Alternative Medicine

Marjorie Lazoff, MD
Emergency Medicine
Philadelphia, Pennsylvania
Medical Editor
Medical Computing Today

accepted for publication in Medical Computing Today August 1997
(updated) Content: June 1998; Correspondence: June 1999
Originally published in edited form August 1997 in Medical Software Reviews.

OAM - Online Resources - Organizations - Ed/Research - Lists of Lists - Skeptics - Selected Therapies - Summary

Whether yesterday's fad or tomorrow's paradigm, alternative medical therapies such as acupuncture, chiropractic, homeopathy and herbal medicine are part of today's American health care. First, the number of devotees is staggering; David Eisenberg, MD, noted in his landmark 1993 article1 that an estimated 60 million Americans tried at least one of several alternative medical therapies-and more than 70 percent of them never told their physician they had or were doing so. Alternative therapies can affect medical care, by delaying or interacting with prescribed treatments and by introducing new personnel and belief systems not typically a part of the doctor-patient relationship. Further, legal issues surround physicians who recommend or monitor-or, arguably, who fail to inquire about-their patients' participation in alternative care. Academicians within the medical establishment are responding to the popularity of these therapies: The NIH Office of Alternative Medicine is now well established and funding clinical trials at institutions such as Harvard, UCSF, Stanford and Bastyr University.
Complementary or integrative medicine are terms coined to describe the integration of all healing therapies within a holistic care framework either overseen or provided by an MD or DO Supporters insist that many of these therapies have already proved their safety and effectiveness by serving humankind long before public health, high-technology, and molecular biology "revolutionized" medical care. Others believe incorporating alternative medicine has a negligible effect physically but helps our profession reclaim the art and humanism within the science of medicine.
In today's evidence-based, medically managed universe one might assume any therapy without strictly proven efficacy would wither. Yet centers for alternative medicine created or supported by hospitals and HMOs are flourishing, and health insurance coverage for alternative therapies, with its emphasis on low cost preventive medicine, is becoming commonplace. If we believe the alternative medicine skeptics, it is the $13.7 billion alternative medical industry, together with the political correctness and antiscience sentiments of the 1990s, that are driving the U.S. government and mainstream American medicine to embrace, if not respect, these health care practices.2
David Eisenberg, MD's Advising Patients Who Seek Alternative Medical Therapies is both the primary reference for the above introduction and also a good starting point for this review. Dr. Eisenberg, a principal investigator at Harvard University's Center for Alternative Medicine Research, presents a practical nine-step strategy to assist physicians in approaching the subject with their patients and in monitoring those who, after counseling, elect treatment with alternative medicine practitioners. The article also includes an Appendix listing alternative medicine research databases and journals, foundations, institutions and state licensing agencies, many with online resources. Finally, the first 52 references provide a core list of (off-line) general medical and non-medical articles, texts and conferences covering the fundamentals of alternative medicine.
In reply are several letters from physicians who felt his article went too far...or not far enough. Eisenberg further defended his stance in an address to the ABIM and in a US Senate testimonial, both from Fall 1997.
Those interested in an overview of alternative medicine's impact on the medical industry, including physicians, will enjoy an Annual of Internal Medicine's February 1997 article on Patients- and Money-Compelling Doctors To Look At Alternative Medicine. A Pulse editorial from March 4, 1998's JAMA, Evaluating the Alternatives calls for more rigorous studies in what is described as the poorly-defined field encompassing alternative medicine. Across the Atlantic Ocean, a news item in November 1, 1997's British Medical Journal discusses a newly released government report supporting an increased role for integrative medicine in Britain's NHS. Experts agree, but here too warn that there is little proof of efficacy for most alternative medical therapies, despite Prince Charles being "a great advocate of complementary medicine".
BioMedNet's excellent electronic journal HMS Beagle's article on Checking Up on Alternative Medicine discusses how American news media has covered, and should cover, alternative medicine stories.
Sections Office of Alternative Medicine
National Institutes of Health's Office of Alternative Medicine (OAM) has been on line since June 1997 with a graphically pleasing, technically sophisticated and disclaimer-laden site. OAM's Site Index is the least scenic but most convenient way to navigate the site. Two slide show presentations one on AOM as an organization, and a second on Alternative Medicine, introduce the site and can be viewed online or downloaded.
Midway down the General Information page is a list of broad categories adapted from Alternative Medicine: Expanding Medical Horizons, a 1992 report available for purchase on line. OAM's classification is far-reaching, including bioelectromagnetic applications and apitherapy (bee venom) alongside naturopathic medicine and acupuncture. The core of OAM's activities involves Six Program Areas. All are accessible on line and several are interesting resources, such as the research grants database. What's New lists available NIH research funds such as fibromyalgia, ischemic heart disease, and acupuncture. Also available at the site is the Complementary and Alternative Medicine Newsletter. Unfortunately, the reference area is very limited and almost exclusively for patients, and the files for downloading are taken word-for-word off the site.
One important addition is a page linking all ten complementary and alternative medicine (CAM) research center Web sites. Each federally funded center applies alternative medical therapies to a different area or aspect of clinical research. As a group they cast a powerful presence online; this is a well-funded and clinically strong network from which we can expect the core of research into alternative medical therapies to emerge. An eleventh CAM research center, the Center for Chiropractic Research was announced in March 1998.
The best of these CAM center Web sites is University of Texas at Houston's Center for Alternative Medicine. In collaboration with UT-M.D. Anderson Cancer Center, this CAM seeks to facilitate the scientific evaluations of biopharmacologic and herbal therapies and innovative approaches, primarily in cancer. Its attractive site includes, among other things, a scholarly reference listing of herbal and biological agents on its cancer research page, many of which also contain critical analyses of the literature.
Another site with useful online information is the Center for Research in Complementary and Alternative Medicine for Stroke and Neurological Disorders. This center, a joint project of Kessler Medical Rehabilitation Research and Education Corporation and the University of Medicine and Dentistry of New Jersey, Newark, New Jersey, assesses the current state of complementary and alternative medicine rehabilitation techniques as applied to stroke, brain injury, spinal cord injury, and related neurological injuries and disorders, including multiple sclerosis and Parkinson's disease. Their online descriptions of neurologic disorders is accurate enough for health professionals and students but may prove difficult reading for the average patient. One nice feature is on line technical help in designing OAM research protocols. Included too is a moderated bibliography of clinical studies.
U Minn's Center for Addiction and Alternative Medicine Research was created to study the prevalence and efficacy of alternative/complementary modalities in the treatment of substance abuse. Site highlights include a concise description (with contact points for further information but, alas, no references) of various alternative medicine modalities and their relationship to addiction medicine.
Columbia-Presbyterian's The Center for Complementary & Alternative Medicine Research in Women's Health is part of the well-regarded Rosenthal Center for Complementary and Alternative Medicine. It too lists research projects, but this CAM center's best online feature is a list of Women's Health Resources on the Internet.
Other CAM centers on line: Complementary and Alternative Medicine Progam at Stanford is researching the topic of "Successful Aging". This page describes its research interests and provides users with print and online references. Virginia Med School of Nursing's Center for the Study of Complementary and Alternative Therapies fact sheet discusses its mission and research into pain control. Beth Israel Deaconess's Center for Alternative Medicine Research provides a somewhat dated summary of research projects and other information.
Unfortunately, two CAM centers provide good examples of how not to design a Web site. UC Davis' Center for Alternative Medicine Research in Allergy and Immunology opens with a single slow-loading "welcoming" graphic that does not consistently go to its busy frames-laden home page. Once home, the site has information about itself, its staff, and summaries of research proposals. Other information is either promotional or mentioned elsewhere in this article. Another visually noisy home page is Bastyr U's AIDS Research Center. Better to enter directly to the Information Page, which describes their research efforts, or its newsletter.
A commentary in March 4, 1998's JAMA by OAM's director, Wayne Jonas, MD, on Alternative Medicine and the Conventional Physician gives a great deal of information in a relatively short article: a background of complementary and alternative medicine as practiced today, history of the AOM, recommendations for conventional physicians who wish to introduce CAM into their practice, and guidelines for medical education.
The OAM has received both criticism and support, some of which is reflected online. "The AMA encourages the Office of Alternative Medicine of the National Institutes of Health to determine by objective scientific evaluation the efficacy and safety of practices and procedures of unconventional medicine" comes from 1993's AMA Policy on Alternative Medicine. Far stronger concerns about alternative medical therapies and the OAM are voiced by Stephen Barrett, MD, in his Be Wary of "Alternative" Health Methods. Although no longer on line for free, it's easy to reconstruct at least part of Leon Jaroff's NY Times' October 6, 1997's op-ed article, Bee Pollen Bureaucracy -- that the "objective scientific evaluation" has become secondary to OAM's political agenda -- by reading an unpublished reply to Jaroff's criticism of OAM. The author of this reply, David Moss, PhD, also posts his 1996 An Interview With OAM's Advisory Council Chair James Gordon, M.D.
Sections Online Resources
HealthWorld Online's Alternative Medicine lists about 10 articles on complementary and alternative medicine, most written by physicians. At the same site, Mary and Michael Morton write to patients about The MD as an Alternative Practitioner and Ten Frequently Asked Questions about Alternative Medicine. They warn of physicians who are not competently trained in alternative medical therapies or who prescribe alternative care without embracing the holistic care principles behind these therapies.
The conventionally-designed Alternative Health News Online offers consumer news from a plethora of sources, and links on both alternative and conventional medicine.
The Institute for Traditional Medicine is a nonprofit organization whose ITM Online sells educational materials and posts articles written by the Institute's Director, Subhuti Dharmananda, PhD. Advanced Information for Traditional Practitioners offers 25 articles on aspects of acupuncture, Chinese herbal medicine, and therapies for specific disorders such as asthma, arthritis, multiple sclerosis, HIV/AIDS and cancer. Also included on the site are general articles on the philosophy and practice of Chinese, Tibetan, Ayurvedic, Native American and Thai traditional medicine, and several articles warning of deliberate contamination of herbal medicines with prescription drugs. Without the requisite expertise I can not comment on the content, except to note the articles' lack of hyperbole and thoughtful explanations of eastern concepts to western medical minds. Some references are provided.
Nutritional supplement manufacturer/supplier Thorne Research Company's Top of the Heap posts a few dozen journal abstracts from Medline and peer-reviewed alternative medical journals. Health professionals who register with the company have access to additional online educational materials. Thorne publishes Alternative Medicine Review, abstracts and editorials of which are on line gratis. Synergistic Health Center Services' Aesclepian Chronicles alternative medicine online journal is largely written by its staff. This site has a nice list of links, although its HTML coding is off in a few places and several key links are no longer active. Onhealth's Alternative Healthprovides brief references to Therapies, Herbs and Remedies, and Medicines.
F or those who missed the media hoopla, Andrew Weil, MD, is the Harvard-trained physician whose holistic health books, PBS special, and Ask Dr. Weil Web site brought Integrative Medicine to a spring 1997 cover of Time. One of the original Web resources originally housed on the trendy HotWired site, Ask Dr. Weil joined the entrepreneurial Pathfinder Network in May 1996, where it remains hugely popular. Supporters view Dr. Weil as the prototype physician advocating sensible alternative medical therapies within a conventional medical framework and believe his Institute of Integrative Medicine at the University of Arizona is at the vanguard of American medical education. Detractors condemn Dr. Weil's limited clinical experience, the almost total lack of scientific documentation supporting his recommendations, and his overtly commercial stance. This is the same Andrew Weil whose first book, The Natural Mind, was very popular on college campuses in the 1970s.
The site has been redesigned, and while still in frames format many of the old bugs have been eliminated. Its main feature remains the archives of daily Q&A questions on contemporary health issues submitted by readers with answers by Dr. Weil. There are also various references under Self-Help and Community, in additional to several linked commercial ventures. Professionals will want to avoid the slow-loading bulletin boards unless they wish to join in the self-promotional postings.
O ther helpful/interesting online resources: University of Washington's Medical Herb Garden Home Page is for herbalists, medics and botanists but includes for the rest of us a very picturesque database. UCLA Center for East-West Medicine has administrative information and two issues of its newsletter last published in early 1996. Hesketh and Wei's British Medical Journal article Traditional Chinese medicine: one country, two systems discusses TCM within China's increasingly Western-influenced culture. University of Pittsburgh's Studies on Use of Alternative Therapies is a 1994 bibliography of research articles from mainstream medical journals.
American Health Consultant's, a vehicle to promote its new newsletter, Alternative Medicine Alert, is designed for medical practitioners to keep abreast of alternative medical therapies. It provides links to lists of alternative health practitioners. A message board started in the end of April 1998 that remains unused a month later.
Sections Organizations
Myriad professional organizations are included in the Lists of Lists section below; several with fully realized or interesting sites are included here. The American Association of Naturopathic Physicians (AANP) represents licensed NDs. Their online edition of A Textbook of Natural Medicine contains 22 chapters that are freely accessible on site, in addition to 50 chapters accessible for a $2 fee, payable in CyberCash. AANP's Library lists a number of free resources, including articles written by NDs and abstracts from their peer-reviewed Journal of Naturopathic Medicine. For an editorial in response to Eisenberg's landmark 1993 study cited above see Hard facts from the fiction department. Many Internet references are listed under Natural Links, a number of which are appropriate for health care professionals. AANP is politically active, and the site contains information regarding their efforts.
Federation of Chiropractic Licensing Boards' site is largely administrative, although it does list a helpful FAQs on Chiropractic Licensure, describing what credentials are required and what the public can expect from a doctor of chiropractic. Other nonmedical information can be found on American Chiropractic Association (ACA) Chiropractic Online.
National Center of Homeopathy, comprising 7,000 consumers and professionals, is the largest homeopathic organization in the United States. Its Web site is simple text, with straightforward articles describing homeopathy theory, practice and research. The comparatively low-key International Foundation for Homeopathy also provides some general descriptions and introduces its 240 hour Professional Course.
American Holistic Health Association has online information defining a holistic lifestyle and encourages all health practitioners to join their ranks.
The Great Lakes Association of Clinical Medicine is a nonprofit corporation of primarily Midwestern MDs and DOs providing an educational forum for member physicians and their staff regarding developments in medical practice and patient care. Their lectures and meetings are focused on alternative medicine issues.
Sections Education/Research
I was unable to locate online CME on alternative medical practices or therapies, and not much more could be found on medical schools/institutions regarding alternative medicine education or research. A laudable exception is Columbia-Presbyterian Medical Center's The Rosenthal Center for Complementary and Alternative Medicine, which introduces its goals and presents its present and future cancer research activities. Click on the home page's Information Resources for physician-oriented databases and other network resources, including Internet resources. Also included is a list of residency and fellowship programs and educational programs for med students/MDs in homeopathy, acupuncture, and herbal medicine. There are two Web listings of alternative therapies courses (1st listing 2nd listing) taught at US medical schools.
Many CAM centers listed above include reference to their research efforts. As one of this country's premier schools of naturopathy, Seattle's Bastyr University's research page lists bibliography of past and present research at this nation's top college of naturopathy, and links to Alternative Medicine on the Internet.
Sections Lists of Lists
In addition to the Rosenthal Center noted above, three online references will take the reader beyond this review to alternative medical therapies and their medical, legal and political ramifications. University of Pittsburgh Falk Library of the Health Sciences Alternative Medicine Homepage includes an excellent although dated annotated Internet list. McMaster University Health Science Library's Healthcare Information Resources: Alternative Medicine has another excellent annotated listing, divided into general and specific sites. The popular Alchemical Medicine Research and Teaching Association (Amr'ta) includes multiple lists of Internet and offline resources, and has information regarding Paracelsus, an Amr'ta-sponsored clinical discussion list for health care professionals.
New York Online Access to Healh (NOAH)'s Alternative (Integrative) Medicine is a list of articles organized by topic and maintained by librarians. Arbor Nutrition Guide's annotated list on clinical nutrition has a decidedly alternative medicine slant, yet includes many good scientific and referenced articles and resources, and Sympatico's HealthWay list of Alternative Medicine is particularly useful for its descriptions and rating system. Peter Bowers, MD of Virginia Med's List of Alternative and Complementary Sites is a popular reference, but it leans strongly away from scientific medicine.
For those seeking online references, a PubMed search of alternative medicine calls forth articles published since January 1, 1998, most with abstracts and several with full text versions available on line.
Sections Skeptics
National Council Against Health Fraud (NCAHF) is a private nonprofit, voluntary health agency that focuses on health misinformation, fraud and quackery as public health problems. Included on the site are its sometimes dated but well-referenced position papers on a number of alternative practices, including acupuncture, chiropractic and homeopathy. Other sections include News and Announcements, and its newsletter, current as of February 1998.
Many of NCAHF's resources, and more, are presented in a more graphically pleasing format on the new Healthcare Reality Check. Also available on this site is the 1,200-plus term Dictionary of Metaphysical Healthcare: Alternative Medicine, Paranormal Healing, and Related Methods by Jack Raso, MS, RD. Check out its anti-quackery mailing lists, links to other sites and alternative medicine annotated bibliography for reviews of books. New features include sample articles from the inaugural issue of Scientific Review of Alternative Medicine, and a developing section on Victims of Quackery, which aims to debunk the myth that alternative medicine always entails a "first, do no harm" approach.
Quackwatch, founded in 1969 by Stephen Barrett, MD, is a nonprofit corporation to combat health-related frauds, myths, fads and fallacies, and to improve the quality of health information on the Internet. The major categories of practice are defined under Miniglossary of "Alternative" Methods. Dr. Barrett's Be Wary of "Alternative" Methods argues in support of what he feels has become politically incorrect scientific medicine. In a related article, he makes two critical definitions: "Quackery entails the use of methods that are not scientifically accepted. Malpractice involves failure by a health professional to meet accepted standards of diagnosis and treatment."
Philosophy professor Robert Carroll, PhD's well-regarded The Skeptic's Dictionary section on Alternative Health Practices includes an article contrasting the benefits and limitations of both alternative and traditional medical care, and links to alternative therapies from the Dictionary. Filipino health journalist George Nava True II's Health Frontiers' Center for Quackery Control is an ambitious labor-of-love project for consumers. Australian's cleverly titled Qakatak isn't quite up to the standards set by Quackwatch and the HCRC.
The American Council on Science and Health (ACSH) is a non-profit independent organization founded in 1978 by a group of scientists concerned that many public policies related to health and the environment did not have a sound scientific basis. Only a handful of its medicine articles are directed at Alternative Medicine but readers who peruse this section, and others, are likely to find interesting, relevant, and succinct articles on a number of health issues. Unfortunately, these articles and the site itself carries no primary references. One worthy editorial, by Priorities editor-in-chief Jack Rao, MS, RD, evokes Drs. Weil and Eisenberg, among others, in asking Is There a Cure for Alternative Medicine?. Rao argues that the non-scientific basis of most alternative medical practices is best defined from a religious perspective. "Indeed, in my view, alternative healthcare's acceptance of "spiritual health" as a medical concern is what chiefly distinguishes it from science-oriented medicine (which typically relegates spiritual matters to pastoral counselors and other religion professionals). In this article I hope to show that alternative medicine is, by and large, religious medicine."
Finally, PhACT Links lists Web sites for skeptics, many of which contain medical information.
Sections Selected Alternative Medical Therapies
In November 1997, the NIH (to which OAM belongs) issued a consensus development paper on Acupuncture online. While more accomplished expositions on acupuncture exist elsewhere (see below), this paper is enlightening from a government policy perspective. The authors conclude, "There is clear evidence that needle acupuncture is efficacious for adult post-operative and chemotherapy nausea and vomiting and probably for the nausea of pregnancy...there are reasonable studies (although sometimes only single studies) showing relief of pain with acupuncture on diverse pain conditions...while many other conditions have received some attention in the literature and, in fact, the research suggests some exciting potential areas for the use of acupuncture, the quality or quantity of the research evidence is not sufficient to provide firm evidence of efficacy at this time." The NIH predicts, "As acupuncture is incorporated into today's health care system, and further research clarifies the role of acupuncture for various health conditions, it is expected that dissemination of this information to health care practitioners, insurance providers, policy makers, and the general public will lead to more informed decisions in regard to the appropriate use of acupuncture...Issues of training, licensure, and reimbursement remain to be clarified. There is sufficient evidence...of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value." This paper's large bibliography is drawn from the spectrum of mainstream and alternative medical journals.
England's Research Council on Complementary Medicine is closely linked to The Foundation for Traditional Chinese Medicine. The foundation was established in 1991 to "promote research into acupuncture and to bring the traditional Chinese system of acupuncture more centrally into the national health care system". Summaries of research proposals are presented for low back pain, migraines, research methodology, and acupuncture. Also included is a rather superficial review of acupuncture from a patient's perspective, and a list of British training programs for practitioners.
Charisios N. Karanikiotes M.D. maintains The Medical Acupuncture Web Page from the medical school at Aristotle University, Greece. Site highlights includes Therapeutic Basics, for those curious about needling methods and points, and The Web Journal of Acupuncture which, together with articles represent two of the better consumer and acupuncture professional article resources. Those looking for a scientific approach to acupuncture will appreciate The Mechanism of Acupuncture.
From a more skeptical perspective, see Stephen Barrett, MD's article from November 1997's Quackwatch, Acupuncture, Qigong, and "Chinese Medicine, Robert Carroll, PhD's Acupuncture from The Skeptic's Dictionary, or even the irreverent Fortean Slips's The FDA Approves Acupuncture. But the most balanced view on acupuncture are offered in editorials by George Ulett, MD and Jack Rao, MS, RD, in ACSH's quarterly magazine Priorities.
On re-reviewing the Association of American Naturopathic Physicians' Library, I was unable to locate the journal abstracts mentioned on the home page, and their Database of Articles has contents which will likely frustrate those with a scientific bent. If (unlike me) you know the most potent herb used to control hypertension, and the homeopathic remedy with a history of repeated vaccinations, then you can gain access to the Naturopathic Medicine Network Professional Section for NDs and their students. Medical Sciences Bulletin, an online pharmacology resource, describes how Herbal Medicine Can Reduce Cost in HMOs.
Plant Abstracts from the Southwest School of Botanical Medicine is a list of Chemical Abstracts and Medline references, listed by genus. This enormous resource is of limited utility without a full-text search engine. For those who like to match pictures to words, The Internet Directory of Botany: Images is a well-regarded and maintained reference. Scroll to the bottom of this page for other botanical references.
Amid threats of loss of funding, there is information about plants used in traditional medical practice, such as colchricine, vincristine, and hemp at Indiana University's BioTech Project's Cyberbotanica. This is a nice site; considering the Project in general, it's easy to imagine how Indiana U might justify BioTech's grant renewal.
By way of background, the ACA's Chiropractic State of the Art 1994-5 provides a good description of the philosophy behind chiropractic treatment, and optimum clinical and professional practice. The Chiropractic Research Journal needs a text search engine to best access its generous offering of articles online, but scanning the table of contents on the bottom of the home page gives a good feel for this reference. ACA's Links is a huge list of lists for chiropractic and other alternative medicine Web sites, and Canada's The Chiropractic Page is an annotated list of chiropractic sites.
Alternative Cancer Therapies
The Journal of Clinical Oncology's Web site includes an abstract from its April 1998 issue on Alternative and Complementary Therapy Use in Pediatric Oncology Patients in British Columbia: Prevalence and Reasons for Use and Nonuse, a descriptive study.
The Office of Technology Assessment (OTA)'s 1990 report on Unconventional Cancer Therapies is applauded by some who support an integrative approach to health care. Like all OTA reports, this US government-funded report can be freely downloaded.
The entire contents of Choices in Healing is online. This book was written in the mid 1990s by Michael Lerner, Ph.D (political science) and founder of Commonweal, an institute which, among other things, supports integrating "mainstream and complementary cancer therapies". Chapter 27 provides a good summary of Lerner's philosophy and generally balanced advice.
Dr. Moss is a self-described scientific writer who boasts past advisory positions at Memorial-Sloan Kettering and the OAM, among others. His freely available Moss Reports contains articles on alternatives to cancer treatments. One Report, a 1998 special issue on Congressional hearings regarding alternative cancer therapies provides a one-sided critique of the government proceedings. It also proclaims the subsequent removal of "offensive" statements about alternative and complementary medicine from the National Cancer Institute Web site and elsewhere. Dr. Moss offers an extensive list of articles on treatments for specific cancer which can be purchased off line (at $275 each).
Sections In Summary
In the original NetView I expressed dismay over how little practical clinical information on alternative medical therapies was available on line for scientifically-oriented physicians. This is as much a reflection of the discipline's lack of good research, trials, and outcome studies as to a lack of disciplined online information. As before, almost all online alternative medicine resources can be divided into two groups: those offered by proponents of such therapies who provide little evidence beyond anecdotal cases and soft research studies, or those by critics who condemn these therapies without proving their complete futility.
While still lacking quality content, I now find that the Web is developing a quorum of alternate viewpoints by which scientifically-oriented physician, reading representative online writings, can begin to grasp key issues in alternative medicine. This provides us with much-needed information at a critical junction in American medical care. As leaders within alternative medical movement accept positions of power within government agencies and corporations, the dynamics of American medical care is likely to change in the direction of incorporating alternative medical therapies into our clinics, offices, ORs, EDs, hospitals, organizations, and insurance plans. Those of us who are without clinical experience or information on these alternative therapies need reliable resources by which to educate ourselves.

1. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: Prevalence, costs, and patterns of use. N Engl J Med 1993;328:246-52.
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2. Eisenberg D. Advising patients who seek alternative medical therapies. Ann Intern Med 1997;127:61-69
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June 4, 1999

Sirs --

In her otherwise excellent article providing links to alternative medicine resources, Marjorie Lazoff concludes by saying, "As before, almost all online alternative medicine resources can be divided into two groups: those offered by proponents of such therapies who provide little evidence beyond anecdotal cases and soft research studies, or those by critics who condemn these therapies without proving their complete futility."

While I agree with the first part of her statement, stating that critics fail to prove the "complete futility" of alternative medicines unfairly shifts the burden of proof of efficacy from proponents to critics. In fact, it is generally not possible to prove something false. Rather, false ideas are generally discarded as evidence for their effectiveness fails to accumulate (a state of affairs that has so far been avoided by unproven "alternative" therapies).

Furthermore, there is an accumulating pile of evidence that many "alternative" therapies are not effective. For example, 12 reviews and meta-analyses of homeopathy over the past 13 years in 3 languages have failed to come up with a single condition in which it is an effective therapy. Similarly, studies consistently fail to show differences between "real" and "sham" acupuncture, fail to distinguish between chiropractic and other "hands on" therapies (or even exercise pamphlets) or fail to show that herbal remedies contain therapeutic levels of their active ingredients (even when there *are* active ingredients). Nevertheless, this evidence of ineffectiveness is blithely ignored by proponents of "alternative" therapies. It's a shame that such hard evidence was overlooked by Dr. Lazoff in her conclusion.

David Ramey, DVM
The above was forwarded to the author of the article, who responded:
June 4, 1999

Dr. Ramey,

Thank you for your thoughtful comments. Your point is well taken; we should not set the skeptics' bar so high that they are faulted for failing to demonstrate alternative medicine's "complete futility," and in doing so I clearly overstated. As you say, science cannot prove a negative.

My point in that poorly worded sentence was that both the proponents' acceptance and skeptics' condemnation of alternative medical therapies seemed inappropriate given the actual content on their respective Web sites. That there isn't a plethora of good studies at present should attenuate both acceptance and criticism of these therapies until such studies become available, in my opinion.

I too am frustrated with studies on herbal remedies that do not bother to verify potency or measure blood levels of active ingredients -- or having done so, denounce the remedy without verifying that these measurements fall within therapeutic range. Our sole difference may be that you have already written off homeopathy, acupuncture, and chiropractic based on our present crop of studies while I am still straddling the fence, unconvinced but hopeful, waiting for those better designed and conducted double-blind, randomized clinical trials to tell us if a given therapy is efficacious for a specific population with a particular condition, so we can make practical use of that information in caring for individual patients. No doubt you think I'm waiting for Godot.

Marjorie Lazoff, MD
To which Dr. Ramey replied:
June 4, 1999

Dr. Lazoff -

I hope that you will not characterize me as having "written off" anything but homeopathy. That science, based on an unscientific and semi-mystical concept has been so thoroughly discredited that it is virtually beyond salvation. Its concepts are against any number of branches of science (physics, chemistry, pharmacology, to name three) and the enormous weight of studies fails to show efficacy. At some point, looking for evidence becomes a futile exercise. After 200 years in which homeopathy cannot be shown to be effective for a single condition, I wonder when that time will come.

Acupuncture and chiropractic represent far different challenges. Both systems were founded in ideas that do not stand up to any form of scrutiny - neither acupuncture's qi nor chiropractic subluxations can be shown to exist. Nevertheless, it is reasonable to hypothesize that placing a needle might have a physiologic response (whether the site of needle placement matters is another question) or that physical manipulations of the body might have some sort of a therapeutic effect. Just because the philosophies are at odds with scientific reality doesn't necessarily mean that the therapies are. Again, after much time (2000 years for acupuncture; over 100 years for chiropractic) it's perhaps instructive that we are still wondering about their efficacy; you never know, Godot might show up some day.

David Ramey, DVM
June 5, 1999

All good points, Dr. Ramey, although a devil's advocate might defend the historical importance of homeopathy as the foreboder of allergy and immunology, in spirit if not actual science.

Meanwhile, the hopeful among us could use a good game of Waiting for Godot -- The Interactive Adventure.

Qi sera sera,
Marjorie Lazoff, MD
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