The Applicability of Evidence-Based Practice to Complementary and Alternative Medicine - Research Paper Example

The Applicability of Evidence-Based Practice to Complementary and Alternative Medicine with Specific Reference to Naturopathy Introduction Evidence based practise has been defined by Sackett et al (1996, p.71) as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” based on the doctor’s skills in the evaluation of both personal experience and external evidence in a systematic and objective manner. Complementary and alternative medicine has been defined as “healthcare practices that are not an integral part of conventional medicine” (Coulter & Willis 2004, p.587). Due to its increasing use, health care practitioners of complementary and alternative medicine have to meet the standards of proficiency underscored by evidence-based practice, as in mainstream medicine (Hadley et al 2008). Further, a radical viewpoint is that only conventional medicine has empirical support, and that CAM should demonstrate similar support to be considered complementary or alternative (Coulter & Willis 2004). Conversely, a significant proportion of CAM practitioners do not consider the implications of evidence-based practice as essential for CAM (Vickers 2001). Thesis Statement: This paper proposes to investigate the applicability of evidence-based practice to complementary and alternative medicine such as naturopathy. Discussion Complementary and alternative medicine (CAM) includes five major domains: alternative medical systems, mind-body interventions, biologically-based treatments, manipulative and body-based methods, and energy therapies. From very focused therapies such as reflexology the diverse practices range to whole medical systems such as Ayurvedic medicine and traditional Chinese medicine (Coulter & Willis 2004). Strengths in the Applicability of Evidence-Based Practice to CAM According to Vickers (2001), the essential requirement for both conventional medicine and for complementary and alternative medicine is evidence of effectiveness. Consequently, CAM should use the opportunity provided by evidence-based medicine to secure its place in health care as an effective and valid system of treatment which is equal to conventional medicine in significance. Tonelli & Callahan (2001) state that it is important to determine whether CAM therapies can prove themselves to be effectve through sound, systematic clinical research using control groups, placebos, and statistical analysis, in the same way as orthodox medicine. The clinical practice of evidence-based medicine does not discount the value of clinical experience and inductive reasoning; it brings out the best available evidence from systematic research, and uses it for making clinical decisions. Evidence-based practice refers to the broadening of the core concepts and principles of evidence-based medicine, and their interdisciplinary application in health care practice. It is the effective use of findings which are the “best available, current, valid” (Hadley et al 2008, p.2), besides being relevant and clinically significant, derived from research to improve and optimize health care practice on a scientific basis. An effective link between research and practice is required, to resolve the practical needs of clinical work in the care of individual patients (Trinder & Reynolds 2000). In the practice of CAM, evidence from research is found to be inadequate, but can be used to support the therapeutic framework on which CAM modalities are built. The use of evidence-based practice in the CAM field of naturopathy involves five key steps taken by the clinician: development of a clearly defined question based on the client’s needs and goals, the specific intervention and the expected outcomes of the intervention, collection of relevant evidence from literature related to the topic, critical analysis of the validity, reliability and reproducibility of the research, integration of the evidence with clinical experience and client’s requirements to develop an intervention plan, and evaluation of the plan of action. To prevent the results from conflicting with basic CAM principles, “a naturopathic filter needs to be incorporated into this process” states Chaitow (2008, p.211). The effectiveness of individualized and patient-oriented decision making has been emphasized by Caspi et al (2004). Limitations in the Applicability of Evidence-Based Practice to CAM In a particular system of medical therapy, the underlying theory of disease and healing needs to be taken into consideration; the results of clinical research do not form the most important source of medical knowledge for application in practice. Firstly, even in orthodox or conventional medicine the epistemology or knowledge of evidence based medicine (EBM) is problematic. According to Feinstein & Horwitz (1997) the evidence that is considered to be the best available according to EBM may not be suited for guiding many clinical decisions; while it may be useful for decisions pertaining to public health or healthcare economics. Therefore, under several circumstances, the alternate method of preferring the direct observation of the individual patient is more valid, as compared to relying on evidence from clinical trials. The above method is supported by the fact that the knowledge forming the basis of evidence based medicine may be problematic because other factors such as “clinical experience, expert opinion, or a pathophysiological rationale may be more compelling than evidence from even large well-designed clinical trials, meta-analyses, or systematic reviews” (Tonelli & Callahan 2001, p.1214). Until now, EBM has not provided any information on when such alternative factors can take precedence over the best available scientific evidence; though EBM has begun to recognize that such knowledge should play a part in medical decision making. Secondly, medical epistemology or medical knowledge based on philosophy cannot be considered separate from medical metaphysics. The epidemiologic epistemology of EBM, which is study of the causes, prevalence and control of diseases in a population correlates well with orthodox medicine’s biophysiologic theory of disease. However, it may not be coherent with other theories of disease and healing. Thirdly, there is a requirement for potential alternative methods of generating medical knowledge in CAM (Tonelli & Callahan 2001). The methods of obtaining knowledge in a healing art such as CAM must suit the art’s underlying understanding and theory of illness. Therefore, disciplines such as complementary and alternative medicine (CAM) that diagnose and treat illnesses on non-measurable but detectable differences between individuals such as Qi, cannot be based on EBM since it cannot fulfill all its requirements for optimal clinical practice. Hence,“the method of EBM and the knowledge gained from population-based studies may not be the best way to assess certain CAM practices” (Tonelli & Callahan 2001, p.1213) which take into consideration illness and healing within the context of a particular individual only. Currently, however, the methods of developing knowledge within CAM have limitations, are subject to bias and different interpretations. It is essential that CAM should develop a rigorous alternative epistemic framework of knowledge and method based on its philosophy, if it hopes to be accepted as a valid medical discipline by orthodox practitioners. According to Long (2002), monitoring the achievement of desired outcomes of research is essential. The effects of a CAM intervention are of three types: those arising from the philosophy and practice of health and healing, factors emerging from the relationship between the patient and the practitioner, and the factors resulting from the interventions used to enhance the healing process. This delineation of effects is relevant to conventional medicine also. For the full effect of a CAM discipline to be recognized, the measurement of all three types of outcomes is required. CAM related to evidence based practice does not adequately reflect the clinical practice and the explanatory models of the therapies being assessed. Clinical practice based on EBM guided according to “positive outcome, placebo-controlled, randomized controlled trials” (Hammerschlag & Zwickey 2006, p.349) is being inappropriately applied to CAM according to standards set by the biomedical field. There is a fundamental misrepresentation of Chinese theoretical concepts in the “simplistic and invalid superimposition of biomedical concepts over traditional Chinese theory” (Churchill 1999, p.34). For example, the existence of Yin and Yang have not been substantiated by scientific research, and are misrepresented by the biomedical field. If CAM professions consent to EBM as the basis of regulatory decisions, it is possible that research in this area is taken over by the biomedical field to which EBP can be applied. To avoid biomedical control over CAM modalities, it is vital for CAM professions to insist on full recognition and acceptance of their own paradigms, states Churchill (1999). This is supported by Barry (2006), who refers to evidence as highly constructed and changing in form according to the method in which it has been produced and the purpose for which it is used. She states that besides evidence being used to assess the effectiveness of treatments, it is used politically to influence the way in which CAM is combined, assimilated or refused entry into the biomedical system. Conclusion This paper has investigated the applicability of evidence-based practice to complementary and alternative medicine. The strengths and weaknesses of applying EBP to CAM have been discussed. The weaknesses are found to far exceed the strengths, since the factor of evidence from research is currently narrowly defined; hence it is difficult to apply EBP to complementary and alternative medicine. Obtaining a complete medical explanation or critical analysis of a treatment modality is not possible either from research evidence or from an alternative framework of CAM. Significantly, conventional medicine practitioners recognize that all medical questions cannot be answered by the performance of a controlled clinical trial. On the other hand, CAM practitioners have not completely rejected EBM. Gatchel & Maddrey (1998) reiterate that CAM practitioners seek to define the questions within their domain which can be successfully answered by finding evidence from research. To be considered as a valid medical discipline by conventional practitioners of medicine, CAM should develop a more complete description and defense of the alternative knowledge bases and tools on which it is based. That is, with or without using controlled clinical trials, CAM should construct and defend a rational and valid method for assessing the causes of disease, effectiveness of interventions and the success of outcomes. References Barry, C.A. (2006). The role of evidence in alternative medicine: Contrasting biomedical and anthropological approaches. Social Sciences & Medicine, 62: pp.2646-2657. Caspi, O., Koithan, M. & Criddle, M.W. (2004). Alternative medicine or “alternative” patients: A qualitative study of patient-oriented decision-making processes with respect to complementary and alternative medicine. Medical Decision Making, 24: pp.64-79. Chaitow, L. (2008). Naturopathic physical medicine: Theory and practice for manual therapists and naturopaths. New York: Elsevier Health Sciences. Churchill, W. (January 1999). Implications of evidence based medicine for complementary and alternative medicine. Journal of Chinese Medicine, 59: pp.32-35. Coulter, I.D. & Willis, E.M. (2004). 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