The best of all health care

The best of all health care--who wouldn't want to know how to achieve this meritorious aim? Apparently, it's not utopia; we all can go there. We need only to follow the path of "integrated health." Integrated health, we are told by The Prince of Wales's Foundation for Integrated Health, a U.K. lobby group, is

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* An approach to health that looks at the person in the round, taking into account the effects on health of lifestyle, environment and emotional wellbeing

* It offers patients the safest and most effective aspects of mainstream medical science and complementary healthcare

* It places an emphasis on prevention and self-care to help people avoid illness and stay well. (Prince of Wales 2007)

An emphasis on prevention is something I was taught thirty years ago in medical school. It has, of course, been part of medicine for much longer than that. But effective prevention needs evidence and, in this area, reliable evidence is particularly difficult to come by. It took us decades to establish that smoking cessation, blood pressure, body-weight reduction, cholesterol lowering, etc., are effective means of disease prevention. The research to identify other preventative strategies continues but faces formidable problems, often taking decades to generate reliable conclusions. To simply advise consumers that homeopathy is used to treat many health problems or that craniosacral therapy may prevent migraine attacks (Pinder et al. 2005) may look like a tempting shortcut to some, but it is hardly good enough evidence. Without evidence, we have no means of knowing whether such advice is helpful, irrelevant, or perhaps even detrimental. It would be much better to use patients' (often limited) enthusiasm for self-care in areas where we do have solid evidence, e.g., smoking cessation and regular exercise to improve health, etc. I would even go one step further and postulate that an emphasis on prevention and self-care based on wishful thinking distracts from the few evidence-based preventative strategies currently available and is therefore counterproductive.

"Looking at the person in the round" presumably means being holistic. It is hard to think of a single figure from the history of medicine who has not pointed out that patients are more than disease labels. William Osier, for instance, said in an address to students in 1899: "Care more particularly for the individual patient than for the special features of the disease." Good medicine has always been holistic. I, therefore, find somewhat offensive the implication that we need to adopt "integrated health" in order to practice what essentially is good medicine. It is insulting to all those who, day in and day out, do their very best to consider each individual patient in all her or his complexities. And this, I would suggest, includes much more than "lifestyle, environment and emotional wellbeing" (Prince of Wales 2007).

The last point--bringing together safe and effective mainstream and complementary medicine--seems reasonable at first glance. On closer inspection, however, it turns out to be the most astonishing of the above three criteria. This is surprising, because it describes the well-known principle of evidence-based medicine: implementing health care that demonstrably generates more good than harm. Surely we don't need "integrated health" to practice evidence-based medicine? It gets even more baffling knowing how little regard the proponents of "integrated health" seem to have for evidence-based medicine. Their patient guide (Pinder et al. 2005), for instance, proclaims that chiropractic "may also be used for asthma, digestive disorders, menstrual pain, and infant colic." It even implies that "the laying on of hands" can be effective for a wide range of conditions. And, of course, it overtly promotes one of the Prince's favorites: homeopathy. The actual evidence for these treatments, however, is almost entirely negative (Ernst and Canter 2006; Ernst et al. 2006).

Despite the fact that The Prince of Wales's Foundation for Integrated Health has powerful support, not least of all from the U.K. Department of Health, opposition to integrating ineffective treatments into the U.K. National Health Service is growing. A group of British scientists (including me) have now written twice to decision makers urging them to think again. In both cases, homeopathy was used as an example, mostly because it is a fairly clear-cut case of an implausible treatment and negative clinical evidence. As a result, two homeopathic hospitals have come under pressure to either use evidence-based medicine or face closure. But this is clearly not a "turf war"; it is a battle to make sure patients are treated with the most effective treatments currently available. They are not helped by misleading statements or by politically correct distractions. If we want to improve tomorrow's health care, we need one standard, not multiple standards. The best health care includes an emphasis on prevention, holism, and evidence. But this is not the hallmark of "integrated health"; it is characteristic of all good medicine.