…from Steve
Periodically the debate about whether or not clinicians should prescribe alternative or complementary therapies to their patients pops up in both the scientific and mainstream media. Such a debate along with sundry comments recently appeared on The Conversation blog twice (here and here) and also in a slightly different form in the Sydney Morning Herald. In essence, one side of the argument maintains that there is no justification for providing treatments that lack scientific support and the other that it is fine to provide any treatment that the patient feels is beneficial. A similar (but not entirely identical) recurring debate surrounds whether or not clinicians should knowingly provide placebo treatments; Neil O’Connell posted an excellent discussion on this on a little while ago on Body in Mind and the British Medical Journal also addressed the issue.
Judging by the chaotic pile of comments to just these few posts alone, peoples’ views range from the dogmatic at either end of the spectrum and include everything in between, with just a bit of the bizarre and irrelevant thrown in for good measure (I’m still struggling to uncover the link to climate change, but maybe that’s because I lack imagination). While I’m under no illusion that my opinion adds anything to this, reading through did give me pause for thought about where we – as early career researchers – fit in to this debate. Obviously many of us are in, or come from, clinical practice and some will hold strong views on one side or the other, in some cases such pondering might even have prompted the move into research. In my opinion the issues are worth considering for a couple of reasons.
Firstly, given what we do for a living there’s every chance that someone will ask your opinion on the topic so it’s probably worth having something coherent to say. The easy out is to quote the Discussion section of nearly every systematic review out there and declare that “more research is necessary”. On the other hand there is the opportunity to impress friends, relatives and colleagues with a well-considered opinion that requires understanding of both sides of the argument.
Secondly, and probably more significantly, at some point you might be called on ‘defend’ the findings of your research or comment on their implications for clinical practice (which is kind of the ultimate purpose of good quality clinical research right?) This is especially relevant if your findings are at odds with common practice. Such results can be threatening and/or run counter to deeply-held points of view and you should be warned that these discussions don’t always necessarily remain reasonable or even civil, people have turf to protect.
Thirdly, these issues have implications for how research in general should be integrated (or not) into practice. Are we setting rules or informing guidelines? How should evidence-based practice be operationalised?
We’d love to hear your thoughts! Feel free to leave a comment or head to our Facebook page for more discussion.
4 Comments
First of all, thanks for your post Steve!
I have a intricate issue: Imagine a clinical physiotherapist who is also a alternative therapist. So, he/she decided to do his/her master course. So now this person have the contact with the evidence in clinical practice, but some patients want to be treated with alternative therapy, because they like it or some other reason. You know if you don’t treat this patient, he/she will look for another “alternative therapist”.
I would like to know what the people (clinicians or researches) think about this situation.
Thank you!
Hi Luiz, thanks for checking out the blog and getting involved. In my opinion (and I stress that it is only that) this question comes down to the information that the clinician gives to the patient. If the clinician has several treatment options; beliefs regarding what the outcome of each will be and knowledge of what the research says about them, then I think the patient should be presented with that information. If the patient expresses a desire for a particular type of treatment then the discussion should include what the evidence is in support of, or against it and what the likely outcome is relative to other options.
Several writers have mentioned the idea that the traditional-alternative medicine divide is an artificial and arbitrary one that serves no useful purpose, a more valuable distinction is between therapies with, and without, scientific support. I tend to agree with this point of view and think it frames the discussion better. Then the decision doesn’t require some subjective judgement regarding whether a treatment is ‘traditional’ or ‘alternative’, for example where does chiropractic sit? I suspect the answer depends on who you ask!
The final point that I would make is that if a patient wants a type of treatment that the clinician thinks is not worthwhile or can’t deliver, then this becomes something of an ethical issue. At times the clinical needs of the patient and the financial needs of the clinician might be in competition. This is not a simple matter and every individual clinicians decides where to put their line in the sand.
Steve, I think you are right in reminding us that the patient/therapist interface is usually a fee for service scenario, the patient being the consumer. I agree we need to maintain dialogue with patients about the scientific support, or lack of, for a management approach (including that of adverse effects). However, I don’t see how if fully informed there is any ethical issue with providing a treatment that the consumer wants, alternative or otherwise (again with respect to adverse effects and obviously within legal constraints and assuming the therapist is qualified to provide it).
In research studies, it is considered entirely ethical to provide a treatment that is intended to have no treatment value whatsoever, provided informed consent has be gained. In most cases we know the patient will receive no known benefit from these yet the conduct is approved by ethics committees (detuned ultra sound as a placebo control is something that springs to mind).
It seems a little unfair when clinicians are criticised but the research community continues to use placebo or known ineffective comparison treatments.
As you point out the issue with clinical practice is more about the quality of the information we provide. I would argue that the outcome of this information is probably (I have no evidence to support this) more important and more influential than the outcomes we often measure, for the therapies that are provided. I think it raises a question about how we the value of the educational side of ‘therapy’.
Chris
Thanks Chris,
I agree with you in principle that the ethical issue is tied to the adequacy and completeness of the information provided. In research though, this is regulated to an extent by ethics committees i.e. the participant is specifically told that there is a X% chance that they will receive an ineffective treatment. The same is not true in clinical practice.
You describe an hypothetical situation where the patient desires a particular treatment, the clinician knows it is ineffective and has provided this information. I think the question of whether the clinician should provide the treatment is open to debate. On one hand it could be argued that providing the treatment aligns with the ‘respect for patient preferences’ part of evidence-based practice, on the other the clinician may feel that doing so compromises their professional standards.
The point about the place and value of education as therapy is an interesting one, probably worthy of a post of itself. You busy at the moment?
Steve