AMA Journal of Ethics^®

I might as well begin by being blunt. There is no love lost between the medicine I was taught in medical school and the kind I practice now, which used to travel under the name of mind-body medicine. It acquired ayurveda (the traditional medicine of India) along the way and now incorporates influences from many other strains of healing. The relationship between conventional and alternative medicine is like a bad marriage, only in reverse. It began with a divorce, has moved to the stage of wary mediation, and holds some prospects of reaching a shy courtship some day in the future.

The grounds for the divorce are bitter. Conventional medicine is offended that alternative medicine even exists. For the average physician, to hear that an allergy patient is taking extract of nettle to treat his symptoms or that a breast cancer patient is being treated with coffee enemas and a macrobiotic diet arouses scorn. Over a decade ago, when the New England Journal of Medicine reported that Americans pay more visits annually to alternative practitioners than to MDs [1], the attitude of the editorial writer was barely disguised dismay and disbelief. It was as if the whole country had turned its back on jet travel to return to the horse and buggy.

Yet at bottom no one could really object to the aims of alternative medicine, which are to bring relief to the whole patient. Sick people come to us in hopes that their suffering will end. If millions of them have been seeking holistic treatments instead of the two-pronged approach of conventional medicine—drugs and surgery—their motivation isn’t irrational. The average appointment with an MD lasts only a few minutes; there is minimal interaction with the physician (someone undergoing coronary bypass surgery is likely to spend fewer than 15 minutes face-to-face with the surgeon prior to the procedure); the risks of complications, side effects, and iatrogenic disease are far from minimal; the language of diagnosis tends to be strange if not entirely opaque to the layman; worst of all, if the patient winds up being hospitalized, he will lose dignity and control over his own life for a time, being thrust into an environment that feels indifferent at best, cold and frightening at worst.

In other words, the other party in the divorce—those who have lost faith in conventional medicine—has its own valid reasons. But after this blunt assessment, I’d like to move on to the present stage of the relationship, which is wary mediation. The two camps are not as opposed as they once were. Twenty-five years ago the possible efficacy of traditional healing modalities, herbs, Eastern therapies like acupuncture, and even mind-body medicine was so foreign as to be entirely alien. Today there are still die-hard skeptics, of course. But in a mood of expanded tolerance, an MD can look at the research on neurotransmitters, cell membrane receptors, and brain physiology, which has made enormous strides in recent decades. Taken as a whole, this research describes the body as an integrated system that exchanges information continuously between the mind, via the brain, and every cell in the body.

In a nutshell, we now realize that for every mental state there must be a corresponding state of physiology. With real-time scans from functional MRIs staring them in the face, MDs have no reason to look upon the placebo effect, for example, as “not real medicine.” When patients feel relief from chronic pain by being given a sugar pill, the body’s endorphins are filling the same receptor sites in the brain that externally administered opiates fill. There can be a wary mediation between alternative and conventional medicine because science is serving as the mediator. One party in the divorce can no longer claim to be the only one supported by evidence, research, and blind trials. As a prime example, I’d cite the well-publicized research by Dean Ornish, MD, and his team on how comprehensive lifestyle changes, including stress management and meditation, along with improved diet and exercise, can reverse even severe coronary heart disease [2]. His research showed that comprehensive lifestyle changes affect gene expression, turning on disease-preventing genes and turning off genes that promote cancer and heart disease [3]. Additional research in collaboration with Nobel laureate Elizabeth Blackburn, PhD, also indicates that these lifestyle changes can lengthen telomeres, the ends of chromosomes that control how long we live [4].

One sign of growing reconciliation comes in the form of softened terminology. Instead of calling it alternative or holistic medicine, as I’ve been doing, the more acceptable term is complementary and alternative medicine (CAM), which sends the signal, “See? I am not your foe. We can cooperate. We’re complementary.” Which is true. The public has been told for decades now that the primary causes of suffering are no longer infectious disease, epidemics, and lack of proper sanitation. Those have been replaced by lifestyle disorders, which are largely preventable.

The problem is that an MD’s practice is badly set up to promote prevention. Visits are too short. Doctors aren’t adequately trained beyond their specializations. Their habits are focused almost entirely on drugs and surgery as treatment modalities. Prevention is considered too “soft,” and yet, if you shift the burden of prevention to the patient (which most MDs are more than happy to do), there is enormous resistance. The public has been given countless warnings about smoking, poor diet, and lack of exercise, yet we have by no means eradicated lung cancer, obesity, coronary artery disease, and type II diabetes. Lifestyle disorders prove intractable when people cling to bad lifestyle habits and resist adopting good ones. We remain a nation of sedentary overeaters, paying pious lip service to prevention while doing less than enough about it.

This is where CAM makes significant inroads, because one of its main themes is the return of power to the patient. Books with titles like “You Can Heal Yourself” irk physicians, but they empower patients. MDs should welcome the whole trend to self-treatment instead of taking the scornful attitude that nothing works but the modalities taught in medical school. The real mystery—one that deeply intrigued me 25 years ago—is that so many therapies that totally disagree with one another manage to bring results. Ayurveda isn’t qigong; yoga isn’t Reiki; none of them is a placebo. Yet somehow healing exists, and the channel it takes can be quite unexpected and inexplicable.

The inconvenient truth that “you can heal yourself” has always been the foundation of medicine. The body is the locus of the healing system; physicians assist this complex, little-understood system. They do not actually do the healing. If this feels threatening to MDs, there is much more room for pride to take a fall. To touch upon only recent headlines, there is evidence that the underlying science for antidepressants is faulty if not entirely invalid. Patients suffering from depression have been shown to have no genetic irregularities of the kind that would promote imbalances of serotonin in the brain; in addition, it seems that the most popular class of antidepressants, SSRIs (selective serotonin reuptake inhibitors), may not be acting on the brain as they claim to act, or are acting with less efficacy than claimed [5]. And although the American Heart Association tells us about 2 million angioplasty and coronary bypass procedures are performed each year at a cost of $100 billion, a randomized controlled trial published in April 2007 in The New England Journal of Medicine found that angioplasties and stents do not prolong life or even prevent heart attacks in stable patients (i.e., 95 percent of those who receive them) [6].

Conventional medicine also faces the mysterious “decline effect”—established medications steadily lose their effectiveness over time, as if the newer generation of patients has different, less receptive physiologies. Add to this the hidden flaws in research studies. Since the average MD knows nothing about this topic, we would all do well to read Jonah Lehrer’s eye-opening New Yorker article, “The Truth Wears Off” [7]. Here are some disturbing highlights.

What Lehrer is primarily concerned with is replicability, the term scientists use for repeating an experiment and arriving at the same result. Certainly the most important findings in science have been repeated many times over. Not necessarily. Some results, particularly in medicine, are not holding up at all. Lehrer cites prominent examples of antipsychotic drugs and the use of aspirin to prevent heart attacks. These treatments are still widely endorsed in the medical literature, ignoring the fact that the decline effect is in full swing, meaning that the original results expected from these treatments are simply not there anymore or have declined to a fraction of what they once were.

For me, the most distressing aspect of the decline effect is how widely it is being ignored. Medicine is the branch of science that touches most people’s lives most closely. A 2005 review article in the PLoS Medicine examined the 49 most cited articles in leading medical journals [8]. Lehrer writes, “of the thirty-four claims that had been subject to replication, forty-one per cent had either been directly contradicted or had their effect sizes significantly downgraded” [7]. If that isn’t troubling enough, there is the huge problem, also widely ignored, of results that get accepted without being replicated either enough or at all. For example, there has been a widespread fad for claiming that genetic differences between men and women account for differing risks in acquiring disorders as various as schizophrenia and high blood pressure. Yet a probe of the underlying research found serious flaws in the vast majority of the studies. And worse was to come: “out of four hundred and thirty-two claims, only a single one was consistently replicable.” One!

Logic tells us that just because one proposition (A) is fallacious, it doesn’t make a contending proposition (B) more true. At this point, MDs rely too much on that logical truism, grudgingly admitting that there may be problems with conventional medicine, but those problems don’t prove that CAM is any better. My purpose isn’t to justify the vast universe of healing modalities that exist outside Harvard Medical School. I look instead toward the next phase of this reverse marriage, which is shy courtship. If both sides stopped being defensive, they would see that they share core values: treating the whole patient, reducing suffering, closing the gap between healer and healed, and doing the least harm while bringing the greatest good. Speaking personally, I stand for alternative medicine while remaining a board-certified endocrinologist, and the reason I straddle two worlds is that I envision expanded medicine in the future, not alternative or mainstream medicine as divergent choices or warring camps.

What would this expanded medicine look like? An adequate answer would take thousands of words. Basically, it requires a lot more marriage counseling between the estranged parties. With that in mind, I have little desire to debate with skeptics and scientists who disdain CAM and falsely claim that only their side is valid and evidence-based. The mystery of healing remains unsolved. If we combine wisdom and science, tradition and research, mind and body, there is every hope that the mystery will reveal its secrets more and more fully. For example, for the last 30 to 40 years we have documented the effect of stress on cardiovascular disease, but we have only recently begun to look into what the opposite of stress could do for our well-being. The experiences of joy, compassion, and meditative quiescence could be powerful tools to restore homeostasis and strengthen our self-repair mechanisms. The next step will be to remodel medical school curricula so that future physicians are not wandering in the dark as my generation did, totally ignorant, if not blind, about treatments outside our narrow band of knowledge. Expanded medicine is the answer, I am sure of that. The only question is how long and crooked a path it will take to get there.