1. THE MEDICAL PROFESSION AND TRADITIONAL / COMPLEMENTARY MEDICINE Milton Lum FRCOG, FAMM

2. TRADITIONAL / COMPLEMENTARY MEDICINE §Amorphous §Codified, regulated,taught with defined curriculum and practised widely and systematically §Mystical, secretive and localized with its knowledge passed down by word of mouth

3. TRADITIONAL MEDICINE World Health Organization §“..including diverse health practices, approaches,knowledge and beliefs incorporating plant, animal, and/or mineral based medicines, spiritual therapies, manual techniques and exercises applied singularly or in combination to maintain well being, as well as treat, diagnose or prevent illness.”

4. T/CM Ministry of Health §“…practice other than the practice of medicine and surgery by registered medical practitioners as defined by the Medical Act 1971.”

5. USES OF T/CM IN ALLOPATHIC MEDICINE §Drugs §Acupuncture §Manipulative therapy §Hypnosis §Reflexology §Massage §Homeopathy

6. Uninformed scepticism versus Uncritical acceptance

7. INTERACTIONS BETWEEN MEDICAL PROFESSION & T/CM §Patients may seek advice, request referral, discuss T/CM treatment or advice, or develop complications from drug interactions §Doctors may practise some aspects of T/CM

8. CONCERNS OF MEDICAL PROFESSION §Macro concerns §Individual doctor’s concerns

9. CONCERNS FROM A MACRO PERSPECTIVE §Safety, efficacy and quality §Research §Training, education and regulation

10. Safety, efficacy and quality 1 “The quality and quantity of the safety and quality data on traditional medicine are far from sufficient to meet the criteria to support its use worldwide” WHO (2000). General Guidelines for Methodologies on Research & Evaluation of Traditional Medicine (WHO/EDM/TRM/2000.1)

11. Safety, efficacy and quality 2 §Governments addressing issue by: - regulation and registration of T/CM - publishing national monographs and pharmacopoeia of medicinal plants - safety monitoring - support for clinical research - establishment of national standards and methodology for evaluating safety, efficacy and quality of T/CM

12. Research §Very little high quality research §However, quality of applied research growing rapidly §Use of certain aspects of T/CM supported by conventional medical organizations §Increased awareness of importance of research into T/CM

13. Training, education and regulation §At best inconsistent §Patients not guaranteed of competence of T/CM practitioner §No accountability of T/CM practitioner §Doctors often sort out problems created by T/CM practices §Statutory regulation of T/CM increasing §T/CM training in academic settings

14. INDIVIDUAL DOCTOR’S CONCERNS §Identifying T/CM users §Patients consulting unqualified T/CM practitioners §Minimizing potential risks of T/CM to patients - delayed or missed diagnosis - contradictory advice from T/CM practitioner - drug interactions with T/CM §Ensuring treatment is in best interests of patient

15. HERB-DRUG INTERACTIONS Fugh-Berman A (2000). Lancet 355: 134-138 §Betel nut (Areca catechu) §Chili pepper (Capaicum spp) §Danshen (Salvia millttiorhiza) §Devil’s claw (Harpagophytum procumbens) §Dong quai (Angelica sinensis) §Eleuthero or Siberian ginseng (Eleutherococcus senticocus) §Garlic (Allium sativum) §Gingko (Gingko biloba) §Ginseng (Panax spp) §Guar gum (Cyamopala tetragonolobus) §Karela or bitter lemon (Momordica charantia) §Liquorice (Glycyrrhiza glabra) §Papaya (Plantago ovata) §St John’s wort (Hypericum perforatum) §Salboku-to (Asian herbal mixture) §Shankhapushpl (Ayurvedic mixed herb syrup) §Sho salko to or Xiao chai hu tang (Asian herb mixture) §Tamarind (Tamarindus indica) §Valerian (Valeriana officinalia) §Yohimbine (Pausinyatalai yohimba)

16. MEDICO-LEGAL CONSIDERATIONS §Doctors who practise T/CM §Referral to other doctors §Delegation or referral to non-medically qualified practitioner

17. Doctors who practise T/CM §Bolam test: “A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art…Putting it the other way round, a doctor is not negligent, if he is acting in accordance with such a practice, merely because there is a body of opinion that takes a contrary view.”

18. Referral to other doctors for T/CM §Same legal situation as when referring to another doctor for any other service §As long as decision to refer is appropriate, all responsibility is taken over by the doctor to whom referral is made

19. Delegation or referral to non-medically qualified practitioners §Is the decision to delegate or refer to the particular T/CM appropriate? §Have I taken reasonable steps to ensure that the T/CM practitioner concerned is qualified and insured? §Has my medical follow up been adequate?

20. INCORPORATION OF T/CM INTO HEALTHCARE SYSTEM 1 §WHO classification §Integrative system – T/CM is officially recognized and incorporated into the national health care system §Inclusive system – T/CM is recognized but is not fully integrated into all aspects of health care delivery, education and regulation §Tolerant system – National health care system is based entirely on allopathic medicine but some T/CM is tolerated by law

21. INCORPORATION OF T/CM INTO HEALTHCARE SYSTEM 2 §Where are we ? §Where do we want to go ? §Road map §Evidence for decisions §In most inclusive systems, development of T/CM services have been demand rather than evidence led

22. INCORPORATION OF T/CM INTO HEALTHCARE SYSTEM 3 §Framework of evidence based medicine, resource allocation and current healthcare system §Raises concerns for - policymakers,managers and medical profession - patients - T/CM practitioners

23. INTEGRATED MEDICINE §Medicine is a science and an art §Dependent on technological solutions to health problems §Insufficient attention to holism and simple effective interventions §Gap filled by some T/CM practitioners §Integrated medicine is not synonymous with teaching doctors to use herbs instead of drugs §Restoring the soul of medicine §Integrated medicine is good medicine

24. CONCLUSIONS §Substantive shifts in scientific base and organizational structure of T/CM §Convergence of clinical, scientific and regulatory standards applied across all forms of health care §If the soul of Medicine is restored and a list is drawn up of what patients want, what doctors value, what is important to researchers and what matters to payers, there would probably be no reference to historical and political concepts of conventional medicine and T/CM

25. Thank you