Institute for Biomedical Ethics, University of Basel, Switzerland
In a recent research report  and linked editorial , several researchers claim that the use of complementary and alternative medicine (CAM) is increasing in Swiss hospitals and that further efforts should be made to enhance the provision of CAM. However, both papers are flawed by poor use of evidence. Ironically, this paper and editorial act as a perfect example of CAM: both offer enthusiastic conclusions based on weak evidence, which in turn parallels the haphazard and unscientific provision of CAM in Swiss hospitals which is revealed by the report.
In their study, Carruzzo, Fraz, Rodondi and Michaud sent questionnaires to 46 hospitals in the French-speaking part of Switzerland and subsequently interviewed ten CAM therapists working at some of these hospitals. Their main survey findings were that 19 of the 37 hospitals that responded offered at least one type of CAM, and 18 offered none. The main result from the interviews was that provision of CAM was based on therapist motivation rather than hospital procedures (8 out of 10 interviews).
Given these results, the authors claim that “it seems that the number of hospitals offering CAM – in the French-speaking part of Switzerland at least – is increasing.” The authors base this conclusion on a comparison with the results of a 2004 study in which 33% of respondents across Switzerland said their hospitals had doctors who offered CAM . However, they neglect to mention that the proportion of hospitals where CAM was offered by doctors or nurses or other therapists (the relevant comparator for their study, which looked at provision by all practitioners) was actually 51.6% in 2004, as reported by hospital managers. Furthermore, 64% of doctors, nurses and therapists surveyed in 2004 reported that they offered CAM. Therefore, the conclusion of the paper (and the accompanying editorial) should actually be that the use of CAM in Swiss hospitals has fallen since 2004 (or that CAM use is now at a similar level, if we focus on the results from hospital managers). It is disappointing that the authors chose to use the only statistic that supported their claim by quoting it out of context. A more accurate description would be that only half of Swiss-French hospitals offer CAM at all, and 7 of the 19 hospitals that do so only offer one type of CAM. The 2004 study concluded that “the supply of CAM in Swiss hospitals is very small … and concentrates on few hospitals” despite the 64% finding; a more honest interpretation of a modest result. (The 2004 study provided no data specific to French-speaking Switzerland, so the comparison is probably not valid in any case. Even if we accepted the author’s comparison, it would not show that use of CAM is currently increasing, as the number of hospitals offering it could have fallen over the last few years, for which we have no data.)
One of the most striking results from the study is that CAM appears to have been introduced very unsystematically in the hospitals that offer any such therapies. In eight out of ten interviews, it appeared that the procedures for introducing a CAM in the hospital were not tightly supervised by the hospital and were mainly based on the goodwill of the therapists, rather than clinical/scientific evidence. CAM introduction was in all cases the result of interest by an employee. Sometimes it was also a response to repeated requests by patients. No therapist said that the introduction of CAM was based on scientific data. Moreover, no hospital expected research into CAM.
These results are actually quite shocking: they reveal that half of the hospitals in the study allow therapists to provide treatments to patients without assessing whether they would actually benefit them and without ever intending to conduct any research to establish this essential fact. The use of CAM can be legitimately motivated by therapist’s interests or patients’ requests, provided it is evidence-based, but not even one interviewee claimed that evidence was used at all. (Another point that is not mentioned in the paper is the possible disconnect between hospital managers and the therapists offering CAM. If provision of CAM is not supervised or introduced by the hospital, it is very possible that some managers are unaware that their therapists are offering CAM.) Furthermore, while therapists might have been acting with good intentions, providing patients with unproven treatments is unethical . The authors commendably state that "It is extremely disturbing that, apparently, the files of patients who received CAM therapy do not mention these interventions”, but it is hardly surprising that such treatment is not recorded, given that doing so would in many cases be creating evidence that sham treatment had been provided.
Calling some types of CAM “sham” treatments may seem harsh and unjustified, but in many cases this is an accurate description. The authors provide a helpful table that illustrates the types of CAM provided in the respondent hospitals. Some of these, such as acupuncture and hypnosis, are relatively evidence-based, but others are not. In addition to two hospitals that offer homeopathy in the context of gynaecology and paediatrics, the results show that three hospitals provide treatment from practitioners of “the secret”. These were described as healers who play a part in folk medicine and claim they can alleviate the pain due to burns by “talking the fire out” of burns, reduce massive haemorrhages or heal warts, eczema or sprains thanks to a secret incantation: “the power”. They work mostly by phone and do not demand any compensation.
It is embarrassing that Swiss hospitals are offering such superstition-based “therapies” to patients in the 21st century, particularly in paediatrics, which was the context in which one hospital offered “the secret.” This essentially amounts to letting people with no medical qualifications speak to patients over the telephone, and is completely inappropriate for any patient and even more so for children with serious injuries. Even for more respectable CAM therapies, it is inappropriate for therapists to use them on patients without assessing the evidence for their efficacy.
The authors conclude that “The selection of a CAM to be offered in a hospital should be based on the same procedure of evaluation and validation as conventional therapy, and if the safety and efficiency of the CAM is evidence-based, it should receive the same resources as a conventional therapy.” This is commendable, but if these criteria are truly applied the treatment in question will no longer be CAM, but part of the formidable arsenal of mainstream evidence-based medicine. Although their report has some interesting results, they are not encouraging for CAM, but indicate that many CAM therapists are using treatment that is not evidence-based which could harm patients.
Eric Bonvin uses the study in question to call for greater support for CAM in Swiss hospitals, claiming that the results show that “the supply and use of alternative medicine is gradually increasing in hospitals in French-speaking Switzerland”. As already explained, it does not illustrate anything of the sort: at best it indicates that the same amount of CAM is provided in the French-speaking part of Switzerland as was provided across Switzerland almost a decade ago, allowing no inferences about whether rates are currently increasing. Indeed, they may have decreased, if we accept the 64% figure from the older study as a valid comparator.
Bonvin goes on to claim that “this study highlights how inefficient our medical institutions are in terms of implementing alternative medicine to French speaking hospitals, despite them being requested by the people, politicians and all parties, paving the way for tomorrow's medical model.” It is true that the current provision of CAM in Swiss hospitals appears to be somewhat haphazard, but (as the authors of the study state) future provision should be based on systematic assessment of evidence, not on the ill-informed preferences of people and political parties. Is tomorrow's medical model to be based on what people want, or on medicines that work? Hospitals should not be efficient at providing treatments that are not evidence-based, as doing so wastes resources, increases insurance premiums needlessly and can harm patients .
In the introduction to his editorial, Bonvin states that “During the 1970s and 1980s, alternative medicine was distrusted and rejected.” He seems unaware that this trend continued through the 1990s and 2000s into the current decade, and that his editorial and the study it is based on will only continue this trend. We have seen that both this research report and this editorial are wrong to claim that use of CAM is increasing in French-speaking Switzerland. Making exaggerated claims for the efficacy and popularity of CAM does both patients and those treatments that do work a disservice. In fact, the most important conclusion we can derive from this study is that CAM provision in Swiss hospitals is not even slightly evidence-based, which is very disappointing. Action should be taken to ensure that any CAM offered in Swiss hospitals is evidence-based. Ultimately, however, “effective evidence-based alternative medicine” is a contradiction in terms: if we have proof that it works, it is no longer alternative.
Correspondence: Dr David Martin Shaw, PhD, MSc, MA, MML, PGCE, Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland, david.shaw[at]unibas.ch
1 Carruzzo P, Graz B, Rodondi P-Y, Michaud P-A. Offer and use of complementary and alternative medicine in hospitals of the French-speaking part of Switzerland. Swiss Med Wkly. 2013;143:w13756 http://www.smw.ch/content/smw-2013-13756/ .
2 Bonvin E. Alternative and complementary medicine in our hospitals: forbidden yesterday, tolerated today... implemented tomorrow? Swiss Med Wkly. 2013;143:w13886 http://www.smw.ch/content/smw-2013-13886/ .
3 Widmer M, Donges A, Wapf V, Busato A, Herren S. The supply of complementary and alternative medicine in Swiss hospitals. Forsch Komplementärmed. 2006;13(6):356–61.
4 Shaw D. Homeopathy is where the harm is: five unethical effects of funding unscientific ‘remedies’. J Med Ethics 2010;36:130–131.
5 Shaw D. The Swiss Report on homeopathy: a case study of research misconduct. Swiss Med Wkly. 2012;142:w13594
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