Zdrav Var 2006; 45: 59-62 59 COMPLEMENTARY MEDICINE: EVIDENCE VERSUS EXPERIENCE? Edzard Ernst1 Complementary medicine (CM) has become important, not least because a large proportion of patients try it (often without telling their doctor), the media promote it, yet few people seem to understand it. In the following article I will try to highlight some of those aspects of CM which, I feel, are currently plagued by confusion, lack of transparency and sometimes even wilful deceit. Experience The long history of some forms of CM means that they have been “field-tested” in millions of patients. Surely this collective experience weighs heavy and, some insist, must outweigh the evidence from clinical trials which are usually only short-term, and comprise far less people. While this line of argument convinces many CM enthusiasts, it is wholly unconvincing to anyone capable of critical analysis. There are numerous reasons why experience can turn out to be a cumbersome method of reaching the wrong conclusions. There are also many examples where experience has misled our forefathers. Take blood letting, for instance: it was used for hundreds of years in all medical cultures for most medical conditions. Doctors were so impressed by its powers that, when trial data demonstrated its lack of effectiveness, they believed their experience and disbelieved the evidence. In CM, the supremacy of experience over evidence is still fairly obvious. We have shown, for instance, that authors of CM books seem to recommend almost any treatment for any condition (1): 120 CAM modalities for addiction, 131 for arthritis, 119 for asthma, 133 for cancer. But the climate is, I hope, slowly changing. More and more CM experts now recognize experience for what it is: a good method for formulating hypotheses but a very poor method for testing them. Evidence - negative or positive? It has always puzzled me how anyone could be for or against something like a medical intervention. Does it make sense to be for or against appendectomy or anticoagulants? I don’t think so! Why then do people hold emotional views on CM? In matters of healthcare, likes and dislikes should matter far less than evidence. Healthcare should not be a fashion where one might legitimately hold this or that opinion, nor must it be confused with religion in which one either believes or doesn’t. Medical treatments either demonstrably and reproducibly work or they don’t. Therefore reliable evidence on what is effective and safe must always be “good” - to view a trial of spiritual healing, homeopathy etc which fails to show that the tested intervention works (e.g. is better than placebo) as “negative” does simply not make sense. Examples include the recent (first ever) trial of shark cartilage for cancer (2). Its results showed that it has no beneficial effects. Surely this must be good news all around. Sharks will not die needlessly, cancer patients will not attach false hopes to a bogus treatment, money can be directed towards effective treatments. The only people who could possibly perceive this finding as “negative” are those involved in peddling bogus cancer cures and swindling desperate patients and their families of their savings. Neither researcher nor clinicians should be in the service of snake oil traders. Whenever we demonstrate that CM does work, the situation usually reverses. Examples for this scenario can also be found easily. Compelling evidence now suggests that real acupuncture is better than sham acupuncture for a range of pain-related syndromes, e.g. back pain (3). If the findings are based on good science, this must be good news: it could help millions who suffer from back pain, particularly as conventional medicine is not very successful in dealing with this problem. Many systematic reviews of rigorous clinical trials are available today demonstrating that certain CM approaches are efficacious for certain indications. Table 1 summarizes our endeavour to evaluate the existing trial data (1). It suggests that, for many CM methods, we now have compelling evidence that they are effective for specific conditions. Making more general use of these options could benefit many patients -provided that the risks of these remedies do not outweigh the benefit. Finding the evidence (arguably this is what science should be about) is always a good thing, particularly in medicine. As long as the results are reliable, they can only further our knowledge and will eventually improve healthcare. Sound evidence is always positive. 1 University of Exeter & Plymouth, Department of Complementary Medicine, 25 Victoria Park Road, Exeter EX2 4NT, England Correspondence to: e-mail: Edzard.Ernst@pms.ac.uk 60 Zdrav Var 2006; 45 Table 1. List of conditions for which CM methods are effective. Condition Intervention AIDS/HIV (pallation) Stress management AIDS/HIV Exercise (symptomatic) Alzheimer's disease Ginkgo Anxiety Kava Anxiety Massage Anxiety Music Therapy Anxiety Relaxation Benign prostatic hyperplasia African plum Condition Intervention Benign prostatic hyperplasia Saw palmetto Cancer prevention Allium vegetables Cancer prevention Green tea Cancer prevention Tomato (lycopene) Cancer prevention Exercise Cancer prevention Aromatherapy/massage Cancer prevention Exercise Chronic fatigue syndrome Exercise Condition Intervention Chronic heart failure Hawthorn Chronic venous insufficiency Horse Chestnut Constipation Psyllium Depression Exercise Depression St. John's Wort Diabetes Guar gum Diabetes Psyllium Erectile dysfunction Yohimbine Condition Intervention Hypercholesterolemia Guar gum Hypercholesterolemia Oat Hypercholesterolemia Soy Hypertension Biofeedback Hypertension Co-enzyme Q10 Insomnia Relaxation Insomnia Melatonin Irritable bowel syndrome Fibre Condition Intervention Labor Pain Hypnosis Labor Pain Water immersion Menopause Red Clover Migraine Biofeedback Nausea and vomiting (induced by chemotherapy) Acupoint stimulation Nausea and vomiting (induced by chemotherapy) Relaxation Non-ulcer dyspepsia Peppermint and caraway Condition Intervention Osteoarthritis Acupuncture Osteoarthritis Phytodolor Osteoarthritis Chondroitin Osteoarthritis Glucosamine Osteoarthritis S-andenosylmethionine Overweight/obesity Ephedra sinica Peripheral arterial occlusive disease Ginkgo Peripheral arterial occlusive disease Padma 28 Condition Intervention Rheumatoid arthritis Diet Rheumatoid arthritis Phytodolor Smoking cessation Group behaviour therapy Upper respiratory tract infection Vitamin C (treatment not prevention) Legend This list is based on a review of the existing evidence. Only condition/intervention combinations are listed for which the amount, quality and quantity of evidence was sufficient and the direction of the evidence was clearly in favour of the intervention. Data extracted from reference 1. Ernst E. Complementary medicine: Evidence versus experience? 61 Poor Science In CM, many researchers seem to use science to prove that what they already believe is correct. Ye t science is not for proving but for testing. The former approach does not only reveal an unprofessional attitude, it is prone to seriously mislead us all. Emotions and strong beliefs can lead to bias (4), and bias leads to bad science. Sadly poor science is rife in CM. Here I could cite hundreds of examples. A recent study of anthroposophy (5) may suffice. Its aim was “to compare anthroposophic treatment to conventional treatment”. Patients elected to consult either an anthroposophic or a conventional doctor. The results of this study showed more favourable outcomes for the former approach. The authors concluded that “anthroposophic treatment… is safe and at least as effective as conventional treatment”. Because of numerous sources of bias and confounding, many other conclusions are just as likely (e.g. patients who elect to see an anthroposophic doctor differ in many ways from patients who consult a conventional physician). This example highlights much of what frequently is wrong with CM and CM research. It typifies how the aims of a study can be mismatched with the methodology and how the results may not justify the conclusions. If I had to name the characteristic that I find most disturbing in published CM research it would be this frequent inconsistency. Wishful thinking is, of course, only human. But the regularity of this incongruence in CM is nevertheless most remarkable. What follows is, I believe, more than obvious: poor science is bad - not because some ‘out-of-touch’ scientists in the ‘ivory towers’ think so - it is bad because it leads to wrong decisions in healthcare. Ultimately this will be detrimental to those who we should care for most: our patients. Double Standards In CM, double standards seem to be everywhere. They are typified, I fear, in the new and increasingly popular movement (its proponents would probably say ‘philosophy’) of ‘integrated medicine’! Its two basic tenets are that a) integrated medicine cares for the individual as a whole rather than looking at a diagnostic label and b) integrated medicine uses “the best of both worlds”(6). Both claims look superficially convincing and plausible; at closer inspection they are, however, neither. (7) Caring Table 2. Selected statements from a recent (government-sponsored) patient guide.* Statement (quote) ** Evidence *** .. the risk of a stroke (after upper spinal manipulation) is between 1 and 3 in 1 million manipulations. There are many published estimates that suggest much higher incidence figures. However, due to extreme under-reporting, the risk remains undefined. Acupuncture is being increasingly used for people trying to overcome addictions... A Cochrane review fails to demonstrate efficacy of acupuncture for this indication Craniosacral therapists treat a wide range of conditions from acute to chronic health problems... There is no trial evidence at all to suggest that craniosacral therapy is effective Healing is used for a wide range of... conditions. Research has shown benefit in many areas, including healing of wounds, ... migraine or irritable bowel syndrome..." The best evidence available to date fails to demonstrate effects beyond a placebo response "Homoeopathy is most often used to treat chronic conditions such as asthma" A Cochrane review fails to demonstrate efficacy of homoeopathy for asthma * Its aim was to “give (you) enough information to help you choose a complementary therapy that is right for you” ** The guide does not contain anything else by way of evidence on effectiveness (but was commissioned by the DoH to provide such evidence) *** Evidence extracted from reference 3 62 Zdrav Var 2006; 45 for the whole individual has always been and will always be a hallmark of any good medicine. (8) It is thus not legitimate to adopt it as a main characteristic that differentiates ‘integrated medicine’ from conventional healthcare - on the contrary, conventional healthcare professionals who work towards optimising patient care must feel insulted by it. Using “the best of both worlds” (i.e. CM and mainstream healthcare) sounds fine until one realises how crucially it hinges on the definition of “best”. In modern healthcare, this term can only describe those treatments that reproducibly do more good than harm. But this is precisely what evidence based medicine (EBM) is all about. Either ‘integrated medicine’ is synonymous with EBM (in which case the term would be redundant) or it applies a different standard for the term “best”. Considering what ‘integrative medicine’ in the UK currently promotes (Table 2), one has to conclude that the latter applies. This discloses integrative medicine as an elaborate smoke screen for adopting unproven treatments into routine healthcare (10). In the long run, this strategy can only turn out to be detrimental to everybody, including patients and even CM itself. Conclusion At present, CM seems to be in transition from an experience-based activity to an evidence-based area of healthcare. Only if CM applies the same standards as the rest of medicine does, will we be able to see its true value. And only then can we be sure that CM does more good than harm to those who count most: our patients. References 1. Ernst E, Pittler MH, Wider B, Boddy K. The desk top guide to complementary and alternative medicine. 2nd Edition. Edinburgh: Mosby/Elsevier. 2006. 2. Loprinzi CL, Levitt R, Barton DL, Sloan JA, Ahterton PJ, Smith DJ et al. Evaluation of shark cartilage in patients with advanced cancer. Cancer 2005; 104: 176-82. 3. Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain. Ann Intern Med 2004; 142: 651-63. 4. Ernst E.,Canter PH. Investigator bias and false positive findings in medical research. TRENDS in Pharmacological Sci 2003; 24: 219-21. 5. Hamre HJ, Fischer M, Heger M, Riley D, Haidvogl M, Baars E et al. Anthroposophic vs. conventional therapy of acute respiratory and ear infections: a prospective outcomes study. Wien Klin Wochenschr 2005; 117: 256-68. 6. Rees L.,Weil A. Integrated medicine. BMJ 2001; 322: 119-20. 7. Ernst E. Disentangling integrative medicine. May Clin Proceed 2004; 79: 565-6. 8. Calman K. The profession of medicine. BMJ 1994; 309: 1140-3. 9. The Prince of Wales’s Foundation for Integrated Health: Complementary Healthcare: a guide for patients. 2005; www.fihealth.org.uk. 10. Smallwood C. The Role of Complementary and Alternative Medicine in the NHS. An investigation into the potential contribution of mainstream complementary therapies to healthcare in the UK. http://princeofwales.gov.uk/news/2005/ 10.oct/smallwood.php 2005. Zdrav Var 2006; 45: 63-66 63 KOMPLEMENTARNA MEDICINA: DOKAZI PROTI IZKU[NJAM? Edzard Ernst1 Uvodnik Komplementarna medicina (KM) se je uveljavila tudi zato, ker se k njej zateka veliko {tevilo bolnikov (mnogi od njih, ne da bi o tem obvestili svojega zdravnika) in ker jo priporo~ajo mno‘i~na ob~ila, ~eprav jo razumejo le redki. V ~lanku bom sku{al osvetliti predvsem tiste vidike KM, ki so po mojem mnenju zaradi zmede na tem podro~ju, nepreglednosti in celo namernega zavajanja, {e zlasti na udaru. Izku{nje Dolga zgodovina nekaterih oblik KM ka‘e, da so bile preizku{ene v praksi na milijonih bolnikov. Ta kolektivna izku{nja ima seveda precej{njo te‘o, po prepri~anju nekaterih mnogo ve~jo kot dokazi, pridobljeni s klini~nimi raziskavami. V te je zajetih precej manj ljudi in ponujajo le kratkoro~ne izsledke. Za mnoge zagovornike KM je to prepri~ljiv dokaz, ki pa ni sprejemljiv za vse, ki so sposobni kriti~ne presoje. [tevilni razlogi govore za to, da je sklepanje, ki temelji zgolj na osnovi izku{enj, lahko zmotno. To se je izkazalo `e ve~krat v preteklosti. Tak{en primer je pu{~anje krvi, ki so ga stoletja uporabljali v vseh kulturnih okoljih za zdravljenje ve~ine bolezni. Zdravniki so bili tako navdu{eni nad u~inki tega zdravljenja, da so raje verjeli svojim izku{njam kot dokazom tudi potem, ko so s poskusi dokazali njegovo neu~inkovitost. Na podro~ju KM izku{nje o~itno {e vedno nadvladajo dokaze. Pisci knjig o KM priporo~ajo skoraj vse na~ine zdravljenja za vse bolezni (1): 120 oblik KM za zasvojenost, 131 za artritis, 119 za astmo in 133 za raka. Kljub temu pa upam, da se bo stanje po~asi spremenilo. Vedno ve~ zdravilcev priznava, da so izku{nje koristne za postavljanje hipotez, a slabe za njihovo preverjanje. So izku{nje negativne ali pozitivne? Vedno sem se ~udil temu, da se nekdo lahko zavzema za nek medicinski poseg ali je proti posegu. Je smiselno, da nekdo zagovarja oz. nasprotuje odstranitvi slepi~a ali zdravilom proti strjevanju krvi? Mislim, da ne! Zakaj imajo potem ljudje ~ustven odnos do KM? Na podro~ju zdravstva mora imeti nagnjenje oziroma odpor do ne~esa mnogo manj{o te`o kot dokazi. Zdravstveno varstvo ni moda, kjer je dovoljen razli~en okus, pa tudi ne vera, kjer eni verujejo, drugi pa ne. Bistvo u~inkovitosti zdravljenja je dokazljivosti in ponovljivosti, zato so zanesljivi dokazi o tem, da je zdravljenje u~inkovito in varno, vedno lahko le “pozitivni. Ozna~iti raziskave duhovnega zdravljenja, homeopatije in drugih metod, za katere ni dokazov, da res delujejo (da so bolj u~inkovite kot placebo), kot “negativne,” je nesmisel. Eden tak{nih primerov je tudi nedavna {tudija o uporabi hrustanca morskega psa pri bolnikih z rakom (2), ki ni pokazala prav nobenih ugodnih u~inkov. To je za marsikoga zelo dobra novica: morski psi ne bodo po nepotrebnem umirali, bolniki z rakom se ne bodo ve~ z la`nim upanjem oprijemali tega zdravljenja in denar bo tako lahko namenjen drugim, u~inkovitim oblikam zdravljenja. Edini, ki te ugotovitve lahko sprejmejo kot negativne, so tisti, ki se ukvarjajo z la`nim zdravljenjem raka in ki obupane bolnike in njihove svojce goljufajo za njihove prihranke. Noben znanstvenik in noben zdravnik ne more zagovarjati prodajalcev ka~jega olja. Kadar koli doka`emo, da je KM u~inkovita, se stanje obi~ajno obrne. Tudi primerov za ta scenarij ni te`ko najti. Danes imamo prepri~ljive dokaze o tem, da je pri velikem {tevilu bole~inskih sindromov, npr. pri bole~inah v kri`u, prava akupunktura bolj u~inkovita od “akupunkture” (3).V primeru, da so do teh ugotovitev pri{li po znanstveni poti, je to prav gotovo dobra novica. Tako bi lahko pomagali milijonom ljudi z bole~inami v hrbtenici, {e zlasti zato, ker se uradna medicina v tem primeru ni izkazala kot zelo uspe{na. Izsledki sistemati~nih analiz klini~nih {tudij ka‘ejo, da so nekatere metode KM u~inkovite pri dolo~enih boleznih. Tabela 1 predstavlja povzetek na{ih prizadevanj, da bi ocenili podatke iz {tudij, ki so na voljo (1). Imamo prepri~ljive dokaze, da so mnoge oblike KM u~inkovite pri dolo~enih boleznih. S {ir{o uporabo teh na~inov zdravljenja bi lahko pomagali mnogim bolnikom pod pogojem, da tveganje ni ve~je od koristi, ki jih prina{ajo. Vedno si ‘elimo najti dokaze, {e zlasti na podro~ju medicine, saj je to bistvo znanosti. ^e so dokazi zanesljivi, lahko prispevajo k bolj{emu znanju in bolj kakovostnemu zdravljenju. Zanesljiv dokaz je namre~ vedno pozitiven. 1University of Exeter & Plymouth, Department of Complementary Medicine, 25 Victoria Park Road, Exeter EX2 4NT, England Kontaktni naslov: e-po{ta: Edzard.Ernst@pms.ac.uk 64 Zdrav Var 2006; 45 Tabela 1. Seznam bolezni, ki jih uspe{no zdravijo z KM. Bolezen Zdravljenje AIDS/HIV (paliativno) obvladovanje stresa AIDS/HIV telesna dejavnost (simptomatsko) AIzheimerjeva bolezen ginkgo anksioznost kava anksioznost masaža anksioznost glasbena terapija benigna hiperlazija prostate afriška sliva benigna hiperplazija prostate Serenoa repans preprečevanje raka čebulnice preprečevanje raka zeleni čaj preprečevanje raka paradižnik (likopen) preprečevanje raka telesna dejavnost preprečevanje raka aromaterapija/masaža sindrom kronične utrujenosti telesna dejavnost kronična srčna odpoved glog kronična venska insuficienca divji kostanj zaprtje luske trpotca (Plantago ovata) depresija telesna dejavnost depresija šentjanževka sladkorna bolezen guar sladkorna bolezen luske trpotca( Plantago ovata) erektilna disfunkcija johimbin (alkaloid) hiperholesterolemija oves hiperholesterolemija soja zvišan krvni tlak biofeedback zvišan krvni tlak koencim Q10 nespečnost sproščanje nespečnost melatonin sindrom razdražljivega kolona vlaknine porodne bolečine hipnoza porodne bolečine porod v vodi menopavza rdeča detelja migrena biofeedback slabost in bruhanje (zaradi kemoterapije) akupunktura slabost in bruhanje (zaradi kemoterapije) sproščanje dispepsija brez ulkusa pepermint in kumina osteoartritis akupunktura osteoartritis Phytodolor osteoartritis glukozamin osteoartritis S-andenosilmetonin debelost efedra periferna okluzivna bolezen arterij gingko periferna okluzivna bolezen arterij Padma 28 revmatični artritis dieta revmatični artritis Phytodolor odvajanje od kajenja skupinska terapija Legenda Ta seznam temelji na pregledu razpolo`ljivih dokazov. Obsega le tiste bolezni in tiste vrste zdravljenja, pri katerih obstaja dovolj veliko {tevilo kakovostnih dokazov, ki govore v prid tem na~inom zdravljenja. Ernst E. Kompleterna medicina: dokazi proti izku{njam? 65 Slabo znanstveno delo Zdi se, da mnogi raziskovalci KM uporabljajo znanost le za dokazovanje pravilnosti ne~esa, o ~emer so `e prepri~ani, da je pravilno. Bistvo znanstvenega dela pa ni dokazovanje, temve~ testiranje. Ta pristop ne zrcali le neprofesionalnosti raziskovalcev, temve~ je tudi zavajajo~e. ^ustven odnos in vnaprej{nje prepri~anje lahko vodita v pristranost (4), posledica tega pa je slabo znanstveno delo. Na ‘alost, pa je tak{na znanost stalnica KM. S tem v zvezi bi lahko na{teli na stotine primerov, a dovolj je, ~e omenimo nedavno raziskavo o antropozofiji (5), v kateri so “primerjali antropozofsko in klasi~no zdravljenje”. Bolniki so se odlo~ali med antropozofskim in klasi~nim zdravnikom. Raziskava je pokazala ugodnej{e izide zdravljenja pri antropozofskem pristopu. Avtorji raziskave so pri{li do zaklju~ka, da je “antropozofsko zdravljenje varno in vsaj tako u~inkovito kot standardni na~in zdravljenja”. Zaradi {tevilnih dejavnikov, ki vodijo v zmoto in pristranost, so mo‘ni tudi druga~ni zaklju~ki. Tako se npr. tisti bolniki, ki se odlo~ijo za antropozofskega zdravnika, v mnogih pogledih razlikujejo od tistih, ki obi{~ejo klasi~nega zdravnika. Ta primer osvetljuje pogoste zmote KM in napake raziskav na tem podro~ju. Metodologija pogosto ni prilagojena ciljem in rezultati ne podpirajo vedno zaklju~kov. Pogostna zna~ilnost, ki me najbolj moti pri objavljenih raziskavah KM, je nedoslednost. V ~love{ki naravi je, da vidimo tisto, kar si `elimo videti, kljub temu pa je treba poudariti, da je neskladnost, ki jo redno sre~ujemo na podro~ju KM, prav velikanska. Menim, da je ve~ kot o~itno, da je pomanjkljiva znanost slaba, ne le zato, ker tako menijo znanstveniki v “slonoko{~enih stolpih”, oddaljeni od resni~nosti, temve~ zato, ker vodi do napa~nih odlo~itev na podro~ju zdravstva. Vse to pa gre na {kodo tistih, za katere bi morali najbolj poskrbeti - na {kodo na{ih bolnikov. Dvojna merila Zdi se, da so dvojna merila prisotna povsod na podro~ju KM. Bojim se, da so zna~ilna za novo in vedno bolj popularno gibanje (zagovorniki bi ga verjetno ozna~ili kot “filozofijo”) - integrirano medicino! Ta pa temelji na dveh bistvenih na~elih: a) ukvarja se s posameznikom kot s celoto in ne upo{teva le nalepke z diagnozo; b) uporablja “kar je najbolj{ega od obeh vrst zdravljenja” (6). Na prvi pogled se zdita zgornji trditvi verjetni in prepri~ljivi, ~e pa ju pogledamo pobli‘e nista ne eno ne drugo (7). Skrb za posameznika kot celoto in bo ostala za{~itni znak kakovostne medicine (8). Zato ni po{teno trditi, da je prav to zna~ilnost, po kateri se integrirana Tabela 2. Izjave, izbrane iz priro~nika za bolnike, ki je iz{el nedavno pod pokroviteljstvom vlade.* Izjava ** Dokaz *** ...tveganje za kap (po manipulaciji hrbtenice) je 1-3 na milijon manipulacij Objavljenih je bilo več ocen, ki navajajo precej večje številke. Zaradi pomanjkljivega poročanja pa tveganje ni opredeljeno. Akupunkturo vse več uporabljajo za premagovanje odvisnosti. Cochranovo poročilo ni dokazalo učinkovitosti akupunkture pri premagovanju odvisnosti. Strokovnjaki za kraniosakralno terapijo zdravijo najrazličnejše bolezni, od akutnih do kroničnih. Ni dokazov, ki bi potrjevali učinkovitost kraniosakralne terapije. Alternativno terapijo (healing) uporabljajo pri vrsti bolezni. Raziskave so pokazale njegove koristi na mnogih področjih, za celjenje ran, pri migreni in sindromu razdražljivega kolona. Do danes še niso dokazali, da bi imelo to zdravljenje boljše učinke kot placebo. Homeopatijo pogosto uporabljajo za zdravljenje kroničnih bolezni, kot je npr. astma. Cochrainovo poročilo ne navaja dokazov za učinkovitost homeopatije pri bolnikih z astmo. *Priro~nik za bolnike navaja, da je njegov cilj “navesti dovolj podatkov, ki bi bili v pomo~ pri izbiri ustreznega komplementarnega zdravljenja“ **Priro~nik ne vsebuje dokazil o u~inkovitosti terapij, ~eprav je Ministrstvo za zdravje naro~ilo, naj bodo vklju~eni ***Dokazi iz reference {t. 3. 66 Zdrav Var 2006; 45 medicina razlikuje od klasi~ne. Strokovnjaki s podro~ja uradne medicine, ki si prizadevajo za ~im vi{jo raven zdravstvenega varstva bolnikov, so lahko upravi~eno u‘aljeni. Trditev, da je najbolje uporabljati to, “kar je najbolj{e pri obeh vrstah zdravljenja “(pri KM in pri uradni medicini) zveni smiselno, dokler se ne zavemo, da je njeno bistvo definicija “najbolj{ega”. V modernem zdravstvu lahko s tem izrazom opi{emo le tiste vrste zdravljenja, za katere je dokazano, da ima od njih bolnik ve~ koristi kot {kode. In prav za to gre pri medicini, podprti z dokazi. Sta le dve mo‘nosti: ali pomeni “integrirana medicina” isto kot medicina, podprta z dokazi (v tem primeru je druga~no poimenovanje povsem odve~), ali pa zanjo veljajo druga~na merila za to, kaj je “najbolj{e”. ^e vidimo, kaj danes zagovarja integrirana medicina v Veliki Britaniji (9) (tabela 2), moramo ugotoviti, da velja zadnja trditev. Integrirana medicina je le dimna zavesa za uvajanje nepreverjenih na~inov zdravljenja v rutinske zdravstvene programe (10). Na dalj{i rok se lahko izka‘e, da je ta strategija pogubna za vse, tako za bolnike kot tudi za KM samo. Zaklju~ek Zdi se, da danes KM prehaja iz dejavnosti, temelje~e na izku{njah, v zdravstveno dejavnost, podprto za dokazi. Pravo vrednost KM bomo lahko spoznali le, ~e bo za~ela pri tem uporabljati enaka merila kot ostala podro~ja medicine. Le tako nas bo prepri~ala, da lahko ponudi bolnikom, ki so za nas najpomembnej{i, ve~ dobrega kot slabega. Literatura 1. Ernst E, Pittler MH, Wider B, Boddy K. The desk top guide to complementary and alternative medicine. 2nd Edition. Edinburgh: Mosby/Elsevier. 2006. 2. Loprinzi CL, Levitt R, Barton DL, Sloan JA, Ahterton PJ, Smith DJ et al. Evaluation of shark cartilage in patients with advanced cancer. Cancer 2005; 104: 176-82. 3. Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain. Ann Intern Med 2004; 142: 651-63. 4. Ernst E.,Canter PH. Investigator bias and false positive findings in medical research. TRENDS in Pharmacological Sci 2003; 24: 219-21. 5. Hamre HJ, Fischer M, Heger M, Riley D, Haidvogl M, Baars E et al. Anthroposophic vs. conventional therapy of acute respiratory and ear infections: a prospective outcomes study. Wien Klin Wochenschr 2005; 117: 256-68. 6. Rees L.,Weil A. Integrated medicine. BMJ 2001; 322:1 19-20. 7. Ernst E. Disentangling integrative medicine. May Clin Proceed 2004; 79: 565-6. 8. Calman K. The profession of medicine. BMJ 1994; 309: 1140-3. 9. The Prince of Wales’s Foundation for Integrated Health: Complementary Healthcare: a guide for patients. 2005; www.fihealth.org.uk. 10. Smallwood C. The Role of Complementary and Alternative Medicine in the NHS. An investigation into the potential contribution of mainstream complementary therapies to healthcare in the UK. http://princeofwales.gov.uk/news/2005/ 10.oct/smallwood.php 2005.