Can-CAM-be-EBM

Report
Can Complementary and Alternative
Medicine be Evidence-Based
Medicine?
What is EBVM?
Evidence based medicine is the conscientious, explicit,
and judicious use of current best evidence in making
decisions about the care of individual patients.
…integrating individual clinical expertise with the best
available external clinical evidence from systematic
research.
Sackett, DL. et al. Evidence based medicine: what it is and what it isn't
BMJ1996;312:71
What is EBVM?
The integration of the best research evidence with our
clinical expertise and our patient's unique values and
circumstances.
Strauss, SE. et al. Evidence-based medicine: how to practice and teach
EBM. (2005) 3rd ed. Edinburgh: Churchill Livingstone.
All Evidence is not Created Equal
Critical Appraisal
•Level of evidence
•Control for Bias/Confounding
•Plausibility, Consistency, Coherence,
Strength
What is EBVM?
This succinct, some would say obvious, definition of what
we all try to do anyway, belies the more profound
philosophy behind EBVM. At its heart is the confidence
in the scientific methodology that has developed over
the centuries to enable us to distinguish what is likely to
be true from what is likely to be false (or unproven).
Cockroft, P. Holmes, M. et al. Evidence-Based Veterinary Medicine (2003)
Oxford: Blackwell.
“[Science] is the
“Democracy
is the
worst
worst
form
form
of of
government, except
[epistemology],
except
forfor
all those
all those
other
other
forms that have been tried." (Winston
Churchill, from a House of Commons
speech on Nov. 11, 1947)
We Are Easily Fooled
Self-Doubt is Healthy
•We tend to see what we look for and expect to see, we remember
things which confirm our beliefs and ignore or forget those that show
us to be wrong
•Being smart, well-educated, experienced, or well-intentioned doesn't
protect us much from common errors in judgment
•The judgment of individuals, however respected or numerous, is less
reliable than the assessment of objective scientific research
CONCLUSIONS
Self-Doubt is Healthy
…Often getting the right diagnosis and therapy is less
about what you know and more about being rigorous
about understanding how you know. Only when you
are conscious of your ability to think poorly, can you
compensate.
Mark Crislip, MD
Quackast, Science-Based Medicine, Pus Whisperer
The real purpose of the scientific method is to
make sure Nature hasn't misled you into
thinking you know something you actually
don't know.
Robert Pirsig, Zen and the Art of Motorcycle
Maintenance
Philosophy of EBM
• Realism
• The world really exists
• Empiricism
• We can learn about the world through experiment
• Methodological Naturalism
• The only things we can study empirically are
natural phenomena; the supernatural is out of
bounds
• Reductionism
• We can understand complex systems by
investigating their components
• Scientific Skepticism
• Knowledge claims must be justified by empirical
evidence
What is CAM?
The identification of standard and broadly accepted definitions
applicable to CAVM, including the definition of CAVM itself, is
challenging. …a heterogeneous group of preventive, diagnostic,
and therapeutic philosophies and practices.The theoretical bases
and techniques of CAVM may diverge from veterinary medicine
routinely taught in North American veterinary medical schools or
may differ from current scientific knowledge, or both.
AVMA Guidelines for Complementary and Alternative Veterinary
Medicine
What is CAM?
Holistic (or Integrative) Veterinary Medicine is the
examination and diagnosis of an animal, considering all
aspects of the animal's life…as well as the combination
of conventional and alternative (or complementary)
modalities of treatment.
Holistic thinking is centred on love, empathy and respect.
American Holistic Veterinary Medical Association
What is CAM?
Holistic MedicineA healing philosophy which views the patient as a whole body
rather than as a disease or a collection of symptoms. A patient's
emotional and spiritual state can affect the patient's condition.
Holistic practitioners may combine traditional forms of treatment
(medication and surgery) with alternative forms of treatment
including homeopathy, acupuncture, chiropractic, massage, and
herbal medicine.
Veterinary Institute of Integrative Medicine
Philosophy of CAM
•Holism
•Complete systems in context
• Vitalism
•The spiritual or energetic essence
is essential
•Postmodernism/Constructivism
•Reality as social construct
•Cultural Relativism
•Equivalence of all cultural points of
view
Philosophy of CAM
Holism
Holism or holistic treatment involves treating the body as a whole,
including the mind and spirit …The whole is not entirely
explicable in terms of its parts…This means that we cannot
usefully consider one part of the animal in isolation
Animals (and humans) do not function in parts, we function as a
whole and mind, body…and spirit are an inseparable entity.This is
a fact and to think and work otherwise will inevitably lead to
failure.
Day, C.
Alternative Veterinary Medical Centre
Philosophy of CAM
Vitalism
Acupuncture reconnects and balances Life energy…
Energy medicines such as homeopathy, homotoxicology,
Reiki, craniosacral therapy, and others align the physical,
mental, and spiritual portions of the organism.Yes, I did
say spiritual and that is a big part of holistic medicine –
recognizing the spiritual nature of Life.
Richard Palmquist, DVM
Whole Dog Journal
Philosophy of CAM
Vitalism
"pharmacological and surgical approaches appear
incomplete because they ignore the Vital Force which
animates and breathes life into the biomachinery of
living systems…" Energetic force is unique, distinguishing
living from nonliving systems and people from machines.
Medical therapies that promote this energy…should be
given primary consideration.
Stefanatos, J.
Complementary and Alternative Veterinary
Medicine: Principles and Practice
Philosophy of CAM
Post-Modernism/Relativism
Although the basic concepts and conceits of Western and Chinese
medicine differ widely, both disciplines address the same physical
disorders…TCM considers neither the endocrine nor peripheral
nervous systems, and Western medicine has no format for
diagnoses of diseases caused by "external pathogenic factors"
such as Heat, Cold,Wind, or Damp.
Limehouse, JB. Taylor, PA.
Complementary and Alternative Veterinary Medicine:
Principles and Practice
Philosophy of CAM
Post-Modernism/Relativism
If no paradigm does have absolute value, there is no
absolute basis with which to judge another paradigm.
Any paradigm will appear limited or incorrect from the
perspective of a different paradigm, so Chinese medicine
will seem incorrect from a biomedical point of view, and
vice versa.
Churchill, W.
Journal of Chinese Medicine
Philosophical Principles
Evidence-Based Medicine
Principle
Description
Realism
The world exists
independent of human
beliefs
Complementary & Alternative Medicine
Principle
Description
Postmodernism/Constructivism
Our models of reality are
only social/cultural
constructs
Empiricism
We can develop true
knowledge of the world
through perception and
experimentation
Cultural Relativism
Reductionism
A powerful way to
Holism
understand complex entities
is to investigate their
components
Complex systems can only
be truly understood as
whole entities in context
Methodological
Naturalism
Science can only test and
employ claims about the
natural, physical world
Vitalism
Living systems are defined
by the presence of a
nonphysical vital essence
Scientific Skepticism
Knowledge claims must be
justified by empirical
scientific evidence
Panepistemia*
Non-empirical forms of
evidence, including
tradition, intuition, and
revelation, are equivalent
to scientific evidence
All cultural paradigms are
of equal value
*This is not a standard term in the philosophy of science but a neologism I have coined to describe the view that many
forms of evidence are just as cogent and compelling as empiric scientific evidence.
Potential Conflicts
Holism
…[EBM requires] the idea that there is a legitimate hierarchy of knowledge
and method with the RCT as the gold standard and the clinician’s notes,
observations and judgments right down there in status with ethnography,
sociology and anecdote…
There are practitioners of naturopathic modalities who do not subscribe to this
hierarchy at all; they tend to see this as a form of nonholistic reductionism.
It is inappropriate to superimpose reductionistic methodologies that are
paradigmatically incongruent with the holistic practice of naturopathy.
Jagtenberg, T. et al
Journal of Alternative and Complementary Medicine
Potential Conflicts
Holism
…Reductionism may be the opposite of holism. It
is anyway very foreign to the methodology and
reasoning of a holistic vet…
Day, C.
Alternative Veterinary Medical Centre
Potential Conflicts
Vitalism
Holistic practitioners believe that vital life energy is the
most important factor in the health of the
patient…Because medical science has defined itself on a
strictly physical basis, it is true that vitalism is unscientific.
By definition, vitalism embraces a concept about a
nonphysical force that can never be understood within
the current scientific, medical paradigm.
Doug Knueven, DVM,CVA, CAC
The Holistic Health Guide: Natural care for the
whole dog
Potential Conflicts
Vitalism
The belief that spiritual, emotional, psychological, or other nonmeasurable aspects of the individual patient’s presentation are
important for healing does not require one to reject evidence
obtained from clinical trials, but it does require the recognition that
knowledge gained from such methods will be insufficient to guide
optimal clinical practice…The importance of Qi in traditional
Chinese medicine means that research that cannot and does not
account for the force will never be compelling for a TCM
practitioner.
Tonelli, MR. Callahan, TC
Academic Medicine
Potential Conflicts
Post-Modernism/Relativism
The invocation of a saint can cure intractable cancer;
a voodoo curse can kill…A shaman applying a curse
does not consider it to be a placebo, nor does his
victim.To them, real magic is involved. To interpret it
otherwise is to make a culturally, paradigmatically
biased judgment. We can never prove the shaman
wrong, only offer an alternative explanation.
Churchill, A
Journal of Chinese Medicine
Potential Conflicts
Post-Modernism/Relativism
The methods for obtaining knowledge In a healing art must be coherent with that
art’s underlying understanding and theory of illness. Orthodox medicine should
consider abandoning demands that CAM become evidence-based, at least as
‘evidence’ is currently narrowly defined…
Tonelli, MR. and Callahan, TC.
Academic Medicine
[EBM] frameworks presume the “objectivity” of the evidentiary practices of modern
Western science and privilege the epistemologies, ontologies, and practices that
underlie biomedicine. They hold that notions of evidence underlying EBM standards
and RCTs entail a series of assumptions that are incompatible with theories and
practices central to Chinese medicine.
Shea, JL
Journal of Complementary and Alternative Medicine
Potential Conflicts
Who Needs Scientific Evidence?
For ancient and traditional healing modalities, one could argue that history
provides the evidence…. One cannot conclude that, because a healing system
cannot be measured conventionally, it is ineffective or unsafe. Instead one
might come to appreciate the limitations as well as the strengths of the
conventional research methodology.
Gaylord, S. et al
Evidence-based medicine and complementary and alternative therapies
As a veterinarian now practicing homeopathy and chiropractic almost
exclusively, I have all the proof I need every day in my practice to justify these
modalities.
Jewell, G.
Canadian Veterinary Journal
Potential Conflicts
Who Needs Scientific Evidence?
Users of homeopathy did not see a need for scientific testing and were happy
with their own judgment of whether the treatment was working for…RCTs
came at the bottom of their hierarchy of evidence. Anecdotal evidence,
particularly from friends and family, rated highest.
Barry CA
Social Science and Medicine
To prefer indirect evidence, such as that from clinical trials, over primary
experience represents an epistemic choice…CAM practitioners…can continue
to emphasize individual outcomes without inconsistency even when the
therapies they utilize have failed to demonstrate efficacy in controlled
clinical trials.
Tonelli, MR. and Callahan, TC.
Academic Medicine
Potential Conflicts
EBM Might Change CAM
The very publication of trials can act as a reformulation of the very nature of a
therapy, generally in the direction of medicalisation. Where homeopathy has
been tested on a biomedically diagnosed disorder…it suggests to the readers
that homeopathy can be used in a biomedicalised way…ignoring the mental,
spiritual, and relational picture in favour of physical symptoms…
Evidence-based epistemology can in itself have transformative effects on
alternative therapies…scientifically constructed ‘evidence’ for an alternative
therapy only works when the therapy has mutated into a medicalised version
and divested itself of its alternative philosophy.
Barry, CA
Social Science and Medicine
Can Complementary and Alternative
Medicine be Evidence-Based
Medicine?
Can Complementary and Alternative
Medicine be Evidence-Based Medicine?
Yes- If
•Individual interventions are tested for specific indications at all levels
of evidence
•Levels of evidence are respected and the highest level given
precedence
•Interventions are accepted or rejected as indicated by the formal
evidence appraisal
•But will these interventions still be CAM? Will CAM disappear as a
category? Should it?
Can Complementary and Alternative
Medicine be Evidence-Based Medicine?
No- If
•If EBM methods are incompatible with CAM therapies because of
•Holisms vs Reductionism
•Vitalism vs Methodological Naturalism
•Post-modernism- No such thing as true or false, just points of
view
•Cultural Relativism- Inappropriate to judge one paradigm by
another; all sets of metaphors are equally valid
•Medicalizing CAM therapies strips them of their character and value
•The results of EBM evaluation will be ignored
Things to Think About
•What philosophical principles underlie our approach?
•How do these complement or antagonize other approaches?
Particular therapies?
•How can understanding these issues facilitate productive debate and
discussion?
•Should CAM assimilate? Should EBM accommodate? Should they be
separate but equal? Separate but unequal?
•What about other values?
•What clients want?
•Spiritual or religious values?
•Practitioner autonomy?
•Protection of the public?

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