Changing physician perspectives on complementary and alternative medicine: the need for a top-down approach.

Dear editor

We read with great interest the article by Patel et al1 discussing the changing perspectives towards complementary and alternative medicine (CAM), and an impetus for additional physician knowledge of the strengths and drawbacks of CAM. These findings are indeed relevant in the UK, with an estimated 41.1% one-year prevalence of CAM use, responsible for an annual out-of-pocket expenditure of £1.6 billion.2 We agree that improved training and education in medical school and residencies – which can be thought of as a “bottom-up” approach – are fundamental in preparing the health care system for improved integration of CAM. However, we also suggest that “top-down” changes are required to optimize patient care.

The top-down approach suggests that to better clarify CAM’s role in conventional modern health care, changes must originate from governing bodies and organizations in the form of clearer guidelines. There is no clear consensus within the UK medical community regarding the efficacy of CAM therapies. As Ernst and Terry reported, interpreting recommendations made by the National Institute for Clinical Excellence (NICE) in the UK can be challenging.3 Using statements such as “some patients may find CAM useful” and “further research is needed”, guidelines often imply that patients should decide the value of CAM by “trial and error”. Nevertheless, the UK National Health Service (NHS) currently recommends and provides CAMs in specific circumstances, including the Alexander technique for Parkinson’s disease and acupressure for morning sickness.

The disconnect separating CAM from mainstream medicine is stark not only in the (lack of) physician training about CAM, but equally apparent in the contrast in clarity between NICE guidance for conventional treatments compared with CAM. Ernst et al reported in 2010 that the guidelines appear to exclude CAM in certain cases where there is evidence for its use, the example given being that of chronic back pain for which massage and acupuncture are recommended whilst other CAM modalities such as hydrotherapy and yoga are not mentioned despite having similar evidence bases.4 Similarly, the herbal remedy St John’s Wort is not recommended by NICE due to uncertainty about appropriate doses and interactions, despite being shown to be more effective than placebo for depression.5 This inconsistency suggests a lack of uniformity in the consideration of CAM when publishing these guidelines and may feed underlying negative perceptions of the validity of CAM within the medical community.

Public use of CAM therapies is increasing, and their gradual inclusion in national guidelines signals greater acceptance of their use alongside conventional therapy. Although a lack of understanding about CAM therapies can be rectified by improving physician education, we feel that unless guidelines change to gain more clarity and consistency, patient–physician miscommunication, confusion and skepticism will persist. Given the potential for CAM to cause harm, particularly through dangerous interactions with or neglect of conventional treatments, we feel that it is vital to have clearer and more consistent guidelines with which to educate physicians about CAM.

Dear editor

We agree the letter is worthy of publication but have a little to add: a top-down approach (as suggested and described by the authors of the letter) certainly complements the bottom-up approach (described in our article).1