Jane Guiltinan, ND1; Joshua Z. Goldenberg2; Rachelle L. McCarty, ND, MPH3; *Erica B. Oberg ND, MPH3
1 School of Naturopathic Medicine, Bastyr University, Kenmore WA, USA
2 Bastyr University, Kenmore WA, USA
3 Bastyr University Research Institute, Kenmore WA, USA
Correspondence to: Erica Oberg – firstname.lastname@example.org
The past two decades has seen a tremendous shift in the attitudes towards research and evidence based medicine (EBM) within the naturopathic community (see Goldenberg et al in this issue). Despite, and perhaps because of, the swiftness of this transition, there is some concern in our community as well as other complementary and alternative medicine (CAM) professions about the role of scientific inquiry and the integration of EBM into our education and practices. These concerns span the gamut from outright hostility to scientific inquiry on one end to issues with specific methodologies used in researching CAM modalities on the other.
There are some within our community who believe that the naturopathic profession should not participate in the conduct of research at all because there is no need to prove that what NDs do is effective. It is enough for these practitioners that we have a set of guiding principles and a philosophy; and as long as we adhere to these, the “truth” of the medicine is apparent by virtue of the fact that many of our patients get well.
While many others in our community respect the value of scientific inquiry, they still harbor concerns that the application of EBM principles is being used to dismiss CAM as ineffective and that teaching and applying EBM in our curriculum will lead to our demise as a profession [1-3]. The concern is understandable as indeed, information derived from EBM approaches have been used as a tool to oppose recognition and reimbursement for many CAM groups including NDs . For such members of the naturopathic community, opposition to the profession regarding the dearth of a naturopathic randomized controlled trial (RCT) evidence base may be particularly frustrating due to similar concerns in allopathic medicine where it has been estimated that only 37% of interventions are supported by RCT evidence .
There are also many naturopathic physicians who see the value in scientific inquiry and warmly welcome the clinical usefulness of EBM but have concerns that the current methodological models may not be the most appropriate for the complex, multi-tiered therapeutic approaches to health and disease utilized by many CAM professions . There is concern among these NDs that while RCTs of single agents may work very well for pharmaceutical testing, they may not work as well for systems of healthcare that utilize multiple modalities, practitioner-patient relationships, and vitalistic and energetic concepts to treat a person or a condition [2, 7, 8].
We recognize that the gamut of concern regarding the impact of EBM on naturopathy stem from the desire to best serve patients. However, we respectfully disagree that teaching and applying EBM will lead to the demise of naturopathic medicine, but instead assert that its application will strengthen our profession and improve our clinical effectiveness. We believe that to best serve our patients we must develop and utilize appropriate methods to evaluate and expand our therapies. The logarithmic growth of the biomedical research literature in recent years has made the ability to critically evaluate this tome of literature essential for any physician. To ignore the EBM tools for such evaluation would be to go against our own first principle to do no harm. While some have used EBM in a hegemonic way the philosophy and tools of EBM at core are not innately contrary to CAM.
This does not mean that we need to slavishly follow RCTs at the expense of all else. Some CAM practitioners may be surprised to learn that most proponents of EBM do not view EBM in such a narrow way either. Dr. David Sackett, considered one of the fathers of EBM, defined evidence based practice (EBP) this way:
EBP is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research… EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. Clinical expertise refers to the clinician’s cumulative experience, education and clinical skills. The patient brings to the encounter his or her own unique concerns, expectations and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology .
It has been suggested that some of the reticence for incorporating EBM into CAM practice may inaccurately stem from assuming that EBM is defined in an exclusive way which the leaders and founders of the movement themselves do not intend . Indeed in our qualitative study of naturopathic physicians published in this issue, we discovered a plethora of definitions and understanding of what EBM is, which informed the participants’ subsequent attitudes towards it – the more inclusive the definition of EBM was, the less hostile the attitude.
An inclusive definition allows for numerous sources of evidence and there is growing acceptance of research designs that may be a better fit to evaluate the effectiveness of CAM therapies. For example, whole practice outcomes research treats the complete naturopathic medical treatment as the unit of intervention instead of isolated treatment modalities. A recent systematic review of such studies in naturopathic medicine report generally favorable results .
Naturopathic medicine can readily and rigorously be evaluated to provide credible evidence of effectiveness or lack thereof. But to do this appropriately we must use the broad definition of EBM supported by its founders, decision making models that view various forms of evidence in a contextually appropriate manner, and incorporate innovative research methodologies.
EBM is a wonderful tool, and is here to stay. CAM professions can and should confront the lack of evidence for their interventions. Our educational institutions should foster the development of research scientists within our professions, and these scientists should press for appropriate and effective ways to measure and evaluate our unique systems of care.
Most importantly, it is the right thing to do for our patients. They deserve therapies that have been validated. The time for excuses why CAM therapies cannot be validated is ending. The time to scrutinize what we believe and what we do with patients in a systematic way is here. We are now building the capacity and the methodologies to do this within our professions and in collaboration with our conventional colleagues.
This project was funded by grant# BU-CSR-Y2-013 from the Bastyr University Student Research Center.
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