Transcript Module 1 Lecture Slides - Instructional Web Server

Winter 2006
Dr 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
H
O
L
I
S
T
I
C
Do we treat
the disease;
OR, do we
treat the
patient ?
Mainstream
Medicine
Human
Body
Altern
methods
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
5th step?
Mindful
Competence
How we learn ?
What are the ways
of 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
b
o
t
h
a*
n*
d
*
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.hcsc.gc.ca/hpfbdgpsa/nhpddpsn/index_e.html
The
Caduceus
Asclepius,
God of
healing
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-ofpocket 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