Sir William Osler, who advised to "be not the first nor the last" in adopting new therapeutic approaches, would probably be appalled at how many physicians are dragging their feet with respect to complementary and alternative medicine (CAM). In fact around the turn of the century Dr. Osler himself recognized that acupuncture was a useful adjunct for patients with low back pain. The objection physicians most often raise for not accepting or adopting CAM is that there are no studies adequately documenting safety and efficacy for these therapies. As more and more studies document both the safety and efficacy of select CAM interventions in specific clinical situations the above objection becomes more of an excuse based on ideology than a reason founded on thoughtful consideration. With a significant percentage of our patients using CAM it is apparent that physicians who choose to remain willfully ignorant of CAM are doing their patients a disservice. 

Ideology Centered Research
Historically, there were two divergent post-Hippocratic schools of medicine. One was called empiricism, which relied on experience and observable events, the other was called dogmatism, which assumed ultimate truth could be known. In Dorland's medical dictionary, the above is explained and an additional entry under empiricism equates it with quackery. The feat of relegating experience and observable events to quackery was accomplished with the adoption of the "scientific method" in medicine. Scientific medicine, also referred to as rational medicine, is in essence a form of neo-dogmatism. The assumption of this approach is that absolute knowledge can be tested and proven or disproven incontrovertibly. The current tool most favored for this is the double-blinded, placebo controlled study. This tool has several assumptions and limitations. The primary assumption is that all extraneous variables can be controlled. If we were studying robots, or genetically controlled strains of mice, in which we control both nature and nurture, this might be true. However, since we are dealing with people, each with their unique variations in physiology and personality, the most favored tool will fail to detect clinically significant outcomes in certain subsets of the studied population. Another shortcoming of the most favored tool is that some therapies cannot be doubled-blinded, thereby excluding these therapies from the "scientific" arena. To give an example illustrating both of the above points - consider a study of acupuncture in the treatment of asthma. The two arms of the study involved patients who were treated with needling of sham acupuncture points (placebo) or needling of real acupuncture points. The patients did not know whether they were receiving sham or real acupuncture, however the practitioner clearly had to know who received what treatment. All patients in the non-sham group had the exact same acupuncture points stimulated in the exact same way. This is an insult to anyone who knows the slightest bit about Traditional Chinese Medicine (TCM). TCM, from which acupuncture is derived, recognizes at least seven major types of "asthma" with many minor variations. A "one size fits all" study tool clearly compromises the underlying principles of the therapy being studied. Therefore it is no surprise that studies with this type of design fail to show a clinically significant effect. A much more reasonable study design would take into account both individual variability and the therapy being studied. Outcome studies, which have been in the press a lot recently, are more suited for CAM research because they focus more on results than on theory or ideology. 

Patient Centered Research
There has been a rude awakening of the medical establishment over the last few years. Limited health care resources and cost containment efforts by third party payers have demanded that we prove that what we do in Western allopathic medicine (WAM) works. Unfortunately, 70 to 80% of what we do in WAM has not met this standard of proof - the same standard of proof being demanded of CAM. The cost of doing research which proves anything "beyond a shadow of doubt" is very high. In fact the cost of this type of research is so prohibitively high that we will never be able to afford proving beyond a shadow of doubt most of what we do in WAM. If WAM with its generous financial resources can't afford to prove everything it does it is obviously self-serving to expect CAM, with more meager funding, to do so. The use of outcome studies levels the playing field for both WAM and CAM. Outcome studies could just as easily be called "patient centered research" because what matters most to the study is what matters most to patients - results. 

The Clinical Dance
The same dogmatism that has prevailed in research until recently has also prevailed in clinical practice. The assumption has been that physicians, with their specialized biomedical training, would always lead the clinical dance and the patient would follow. More and more patients are questioning this assumption and trying to lead the dance at times. Patients who are "stepped on" because the physician refuses to follow often choose to find someone else to dance with. According to a number of studies between thirty and fifty percent of our patients are opting to use some form of CAM for their health care. If we systematically put patients down when they use CAM and refuse to learn anything about CAM they will find someone else to dance with! Am I suggesting that we endorse every fad or agree with everything our patients do? Hardly. I am suggesting that we should take an active interest in what is clearly relevant in our patients' lives. If we get educated about CAM we can engage our patients in meaningful discussion on the subject, with a chance of being heard and of helping our patients make good choices. If we choose to remain dogmatic and uninformed about CAM we will not be heard and will consequently do our patients a disservice. In fact, it is probably negligent to not ask our patients about their use of CAM because of the potential interactions and occasional contraindications with what we do in WAM. If we lead the dance in this direction, as we should, it is vital that we be well informed and able to give good advice and honest answers on the subject. We should try to lead by being well informed. We should be willing and able to follow when patients take the lead. If we're unable to lead and/or follow we should, as the saying goes, get out of the way.

Pragmatism & Medical Evolution
The ever changing knowledge base and climate in medicine requires us to be pragmatic with respect to our research methods - the tools and methodology have to be flexible enough to accommodate what we are attempting to study. Rigid, inflexible tools and methodology will result in bad data, bad conclusions, and the perpetuation of dogma. The changing patient - physician relationship also requires us to be pragmatic. We need to learn some new dance steps if we don't want to left out. Even reimbursement for medical services requires pragmatism. If you remain inflexible in this rapidly changing area you will quickly go out of business.

The physician who refuses to evolve will become extinct. Pragmatism is the attitude that makes medical evolution possible. Dogmatism is the attitude that leads to medical extinction. One of my favorite cartoons depicts two cave men talking to each other with chisels in their hands and some stones in the background. The caption reads, "The trouble with being a cave man is that everything has to be carved in stone." Let us not think that everything has to be carved in stone! 

Patient Centered Medicine
An often quoted saying of Dr Francis Peabody Weld is, "The secret of caring for the patient is to care for the patient!" Well, what exactly did Dr. Weld mean when he told us to care for the patient - and what relevance does it have to CAM? To care for the patient undeniably involves caring what they care about. Patients care about results more than ideology. Patients have their own ideas and preferences. To put patients down for their ideas or preferences or to not give a hoot about how their ideas and preferences impact their health is not what Dr.Weld had in mind. 

The studies show repeatedly that a significant number of our patients care about CAM. We had better start caring about CAM if we care for the patient - otherwise we'll find ourselves deselected from the caring pool by a significant number of patients. Caring about CAM requires, at a minimum, that we become well informed and that we discuss the subject with our patients. For physicians who want to do more than the bare minimum it makes sense to expand the frontiers of knowledge in CAM by doing outcomes research to better define the parameters of safety and efficacy. It also makes sense to offer CAM to our patients as an option in the select instances where research documents a high probability of safety and efficacy.

By being less dogmatic and more pragmatic we will be better able to care for the patient. Pragmatism and a touch of humility will allow us to move from ideology and physician centered medicine to what Dr. Weld had in mind - patient centered medicine.