Winter 2006Dr Don Morrow

460 Students

• The slides posted for each Module will be posted as we finish each module. Please note that for some of the material, below the slides, there is often text to explain the material. So, for example, the slides re Case Control research etc have full explanations below the slides

• Any feedback on how useful this is or is not would be gratefully received

A Brief History of Medicine: 2000 BCE to 2006 CE

"I have an ear ache...."  

2000 BCE - Here, eat this root   1000 CE - That root is heathen, say this prayer   1850 CE - That prayer is superstition, drink this

potion   1940 CE - That potion is snake oil, swallow this pill

  1985 CE - That pill is ineffective, take this

antibiotic   2006 CE - That antibiotic is artificial and

ineffective ! Here, eat this root  

HOL IST IC

Do we treatthe disease;OR, do wetreat the patient ?

MainstreamMedicine

HumanBody

Alternmethods

The Nature of Evidence

• Case studies• Testimonials• 1000s of years ~ 65-75% of world’s

pop uses CAM-only• INTERNET ‘evidence’ ? ~ there is

quackery; quackwatch.com• HUGE need for education about and

inclusiveness of ‘new’ forms of CAM

How to assess health problem or diagnose/treat

one

• The classic approach ( The way your grandparents did )

• Identify the problem • Use your "experience" • Ask a "trusted" colleague • Consult a reference text• Read a review

How to assess health problem or diagnose/treat

one• The E-BM approach

• Formulate an appropriate clinical question

• Conduct a literature search • Select the key articles • Critically appraise the articles • Apply the results of the search to

the situation

What is Evidence-Based Medicine ( EBM ) ?

• Using the best currently available research evidence combined with clinical judgment and experience to make a medical / health decision

How we learn ?

5th step?Mindful Competence

What are the waysof evidence-based‘knowing’ re CAM ?

http://www.cochrane.org/index0.htm

http://www.nccam.nih.gov/

British House of Lords – Nov 28/00

• Science experts in Britain's House of Lords called Tuesday for tougher regulation of alternative medicines, saying many practices offered no evidence of helping the ill. Peers in parliament's upper chamber said there was also a risk that patients would pursue alternative therapies at the expense of traditional treatment, endangering their health. ``One of the main dangers of complementary and alternative medicine (CAM) is that patients could miss out on conventional medical diagnosis and treatment because they choose only to consult a CAM practitioner,'' the Lords’ science and technology committee said in a report.

Canadian Disbelief

• The goverment of Canada moves into the realm of woo woo medicine as it funds the Office of Natural Health Products. It's about to fund $100 million research institute to study alternative medicine in Hamilton, Ontario. Without the support of organized medicine, and the government, much of alternative medicine would be considered quackery and fraud. The derogation of the responsibility of science based medicine and their cooperation with pseudo-science based health gurus is a big mistake. Canadian medicine is hurting, our hospitals are starving for support and our patients are dying in ambulances in our major cities because our government funds alternative medicine. ~ Alt Med Newswatch, Dec 30/00

What is Evidence-Based Medicine ( EBM ) ?

• Using the best currently available research evidence combined with clinical judgment and experience to make a medical / health decision

• Your text, Preface: “As its central theme, integrative medicine advocates the treatment of both the patient and the disease while seeking to redraft the definition of healing. . . reshaping current practices into a more humanistic, scientifically rooted body of medicine”

++ therapist’s values & experience !

The Gold Standard in Science

• Randomized, Double-blind, control studies . . .

Randomized, controlled study

Double Blind Study

Case Series and Case Report Studies

Case Control Study

Cohort Study

Systematic Review or Meta-Analysis

Either / Or ?

Both / And

***

both

and

Whether quantitative or qualitative…

• Alt-comp therapies (like allopathic therapies) must be receptive to being studied for their:– Effectiveness– Potential harm – Unintended side-effects– Utility vs other therapy

What are Natural Health Products ?

• Under the Natural Health Products Regulations, which came into effect on 1 January 2004, natural health products (NHPs) are defined as:

• Vitamins and minerals • Herbal remedies • Homeopathic medicines • Traditional medicines such as traditional Chinese

medicines • Probiotics, and other products like amino acids and

essential fatty acids.

• NHPs must be safe for consideration as over-the-counter products, be available for self-care and self-selection and not require a prescription to be sold. Products requiring a prescription will continue to be regulated under the Food and Drug Regulations

http://www.hc-sc.gc.ca/hpfb-dgpsa/nhpd-dpsn/index_e.html

Asclepius,God ofhealing

TheCaduceus

World Health Organization

Osteopathy

1993 & 1998 Eisenberg US Studies

• NEJM in ’93 nat’l phone survey to determine prevalence of use of “unconventional” therapies (eg acu or chiro)

• 16 commonly used interventions• Random sample of 1539 adults• 1 in 3 persons used 1 or more U-

therapies and 1/3 of these saw an U-therapy provider

1993 Eisenberg US Study

• This 1/3 made 19 visits per year with avg cost of $27.60 per visit

• Use varied by SES: white, 25-49 yrs with hier educ & hier income leaders in usage

• Majority used U-th’s for chronic conditions

• 72% did not tell their MD about U-th visits

• Extrap to US pop means 425 million visits to alt med vs 388 mill to allo med in 1990

98 Eisenberg

• JAMA follow-up from ’93• Used same process as 93, w 2055

adults• Incr from 33 to 42 % in 97 – used

herbal, massage, megavits, self-help groups, folk remedies, energy healing & homeopathy – chronic conditions

• A 47 % incr in use of alt med

98 Eisenberg

• Incr was due to incr proportion seeking alt med, not to more visits by those already using alt med

• 629 million total visits by US pop to alt med practitioners in 97

• Probably a $27 billion out-of-pocket on alt med in 97 thus equal to all out-of-pocket MD expenses in US

1998 CMAJ Study

• ’98 survey of all 16 Cdn med schools to determine what educ is provided re UG med ed in alt med

• Covered 18 comp therapies selected from Office of Alt Med, Nat’l Institutes of Health (acupunc to reflex)

• Most schools do teach alt med but in one course; done via lectures

1998 CMAJ Study

• Most consistently taught are acupunc and homeopathic med (10 schools)

• Then, in descending order: herbal; chiro; naturop; TCM and biofeedback; osteopathy; shamanism, mass ther & therap touch; finally, yoga, aromatherapy, reflex and native trad healing – only 1 used spiritual healing

1998 CMAJ Study

• Only 2 schools provide instruction in use of alt meds (yoga, mt, chiro) w most stating MD could seek tr by pref

• Schools felt they should provide general conceptual overview

• **Need to understand alt med as part of patients’ health care belief system

• Very little alt med tr in UK; most of US’s 125 med schools incorp some alt courses

Readings to Date

Read for Module 1:• Text chapters 1 & 3• 1st reading on web site under Links, “Folk Remedies” (pdf)• Print the Glossary of Terms from Links on

web site

Read for Module 2:• Text chapters 2 & 4• “Are you Considering Using CAM from Links