Research in ND Land Myths and Possibilities in a Brave New World: Part 2 of 2

David Schleich, PHD

We continue last month’s column regarding research and naturopathic medicine’s seeming inclination to support related long-term studies.

Accompanying the calls from within the naturopathic profession for the allopathic world to embrace scientific proof of the efficacy and safety of the therapies, techniques and drugs it utilized, was the claim by biomedicine that its scientific research gave it the ascendant role in health care. Certainly, when the allopathic community asserts, as it did in a recently published monograph for its state associations about naturopathic medicine that our community eschews such rigor, defensive responses ensue and the confusion about whether evidence-based medicine really exists or not grows in parallel.¹

Countering the assumed unassailability of biomedical practice as safe and proven, naturopathic researchers and classroom teachers often cite Johns Hopkins epidemiologist Barbara Starfield’s 2000 JAMA study which disclosed that 225,000 annual deaths occur in American hospitals arising from the “adverse effects of medications, infections, and errors, making hospital care the third leading cause of death in the United States, behind heart disease and cancer”.² Such startling claims, which have the effect of bruising the credibility of the allopathic realm, showed up as well in the Institute of Medicine’s 2000 report, To Err is Human.³ This very same concern had appeared the year before in BMA editor, Richard Smith’s observation that “only about 15% of medical interventions are supported by solid scientific evidence … this partly because only 1% of the articles in medical journals are scientifically sound and partly because many treatments have never been assessed at all”.⁴

The terrain of literature about whether biomedicine can assure safety and efficacy predicated on sound science is littered with many worrying counter claims of this kind. For example, in the same year that Dr. Eisenberg published his landmark study about the use of complementary and alternative medicine by Americans, Dr. David Grimes of the University of California (San Francisco) School of Medicine wrote that “much, if not most, of contemporary medical practice still lacks a scientific foundation”.^5,6 Adding fuel 15 years earlier to the then even more controversial fire that biomedicine was not, after all, solidly predicated upon science, the Congressional Office of Technology Assessment in 1978 determined that only an estimated 10% to 20% of the techniques used by allopathic physicians were empirically proven.⁷ A quarter century later, Brian Berman’s work out of the University of Maryland School of Medicine further stirred this controversial stew of concern about science and biomedicine. Examining a random subset of 159 of 326 completed Cochrane reviews of conventional medical practices, Berman found that “overall, the ‘positive’ and ‘possibly positive’ reviews totaled 38.4%, while the ‘no evidence of effect’ and ‘negative effect’ totaled an alarming 61.6%.”⁸

Given this confusing professional battleground, naturopathic students considering a career enriched by research would do well, some say, not to attribute any kind of patina of unassailability to biomedicine’s stake in science, since naturopathic medicine itself has an equally rich and growing repertoire of studies and outcomes in support of its own principles and practices. Increasingly, some say, those studies will be conjugated through the “integrated medicine” lens, such as in a recent study whose principle investigators included a medical doctor and a chiropractor whose published work correlated a decrease in clinical utilization and cost outcomes over a 7 year period compared with conventional medical strategies.⁹

There is little doubt that NDs are as committed as MDs or DOs or DCs or any other primary care physician to arriving at informed decisions about treatment protocols, relying not only on the traditional theoretical and clinical knowledge of their medicine, but simultaneously interested in any new clinical evidence to find their way. The BMJ Clinical Evidence Initiative referenced earlier is among a growing medley of useful sources for checking in on such current knowledge.³ Illustrative of its utility along the busy thoroughfare of clinical research is a snapshot of recent findings, consistent with the work of these medical researchers in reporting to the UK NHS Health Technology Assessment Programme (HTA) their 6-month clinical evidence evaluations.¹⁰

What proportion of commonly used treatments are supported by good evidence, what proportion should not be used or used only with caution, and how big are the gaps in our knowledge? Of around 2500 treatments covered, 12% are rated as beneficial, 23% likely to be beneficial, 8% as trade-off between benefits and harms, 5% unlikely to be beneficial, 3% likely to be ineffective or harmful, and 49%, the largest proportion, as unknown effectiveness (see figure).¹¹

Figure. Effectiveness of Treatments¹¹

The inclination to support more long term research activity in naturopathic medicine is strong, driven in part, as I suggested earlier, by a perceived need to validate its principles and practice within a milieu of challenge to its credibility by mainstream biomedicine, but also by a broadly emerging interest in research activity to support tradition and current practice.^9,12-16 It’s rather a brave new world, after all, and one in which our colleges will inevitably have to band together to sustain this precious momentum. The AANMC will generate significantly more interest in this aspect of naturopathic medical education in the coming decade.

David Schleich, PhD is president and CEO of NCNM, former president of Truestar Health, and former CEO and president of CCNM, where he served from 1996 to 2003. Previous posts have included appointments as vice presi-dent academic of Niagara College, and administrative and teaching positions at St. Lawrence College, Swinburne University (Australia) and the University of Alberta. His academic credentials have been earned from the University of Western Ontario (BA), the University of Alberta (MA), Queen’s University (BEd), and the University of Toronto

References

1. American Medical Association. Scope of Practice Data Series: Naturopaths. Maves M, ed. Chicago, Ill: American Medical Association; 2009.
2. Starfield B. Is US health really the best in the world? JAMA. 2000;284(4):483-485.
3. Kohn TK, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
4. Smith R. Where is the wisdom…? BMJ. 1991;303(6806):798-799.
5. 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(4):246-252.
6. Grimes D. Technology follies. The uncritical acceptance of medical innovation. JAMA. 1993;269(23):3030-3033.
7. Office of Technology Assessment. Assessing the Efficacy and Safety of Medical Technologies. Washington, DC: Congress of the United States, Office of Technology Assessment; 1978:7.
8. Ezzo J, Bausell B, Moerman DE, Berman B, Hadhazy V. Reviewing the reviews: How strong is the evidence? How clear the conclusions? Int J Technol Access Health Care. 2001;17(4):457-466.
9. Sarnat R, Winterstein J. Clinical and cost outcomes of an integrative medical IPA. J Manipulative Physiol Ther. 2004;27(5):336-347.
10. National Institute for Health Research. Health Technology Assessment Web site. http://www.ncchta.org/. Accessed December 11, 2009.
11. How Much Do We Know? BMJ Publishing Group Ltd. Clinical Evidence Web site. http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp. Accessed December 11, 2009.
12. Rao JK, Mihaliak K, Kroenke K, Bradley J, Tierney WM, Weinberger M. Use of complementary therapies for arthritis among patients of rheumatologists. Ann Intern Med. 1999;131(6):409-416.
13. Richardson MA, Sanders T, Palmer JL, Greisinger A, Singletary SE. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol. 2000;18(13):2501-2514.
14. Wolsko PM, Eisenberg DM, Davis RB, Ettner SL, Phillips RS. Insurance coverage, medical conditions, and visits to alternative medicine providers: results of a national survey. Arch Intern Med. 2002;162(3):281-287.
15. Druss BG, Rosenheck RA. Association between use of unconventional therapies and conventional medical services. JAMA. 1999;282(7):651-656.
16. Lafferty WE, Tyree PT, Bellas AS, et al. Insurance coverage and subsequent utilization of complementary and alternative medicine providers. Am J Manag Care. 2006;12(7):397-404.