western medicine and cam integration

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E T T E R S T O T H E E D I T O R

and the Shanghai EBM Research Centre of TCM. The first

two of these are the Regional Practice Branch of the Chinese

Cochrane Centre. The main work of these organizations is

education and the practice of an EBM approach in TCM.

This includes the training of teachers, student education,

practitioners' practice, and interdisciplinary research. For

example, 66 chief instructors from 23 TCM organizations

have been trained in EBM and systematic reviews through

a program of workshops at the Chinese Cochrane Centre

since 2003. These numbers are set to increase in the com ing

years and, after this training, we expect that they will pre-

pare and maintain Cochrane review as well as providing

teaching and conducting research within their own organi-

zation. We also found more than 30 national-sponsored proj-

ects (conservative figure) of EBM research in TCM that

started since 2000.

Our searches found 2808 items in PubMed and 392 items

in CBM about EBM an d TCM . We identified a total of 161

reviews or protocols in The Cochrane L ibrary (Issue 2, 2008).

About 40% of them (the 161 Cochrane protocols and reviews)

were produced by Chinese scholars, but only nearly 3% of

them had a background in TCM education.

Our findings show that the EBM approach has played

an important role in the development of TCM over the

last decade. However, the application of the EBM ap-

proach in TCM is still in its early stage. There are many

challenges ahead, including the development of appro-

priate methodology. Since 1999, the Chinese Cochrane

Centre has been encouraging the adoption of EBM in TCM

and in healthcare more generally in China. Others have

also commented on EBM and TCM in China, just as in

Japan. 2

TCM needs to be evaluated properly and rigor-

ously, and in doing this we suggest that the attitude

should be that if one believes in something, then go for

it without paying too much attention to what other peo-

ple think or say.3

The collision and combination of TCM with EBM w ill help

to enrich the contents of the EBM , will provide the evidence

needed to make well-informed decisions about TCM, and

will promote both EBM and TCM and their continuing de-

velopment. We believe that this collision and combination is

important for healthcare globally and that additional inter-

national and interdisciplinary dialogue and collaboration

will be vital to this process.

e f e r e n c e s

1. Benitez MA. China takes on evidence-based medicine. Lancet

2003;361:318.

2.

Yokota T, Kojima S, Yamauchi H, Hatori M. Evidence-based

medicine in Japan. Lancet 2005;366:122.

3.

Ming Liu JQ. When the east meets the west. Lancet

2007;370:948.

Shang Hongcai, M .D.1,2,3,4

Zhang Junhua, M.D.1,2

M ike Clarke, M .D.3

Zhang Boli,

Li Y ouping, M.D.4

Evidence-Based Medicine Centre of Tianjin University of TCM

Tianjin 300193 China

Academy

of TCM in Tianjin University of TCM

Tianjin 300193 China

UK Cochrane Centre

Oxford OX 2 7LG

United Kingdom

est China Hospital of Sichuan University

Chengdu, Sichuan, 610041, China

Address reprint requests to:

Shang Hongcai M.D.

Evidence-Based Medicine Centre of Tianjin University of TCM

Tianjin, 300193, China

E-mail: [email protected]

DOI 10.1089/acm.2007.0645

West er n and A l t er nat i ve Medi c i ne: A Compar i son

of Par ad i gms and Met hods

Dear Editor:

Worldwide, half of the population uses complementary

and alternative m edicine (C AM ) annually,

almost always in

combination with Western medicine (WM).

2

Recently, we

found that in the Netherlands CAM is used by 42% of psy-

chiatric outpatients

3

and 62% of patients in general practice

(Borgemeester, Hoenders, Appelo, 2007; unpublished man-

uscript). Most of them favor integration of CA M and WM .3

Although the practical integration of WM and CAM is

growing, 4

their paradigms and therapeutic methods often

differ greatly. At first sight, they even appear im possible to

reconcile. Is theoretical and therapeutic integration of WM

and CAM really an illusion, or is the presumed gap mainly

related to our points of view? We did a literature search on

this issue and this is what we found.5

Comparison of C M and WM

Many authors compared the Western biomedical para-

digm with alternative paradigms. Table 1 9

-29

shows five

factors that in our opinion characterize the differences m ost

clearly, with references to the original authors.

These distinctions are in most cases no t categorical but di-

mensional. Take, for example, the procedures aspect tech-

nology versus natural sources. A great deal of current WM

medications are directly derived from herbs and plant ex-

tracts, such as procaine a nd digitalis. This obscures the bound-

ary between "natural" and "technical." The same applies to

the expert issue. It is clear that during surgical intervention

patients are under anesthesia and the doctor is the expert.

However, afterward patients themselves have to work ac-

tively on re habilitation. The patient's contribution varies from

minimal to a great deal, considering the circumstances. With

regard to the "therapist—patient relationship," mainstream

psychotherapy currently strongly recognizes the importance

of nonspecific factors.

3

° Regarding research, in Western med-

icine it is largely based on positivism, reductionism, objec-

tivism, and determinism . This is sometim es called outer

sci-

ence.

It strives for standardization and generalization. In

furnishing scientific proof, the random ized controlled trial


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LETTERS TO THE E ITOR

TABLE 1. FIVE FACTORS THAT DISTINGUISH

CAM AND WM

Factor

estern medicine

AM

89

Perspective

Procedure

Research method

Organization

Reductionism9,1°

Pathogenesis (focusing on

factors that cause disease)

Therapist is expert and

responsible

Therapeutic

relationship

is minor detaill9

Technology

Outer science 22

evidence 22

RCT, efficacy22

Legitimate, official24

Training26

Costly

Holism

Salutogenesis

7 1 1 1 2

(focusing on

health, well-being, and one's self-

healing capacity)

14,15

Stimulating healing response

(homeopathy)16

Patient is expert and

responsible17,18

Therapeutic

relationship is central2

Natural sources8

Inner science,6,20,21,26

experience 8

N of 1, effectiveness23,29

Unofficia126

Calling 25

2

Cheap

7,28

Paradigm

echanism13

Giving antidote (allopathy)

CAM , complementary and alternative medicine; WM, Western medicine.

is the golden standard. A lternative therapies are particularly

based on subjective expe rience, intuition, and belief. The as-

sumption is that the truth is found by way of personal ex-

perience. 6 This is called inner science (Gangchen Rinpoche,

2006, unpublished data), or first-person science.

2 0

This ap-

proach seems particularly suitable for observations or sin-

gle case studies (n = 1). In research terms, it is related to

the difference between

efficacy

(the ideal outcome in con-

trolled circumstances) and effectiveness

(the clinical out-

come in natural circumstances). According to Bensing,21

"outer" and "inner science" are two different worlds. Some

say inner science is by definition irrational and irreconcil-

able with rational science. 2 6

Conv ersely, the criticism of ran-

domized clinical trials (RCTs) is that the y artificially reflect

a complex clinical practice and that the importance of the in-

dividual patient becomes devalued by this.

Moreover, the

"RCT as gold standard" is, in our opinion, strongly culture-

bound and is implemented much less outside of W estern cul-

ture. After all, for instance, various Eastern spiritual philoso-

phies consider the

inner

experience as the ultimate basis for

attaining knowledge about reality. Assumptions are tested

according to other (inner) research methods.

6

Despite these

differences, it is clear that in the last decade, Eastern ph iloso-

phies have found more acceptance in the W estern world and

in psychiatry; for example, mindfulness and other B uddhist

techniques in the (third generation of) behavior therapy.32

Additionally, the unassailable status of RCT is more fre-

quently put into question, and research m ethods suitable for

inner science are proposed more often.

2 3 2 9

Thus, where

research methods are concerned, the differences found are

not as absolute as they initially seemed to be. The same grad-

ual distinctions seem to be valid for all other factors and as-

pects. Therefore, theoretical and therapeutic integration of

WM and CA M seems relatively easy. But is it?

There seems to be an exception. The contrast between

mechanism and vitalism is categorical and has been one

of the greatest controversies in philosophy. It still leads to

heated discussions between WM and CAM. This absolute

contrast is of a meta-theoretical nature and therefore cannot

be solved through standard scientific logic. 3 3

Supporters of

each paradigm and perspective cannot be convinced by sci-

entific evidence to the contrary because the ir points of view

concern an existential premise, a conviction regarding the

question of why things are as they are.34

However, looking deeper, this controversy also seems rela-

tive. For example, a mechanical, work-related frame of mind

does not rule out religion an d spirituality in private life. Fur-

thermore, a vitalistic philosophy as the leading therapeutic prin-

ciple can occasionally imply a mechan ical working method.

Conclusions

Besides practical integration practiced by patients already

for a long time, the theoretical and therapeutic integration

of WM and CAM is also possible. The findings of our liter-

ature search argue for using the biopsychosocial model as

originally proposed by Enge1

9 3 5

to facilitate this process.

This model fits well because it maintains a middle ground

between the biomedical approach and the holistic-energetic

approach and because its basis is in the biologic systems the-

ory. This theory attempts to surpass (the opposition be-

tween) mechanism and vitalism, partly by nuancing both.33

It is precisely this nuancing that seems important in our post-

modern, multicultural society.

In our opinion, we should support integration of W M and

CAM in a professional, critical manner and with an open

mind so that we can arrive at a complete, efficient, and ef-

fective healthcare system in which everyone, regardless of

his or her culture, race, philosophy of life, or need, can re-

ceive the help he or she needs.


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8 9 6

E T T E R S T O T H E E D I T O R

A c k n o w l e d g m e n t s

The authors would like to thank Prof. Dr. J. de Jong, Prof.

Dr. W. van der Steen, and Dr. F. Milders for their sugges-

tions and comments during earlier versions of the manu-

script.

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H.J. R ogier Hoend ers, M .D.

Center for Integrativ e Psy chiatry of Lentis (a Comm unity

M ental Health Hospital)

Groningen, The Netherlands

Fiona C. W illgeroth, M .Sc.

R esearch Instituut GGz G roningen (RinG)

Lentis, G roningen, The Netherlands

M artin T. A ppelo, Ph.D.

Research Institute of L entis , M.D.

Groningen, The Netherlands

Address reprint requests to:

H.J. R ogier Hoend ers, M .D.

Center for Integrative Psy chiatry of Lentis

Postbus 86, 9700 AB Groningen

The N etherlands

E-mail:

[email protected]

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