medical choices

In The Therapeutic Relationship Between Patient And Physician

  • Physicians must respect the patient’s choice to self-determine his/her own treatment, but it is also his/her right to have his/her autonomy, which includes his/her own clinical judgement, respected.
  • Tension may arise between the physician and the patient if the patient chooses to use alternative therapies instead of conventional medicine
  • If the likelihood of harm is low, it is reasonable to support the patient’s request for complementary treatment
  • If refusal of treatment would result in serious harm, the physician must inform the patient of the risks involved in taking this decision
  • It is unethical for a physician to approve a treatment that has the potential to harm the patient
  • It is important to put personal beliefs aside and talk openly about different potential treatment approaches, rather than downplaying the patient’s questions about alternative treatments.

This Approach

  • It reduces the possibility of physician paternalism, which is overlooked when the physician focuses on the patient’s benefit or harm.
  • Nonjudgemental discussions maintain the therapeutic relationship by ensuring that the patient is willing to return to conventional treatment if their disease recurs or progresses.
  • We must respect their autonomy while fulfilling our obligation to be helpful and do no harm
  • Physicians should be more knowledgeable and open to discussion about CAM treatments, and should adopt a non-judgemental attitude to gain the patient’s trust.
  • Supporting the patient in line with their interests in complementary therapies in cases where there is a possibility of benefit and very little possibility of harm strengthens the patient-physician relationship
  • However, if the patient’s desire to use alternative treatments poses a risk to his/her health, it is an ethical obligation for the physician to recommend medically appropriate treatments to the patient
  • DON’T BE JUDGEMENTAL REGARDLESS OF YOUR PERSONAL OPINION
  • BUILD SINCERITY WITH RESPECT FOR YOUR COUNSELLOR
  • FLAVOUR CAN BE BENEFICIAL WHEN USED CORRECTLY
  • TASTE CAN BE DANGEROUS BY INTERFERING WITH CONVENTIONAL TREATMENT. BE AWARE
  • Some CAM methods are evidence-based, others are based on stories and tradition
  • Some CAM methods may have undesirable effects
  • There may be undesirable herb-drug interactions with some CAM methods
  • Be willing to inform and educate the public about CAM, both positive and negative
  • Recognise that CAM use is popular and should be questioned during anamnesis
  • Recognise that herbs in particular can have significant interactions with prescription drugs and body functions

References

  • https://www.ncbi.nlm.nih.gov/books/NBK83807/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5715216/pdf/main.pdf
  • https://dosyamerkez.saglik.gov.tr/Eklenti/5934,geleneksel-tip-kitabipdf.pdf?0
  • http://nuffieldbioethics.org/wp-content/uploads/Complementary_medicine_FINAL_FL_paper-1.pdf
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3789163/pdf/aim-2008-16-4-10.pdf
  • http://getatportal.saglik.gov.tr/TR,8481/egitim-standartlari.html
  • https://www.gmc-uk.org/-/media/documents/Prescribing_guidance.pdf_59055247.pdf

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