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The term ‘evidence-based medicine’ seemed to me, when I first heard it, utterly ludicrous. It still does. What’s the alternative? Guess-work based medicine?

Quacks are fond of using cuddly words like ‘holistic’ and ‘integrative’, partly, one suspects, in an attempt to gain respectability and to disguise some of their barmier views. See, for example, Prince of Wales Foundation for magic medicine: spin on the meaning of ‘integrated’.

Advocates of evidence-based medicine are often accused by quacks of being hard-hearted calculators who want to take the soul out of medicine. Nothing could be further from the truth in my view. But I don’t practise medicine so it seemed to me to be worth quoting two of the best definitions I know, both from people at the sharp end of medicine.

James Matthew May

James May is a general practioner in London. He is also chairman of Healthwatch, an organisation that was exposing health fraud long before the recent explosion in the ‘skeptical blogosphere’.

The following passage was written as comment (‘rapid reponse’) to an editorial in the British Medical Journal. The editorial itself was (in my view) silly and misguided (Closing the evidence gap in integrative medicine, by Hugh MacPherson, David Peters, and Catherine Zollman). It is best forgotten as soon as possible. But James May’s comment deserves to be preserved and publicised. The highlights in bold font are mine.

The use of the term ‘integrative medicine’ in your editorial seems to confuse more than clarify the problem of ‘holism’ in medicine. Complementary therapists for example often use the term ‘holistic’ to blur the boundaries between the therapies used and the practitioner’s interpersonal skills. It would be better, however, to keep these distinctions clear. Caring is different from curing. The point of RCTs is to establish how much of a treatment’s efficacy is independent of the ideas, concerns, and expectations of either the patient or the clinician. Using ‘multi-modal’ or ‘synergistic’ research methods is likely to confuse this important distinction.

‘Holism’ is not a multifaceted approach to curing, it is a mulitfaceted approach to caring. A truly holistic clinician will ‘cure sometimes, relieve often and comfort always’. Comforting may not produce a positive clinical outcome – but we should still do it. Historically speaking caring pre-existed effective medicine by millenia, but it was a principle motive for finding effective medicine. Caring therefore is not a subset of medicine, instead medicine is one of the tools used for caring. ‘Integrative medicine’ as a concept, however, blurs this boundary.

It has been wisely observed that ‘if we keep trying to measure what we value, we will end up only valuing what we can measure.’ This particular ‘evidence gap’ is therefore probably best left; filled instead by caring doctors.

Effective medicine is best measured with RCTs. Caring is not. ‘Integrative medicine’ therefore risks both damaging how we measure effective medicines (RCTs), as well as reducing caring to measurables. A better term for this might be ‘disintegrative medicine’.

Competing interests: Chairman of HealthWatch

Michael Baum

Baum is a recently-retired cancer surgeon from UCLH. As well as being s surgeon with a strong interest in scientific medicine, he has been at the forefront of thinking about supportive or spiritual care of cancer patients. His 2009 Samuel Gee lecture is available in video, Concepts of Holism in Orthodox and Alternative Medicine. It is a masterpiece. The conclusion puts his view bluntly (again the emphasis is mine).

Conclusion

Holism in medicine is an open ended and exquisitely complex understanding of human biology that over time has lead to spectacular improvements in the length and quality of life of patients with cancer. This approach encourages us to consider the transcendental as much as the cell and molecular biology of the human organism. Alternative versions of “holistic medicine” that offer claims of miracle cures for cancer by impossible dietary regimens, homeopathy or metaphysical manipulation of non-existent energy fields, are cruel and fraudulent acts that deserve to be criminalized. Such “alternative” versions of holism are arid and closed belief systems, locked in a time warp, incapable of making progress yet quick to deny progress in the field of scientific medicine.

Follow-up

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13 Responses to What ‘holistic’ really means

  • I think it is worth reaffirming what EBM actually is, rather than the straw man version of it promoted by alternative medicine.

    “EBM requires the integration of the best research evidence with our clinical expertise and and our patient’s unique values and circumstances.

    By ‘best research evidence’ we mean valid and clinically relevant research, often from the basic sciences of medicine, but especially from patient-centred clinical research into the accuracy of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens….

    By ‘clinical expertise’, we mean the ability to use our clinical skills and past experience to rapidly identify each patient’s unique health state and diagnosis, their individual risks and benefits of potential interventions, and their personal values and expectations.

    By ‘patient values’, we mean the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient”.

    (Straus SE et al. (2005) Evidence Based Medicine. Elsevier Churchill Livingstone, London. Page 1).

    In the light of this patient centred definition, ‘integrative medicine’ is a redundant term.

    The CAM community often ignore things like diagnostics, palliative care, rehabilitation, psychiatry, even surgery, focussing instead on a drug-delivery paradigm which it attacks in a simplistic way. Your correspondent Dangerous Conventional is a good illustration. I personally prefer the term ‘Rational Medicine’ to ‘conventional medicine’, because I think that it is only rational to consider a patient centred approach – and because it makes it clear that the ‘alternative’ is ‘irrational medicine’.

  • @Allo V Psycho
    That is an excellent explanation of EBM. Unfortunately it is not just CAM practitioners who fail to understand EBM, many NHS clinicians do too.

    It is good to be reminded of what EBM is meant to represent, rather than myopic interpretations of it.

  • Instead of the term “Evidence Based Medicine”, I far prefer the term “Science Based Medicine”, coined by Dr. Steven Novella.
    SBM is EBM, but with ‘prior scientific plausibility’ added to the mix.
    SBM avoids the endless trials and retrials of repeatedly failed & utterly implausible modalities, merely in the name of ‘evidence’.

  • Thanks Michael, I do have sympathy with this concept, with some reservations – I prefer the term ‘prior probability’ to ‘prior plausibility’ (I know both are used), and I prefer to think of it as ‘prior probability based medicine’ rather than ‘science based medicine’. This is because, like Sackett et all, I think the unique view point of the patient should be considered, and this is not ‘science’ as a general construct. Does that make sense?

  • “Prior probability” is the term I recognise but it relates primarily to consideration of the totality of (the relevant) science, not the UVP of the patient, surely?

  • Medicine is both a science and an art, surely not. EBM attempts to use the best of both.

    I am sure there is an art to CAM as well, but without the science.

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