Leeches, Spiders, and Astrology: Predilections and PredictionsLeeches, Spiders, and Astrology: Predilections and Predictions

I care for a patient who is 53 and obese with high lipid levels, borderline hypertension, and a strong family history of heart disease. She loves rich foods, hates exercise, and fears synthetic compounds. Recently she has avidly embraced alternative therapies and tells me glowingly about her various healers, the herbal preparations she swallows, and homeopathic medicines that limit her colds.

She is typical of many persons in my practice. People in the United States are rushing toward alternative therapies.¹ What's going on? What does the future hold in the long-standing interplay between allopathic and alternative medicine? Drawing primarily on conversations with my patients, I offer observations and predictions that suggest we are in the midst of a fad that will pass.

Confusing both doctors and patients, contradictory results emerge every week from epidemiologic data and clinical trials. When my patient asks for advice about risk prevention, my response is halting. As I peruse newspapers and medical journals, what's judged best for managing the interplay of obesity, blood pressure, lipids, and family history in a woman feeling exceedingly well changes monthly. And for my other patients, is salt in or out this year? When is wine healthy, and when is it not? What's best for back pain? How do coronary stents, phentermine, or the interferons fare this week? When so much appears uncertain or contradictory, taking the doctor's counsel seriously is difficult.

Prediction.—Rigorous investigators are just beginning to study alternative medicine. As with other new areas of inquiry, few studies have carefully examined the interactions between interventions and outcomes, and few "negative" studies have been published. As scholars compare alternative therapies with sham interventions, and control for patient expectations, their findings will add to the confusion, just as conflicting data remind us that the practice of medicine combines both art and science. Soon the questions will be: How do garlic, ginseng, ginkgo, and St John's wort look this week?

So far, the media have primarily trumpeted success stories and testimonials about alternative medicine. In contrast, a constant barrage of news highlights dangerous medications, medical mistakes, and tragic outcomes in allopathic medicine. Ironically, scientific medicine must take partial responsibility for its own bad press, now that it has grudgingly legitimized scholarly inquiry into the prevalence and nature of medical errors. All the news about disasters and about perverse incentives tempting doctors to "withhold" care leaves public trust in allopathic medicine shaken.

Prediction.—Reporters thrive on trouble and are already spreading word about dangerous herbs and quackery. As they do today with allopathic medicine, the press will soon include alternate clinicians in tales of missed tumors, substance abuse, and sexual misconduct with patients.

Earlier in this century, scientists achieved enormous prestige following their discovery of antibiotic "miracle drugs" and the polio vaccine. But since then, the public has witnessed few miracles. Moreover, few of us, whether patient or health professional, thought we would experience an epidemic with the ferocity of AIDS that has so far stymied the biomedical community. To make matters worse, medical journals, followed quickly by terrifying paperbacks in airport bookstores, carry word of new or newly virulent killer microbes. Why can't scientists sweep away the present and future dangers posed by such organisms? Why does the "war on cancer" remain a skirmish? Public confidence in biomedical science has fallen, and alternative medicine, with its primal message of hope, is currently filling a vacuum.

Prediction.—Despite the public's sense that major advances are elusive, the current infusion of dollars in the National Institutes of Health (NIH) signals society's persistent hopes and expectations for science. For those populations that can afford current therapies, the transformation of AIDS into a chronic illness is reassuring, and cardiologists and oncologists are also beginning to have some striking successes. Viagra and its descendants, new vaccines, and genetic therapies will help scientists to rebuild public trust. No comparable advances within alternative medicine will balance the scales.

The inexorable shrinking of time is not a phenomenon unique to medicine. Just 20 years ago we were told computers would create so much leisure time that we would struggle to fill it. Instead we fight for time to breathe. Whoever or whatever the culprits, doctors spend fewer and fewer minutes assessing and giving counsel; many patients feel a profound sense of loss, and some are angry. They are not particularly interested in how busy we are, or in our casting blame. Alternative healers stand in sharp contrast: patients appreciate the generous amounts of time they offer.

Prediction.—Economic and regulatory constraints that now overwhelm allopaths will close in on alternative practitioners, forcing them to change their habits. Soon the herbalist and homeopath will also drown in charts and forms demanding comprehensive documentation. As alternative practitioners age, they will seek larger incomes. Inexorably, time with each patient will shorten.

In contrast, allopathic doctors, particularly those in primary care, will start to reclaim time, helped by patients who both take a more active role in their care and marshal a collective will that forces payers to replenish the minutes.² Overall the gap in time offered patients by allopathic and alternative caregivers will diminish.

Investment bankers leave the city and refurbish inns in the countryside. Abstract art recedes, as portraits and landscapes return. Audiences ask for music played on the "original instruments" for which it was composed. Films that celebrate the Australian Outback and the Irish village captivate viewers exhausted by the day's travails. Alternative medicine's call back to nature and the "organic" is part of this wave of nostalgia.

Prediction.—Allopathic doctors will learn also to lay claim to the "organic" and "natural" arts. They will move into some of the alternative medicine turf, as they develop a new vernacular that speaks in scientific terms of allopathic medicine's ability to harness nature in the battle against disease.

As my patient demonstrates, exercising, avoiding fattening foods, or overcoming other addictions is difficult and unpleasant. Some call it laziness; others find explanations in Freud or malfunctioning neurotransmitters. In place of taking definitive action themselves, my most honest patients confess they want something done to or for them, rather than meet the demands placed on them.

Prediction.—So far, neither allopathic nor alternative clinicians have significantly improved most human conduct. Despite fervent rhetoric to the contrary, both generally do things to patients, rather than stimulate them to change behaviors. But scientists will soon develop pills that will help safely with obesity, stress, addictions, and other self-destructive behavioral phenomena. At that point, alternative medicine will have trouble competing.

Perhaps it is fitting that this issue of JAMA appears during a season celebrating the contributions of Edward Bernays, inventor of "spin" and public relations.³ Alternative medicines sell direct to the patient, and charismatic healers extolling alternative therapies captivate the media, leaving allopaths dyspneic at the starting gate.

Prediction.—The pharmaceutical industry is suddenly enjoying soaring profits from soliciting patients directly, and allopathic practitioners will learn quickly to market and peddle their wares aggressively to patients. Mobilizing charisma effectively, prominent and articulate doctors will compete with and outspend alternative healers for airtime.

The recent strong economy has lessened the sting of out-of-pocket health care payments. But if they have health insurance, patients feel it should cover most services. In contrast to payers in some western European countries, insurers in the United States are only now beginning gingerly to tread the alternative waters. Some are already beating a hasty retreat.

Prediction.—Fee-for-service remains the rule for alternative practitioners. So far, chiropractors and massage therapists depend on patients coming to them and spend little time teaching family or friends to manipulate or massage at home. A volatile economy and mounting health care costs will accelerate incentives for providers to do less and for patients to stay away. How alternative therapists (and allopathic providers) will deal with rapidly shifting incentives remains an open question, but salaried health professionals, no matter what their practice persuasion, will increasingly become the norm. Then the battle for who gets paid what will begin in earnest!

Focusing on quality of life, comfort, and hope, alternative practitioners have much to teach the allopath who shortchanges such human needs. For such fundamental aspects of care, do we really need to put each intervention to a scientific test? If a clinician spends ample time laying on hands and addressing issues warmly and hopefully with a patient, we don't need a controlled trial demonstrating the value of such interchange. But daggers flash when alternative clinicians claim their wares are not only entirely safe but also effective beyond the placebo effect.

Prediction.—Although Congress has rendered the Food and Drug Administration virtually toothless in overseeing the safety and efficacy of alternative medicines,⁴ academic medicine will soon shatter claims for activity beyond placebo. Moneys spent on research by the NIH Office of Alternative Medicine are already under harsh scrutiny.⁵ The fight is on. A brilliant albeit acerbic bench scientist recently asked a speaker discussing research in alternative medicine at our Medicine Grand Rounds,"Why don't we form a center at Harvard for the scientific study of astrology? After all, it's far more popular than homeopathy and massage therapy!" His point is clear: the public should not stand for spending tax revenues on studies not worth doing.

In France, touring a huge factory manufacturing homeopathic medicines, I watched technicians wearing spotless whites grind up spiders, immerse the morsels in water, dilute the slurry so that the spider molecules disappeared, and shake the fluid obsessively. For such a potion, rigorous scientific inquiry will not demonstrate physiologic impact beyond placebo, and once this is clear, alternative practices that claim such superiority will be dealt a heavy blow.

Moreover, given their safety, low cost, and efficacy, placebos and their virtues will be discussed frankly among allopathic clinicians and their patients. These powerful substances will be advertised in medical journals, but in contrast to the past, doctors will now dispense them without subterfuge or deceit.^{6 - 7} They will simply tell their patients, "This is a placebo. We have little idea right now why it works, but it often does. Give it a try."

Fads come and go quickly. In the past, allopathic medicine touted leeches, frozen stomachs, and thalidomide (leeches may be coming back, and thalidomide has returned, albeit with strict oversight). Today tennis is out; golf is in. Convertibles are deemed dangerous; monstrous SUVs rule the roads. Specialists look for work; primary care doctors are in demand.

Prediction.—Alternative therapies, bathed invariably in optimism and hope, invoke harmony with nature and the human need for mystery. In contrast, scientific medicine focuses on trouble, dysfunction, and disorder, with practitioners discoursing on cancers "eating at the flesh" and autoimmune diseases "turning bodies against themselves." Whatever the guiding metaphors, for those long-steeped in a heritage of chicken soup, religion, copper bracelets—or penicillin—fads will have little impact.⁸

But the current explosion in alternative medicine is rooted differently. Signs of this fact are plentiful: yuppies lead the charge; messianic proselytizers harangue; profiteers follow the scent of blood; philanthropists make huge contributions; media hype drowns out the negatives; and patients spend money that might better go elsewhere. For many recent converts, the lust for alternative medicine seems to run in parallel to the appetite for cosmetic surgery designed to reclaim passing years, signaling both decadence and self-indulgence.

Well before its explosive growth in the United States, alternative medicine proliferated in western Europe. Recent conversations with doctors and patients there suggest that in some regions the bloom is fading, particularly as national health systems constrain medical costs and scrutinize the quality of care.

As my point-counterpoint suggests, the current fascination with alternative medicine will have a lasting and, on the whole, salutary impact on allopathic practice. But I predict that patients' romance with the field will diminish with time, leaving a core of true believers similar to those of the past.

What about my patient? All clinicians are learning that good care, as well as their economic survival, depends on taking into account patients' cultural heritage and habits, on respecting and addressing expectations, beliefs, and unique preferences. In that context, she is telling me to take seriously the messages alternative medicine sends, and I am ready to listen. But how can I help? In the end, whether we focus on allopathic medicine, alternative medicine, or both, she and I need to find a way to improve her lifestyle and prevent future vascular disaster. Right now, we have a long way to go.

I thank Andrew, Jill, and Suzanne Delbanco, Lisa Iezzoni, MD, and Richard Rockefeller, MD, for exceedingly helpful critique of the manuscript.