An alternative to alternative medicine

Few things are more infuriating than watching an argument where both protagonists are wrong. This is how I feel watching debates about complementary medicine. Both sides have misunderstood something fundamental.

The argument, in a much shortened version, goes a little like this:

Scientist:‘We’ve tested your alternative medicines in high quality randomised controlled trials and they don’t work.’

CAM Advocate:‘They do too. Your scientific tests are very reductionistic. Our ways have been used for a long time and they are natural and safe. People say they feel better. Of course they work.’

Scientist:‘No. Actually they don’t work. I can prove it. You’re using placebos.’

CAM Advocate:‘No I’m not. There are other ways of knowing. I just know. My clients aren’t stupid.’

Both sides in this argument assume that the treatment recommended by the practitioner is the only active ingredient in the consultation. Placebo, having no active ingredient, is offered by one side, and accepted by the other as a term of abuse. Neither side considers that personalities, words, or behaviour have a legitimate effect on outcomes, or that many questions arising in consultations will never have answers in blogs or PubMed.

The success of evidence-based medicine has convinced us that placebos are inactive sugar pills. When we say a treatment ‘works’ we’ve forgotten that this means ‘performs better than inactive pills in this particular setting in this particular population and perhaps in others, too.’

But if you look at the placebo arms of randomised controlled trials, placebos make people better too. Sometimes they work better than other placebos. Sometimes they have more side effects. Ben Goldacre reminds us that placebos are not merely sugar pills, the effect is the result of the cultural meaning we attach to a treatment.1 Human beings are meaning-creating machines. We just can’t help it. We attach meaning to colours, so red placebos are better for pain relief, green for sleeping. We attach different meanings to injections and pills. And we attach meanings to our interactions with professional healers and the spaces in which they occur. It’s why a home visit is different to being in the clinic. It’s why most of us don’t consult on beanbags surrounded by Lego^®, no matter how much fun that might be. And it’s why complementary practitioners use curtains, incense and music.

Fundamentally, we know this. I remember being told ‘The doctor without a placebo effect should not be working.’ We have Balint to thank for the concept of the ‘drug doctor’, that we use ourselves therapeutically. More than any other speciality, general practice has discovered worlds of therapeutic complexity in our consultations far beyond anything that happens through a prescription.

Perhaps if we follow the evidence, we shouldn’t just say ‘Don’t provide homeopathy on the NHS.’ We should be saying, ‘The water that homeopaths prescribe doesn’t work, but the time and space homeopaths are able to give to patients does work. General practice understands, teaches, and researches this, so can use effective treatments in a context that adds to their value. Don’t fund homeopaths. Fund GPs to have longer consultations in pleasant environments. Give people the benefits of the treatment and the placebo.’

• © British Journal of General Practice 2013