Conventional Medicine Invites the Rise of Alternative Medicine
Let’s start with some definitions – or at least my definitions.
Conventional medicine is what licensed MDs and DOs should be practicing: the skilled use of the diagnostic sciences, treatments based on the principles of evidence-based medicine, and the provision of prognoses to patients who request them. All this should be done in a caring and empathic manner.
A good definition for alternative medicine might be:
Alternative medicine is a broad term encompassing a variety of medical modalities. Tradition typically supports these and (it) is seldom taught in a Western medical setting. Such modalities range from the ancient Eastern practices of acupuncture and Tai chi to herbal medicine, Reiki, chiropractic manipulation, and more.
Alternative medicine is practiced by an array of providers, some licensed, some not, some with standardized training and some without. Alternative medicine goes by many names including complementary or integrative medicine.
There are similarities between conventional and alternative medicine. Both should be populated with practitioners dedicated to the health and well-being of their patients. Both should use the placebo effect, broadly defined to include a therapeutic provider-patient relationship, to ease patients’ subjective symptoms. Placebos should, however, be employed with great care. They should be inexpensive, harmless, and their use should never delay or interfere with therapy capable of changing the course of a disease for the better (without the patients knowledge and consent).
Practices considered “alternative” that are proven effective in robust trials should be incorporated into conventional medicine.1
It is hard to know if the rise in alternative health is just part of the overall rise in healthcare spending in the US. Certainly, though, when you combine alternative medicine with the $53B being spent in the US on supplements, there is a robust market for non-conventional care.
The rise of alternative medicine invites the question, what is conventional medicine doing, or not doing, that leads to all this alternative medicine? Here are some hypotheses that I invite you to comment on.
1. Time. Over the short span of my career, visits to conventional medicine providers have gotten shorter. A physician with an established practice can make a 20 minute visit work for most patients but for a less experienced doctor, or one seeing new patients with whom they don’t have an established relationship, or even a seasoned practitioner with an established practice who is just having a bad day, 20 minutes is not enough. This leaves patients wanting the greater time and attention that alternative medicine providers usually spend with patients.
2. Better use of placebos. I use the term placebo with absolutely no negative connotations. As I wrote above, and as I have written in this space, the use of the placebo effect, usually in the form of a therapeutic relationship, is a critical part of conventional and alternative medicine. Because conventional medicine does not depend on the placebo effect – your electrophysiology cardiologist can be an uncaring jerk and still effectively ablate your atrial fibrillation – we have gotten lazy in its use.2 Therefore, for the problems for which we have no real solutions, alternative medicine practitioners often do a better job.
3. People value what they pay for. In the US, and in most developed counties, people do not pay directly for their conventional care. On the other hand, it is the rare insurance policy that pays for acupuncture, chiropractic manipulation, or a consultation with a naturopath. Cognitive dissonance occurs when people are faced with the possibility that what they spent their hard-earned dollars on didn’t work. We resolve the dissonance by convincing ourselves that the treatments we paid for did work.
4. The downside of evidence-based medicine. It hurts me to propose this. Practicing evidence-based medicine entails integrating clinical experience and expertise (science knowledge) with the best available evidence from systematic research. Anybody who follows this site, or has read Ending Medical Reversal, knows that conventional doctors often use practices not supported by robust studies. Chapter 2 in Ending Medical Reversal tells us how bad we are at knowing something works just based on our practice experience.3 That leaves science. We are in an age where education and an understanding of science can be a liability. Anybody who knows how to use social media can convince millions that something, anything, is supported by “their science.” Many people regard a treatment based on “rebalancing your life force” or “natural immunomodulators” to be as likely to be effective as ones based on actual biochemistry, immunology, and pathophysiology.
Has the articulation of evidence-based medicine opened the door to alternative medicine practitioners? If we all practice (some occasionally, some always) without data, if we can all quote “clinical experience”, if we all claim that “science” supports our treatment, what does conventional medicine offer that alternative medicine cannot?
In my ideal world, conventional and alternative practitioners would work together. Conventional doctors would diagnose, treat, and prognosticate as best as they can. They would nurture helpful therapeutic alliances with patients. They would also recognize that there are many symptoms that we cannot adequately treat and syndromes that we do not yet understand. Patients with these symptoms and syndromes would be referred to alternative medicine providers. These providers would see if what they have to offer can help. They would also refer back to traditional doctors if the situation changed, progressed, or if findings concerned them.
It is telling that this never happens. The few times in my career that it almost did – saw palmetto, St. John’s Wort, Black Cohosh, (dare I say) Ivermectin – actual data ends the cross-over.
It is not uncommon that I have to encourage trainees to “sell” their recommendations. This is important not only to get the patient to try the meds but because, in the short term at least, belief that a treatment will work might be the most important aspect of its pharmacology.
I still haven’t gotten over the commenter who, after I wrote that one of the things that makes me think masks are effective for COVID is that I worked, unvaccinated but masked for 9 months without getting COVID, asked me if I also put tinfoil inside my white coat.
Photo by Katherine Hanlon
To me, conventional medicine is weird. It operates within certain strange doctrinal limits. These limits can be beneficial. But these limits are sometimes...limiting. At other times these limiting doctrines are just plain wrong. This weirdness makes me not want to use either the terms conventional medicine or evidence-based medicine. It doesn't deserve these. Allopathic medicine is too derogatory. I presently lean towards the term centralized medicine. Everything else is decentralized medicine. This includes terms like integrative, functional, complementary, natural, and alternative.
Putting aside the negative, I've thought for years what defines the positive aspects decentralized medicine, and it boils down to four points:
1. Greater appreciation for the fact that evidence is garbage.
2. Greater appreciation for the environmental causes of disease that are either well-described but ignored, or else can be overall inferred to belonging to a set of possible environmental causes, even when not explicity well-described.
3. Greater appreciation that natural medicines have a strong tendency for being cheaper, safer, more accessible, more pleiotropic, more effective, more inherently biocompatible, and of greater capacity to actually target root environmental causes. Natural is not better. But natural does have a strong tendency to be better. This is not a fallacy.
4. Greater appreciation for simply trying things in series, working with lower levels of evidence and subjective responses, emphasizing safer natural treatments and targeting sets of possible environmental causes. I formalize the best implementation of this as "robust empirical treatment".
I've see plenty of people reverse conditions centralized medicine says are not reversible. So have many on this site. Sometimes such reversals are straight up in the literature that centralized medics never read. There isn't a lot of curing of chronic disease in conventional medicine. That is a big reason why the public is so pissed at the medicine system, cuz their lived experiences have shown them that something is obviously very screwed up when their naturopath or their self-treatment is what cures them.
A couple koans:
"The benefit of a standard of care is that there is a standard of care. The detriment of a standard of care is that you are limited by the standard of care."
"A bird in the hand is worth more than a bird in the bush. But a bird in the bush is worth more than a dead bird in the hand."
Adam, I find your treatment of “ alternative medicine” as somewhat pejorative. In my experience, working in a large academic Medical Center, conventional physicians have little understanding of the basic pathophysiology of how the human body works, how to keep it, healthy and prevent illness. An ignorance of wellness would seem to ill prepare the physician to keep their patients well. They appear to live in a prescriptive paradigm where all conditions are treated with man-made compounds. Alternative medicine or functional medicine practitioners seem to approach patients with an eye toward Wellness, seeking to understand root causes of disease and treating those as well as the vigorous prevention of illness. Consequently, I tell my residents that if they want to cure patients follow the functional medicine route, but if you want to continue to treat patients for their uncured conditions, then follow the “conventional medicine “paradigm” and just keep writing prescriptions.