THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 12, Number 7, 2006, pp. 701–702 © Mary Ann Liebert, Inc.
Diagnostic Accuracy Among the Allied Health Professions: Commentary on Grace et al. DUGALD SEELY, N.D., and EDWARD MILLS, M.Sc., Ph.D.
T
he paper, “Training in and Use of Diagnostic Techniques Among CAM Practitioners: An Australian Study,” by Grace et al. (pp. 695–700) addresses an important issue. Specifically, what are the diagnostic skills and what are the responsibilities for providing accurate diagnosis among practitioners of complementary and alternative medicine (CAM)? The authors’ conclusion from this survey states: “Despite the reported high frequency of training in and use of Western medical and CAM diagnostic techniques, 32% of respondents reported a lack of confidence in identifying patients requiring referral.” This is a most interesting finding and deserves attention by patients, practitioners, and policymakers. CAM practitioners comprise an incredibly heterogeneous group coming from an array of dissimilar medical approaches. Different philosophies are inherent to some of the larger systems of medicine, including: Traditional Chinese Medicine (TCM), Ayurvedic medicine, osteopathic medicine, naturopathic medicine, chiropractic, and homeopathic medicine. The basis for understanding and treating disease are inherently different for each of these systems and the language and meaning of diagnosis are fundamentally different as well. It is important to differentiate among the types of diagnoses made by CAM practitioners. Many of these larger systems of CAM are based on unique approaches to disease with different systems of diagnosis that have nothing to do with the “conventional” Western-based approach. For instance, whereas a conventional medical doctor might diagnose a patient as suffering from a migraine headache, a TCM doctor might diagnose the condition as “Liver Yang Rising” while the Ayurvedic therapist might diagnose an imbalance in one of the three doshas. Then there are CAM therapists whose approach does not include giving any type of formal diagnosis such as shiatsu or reiki practitioners. In fact, it may be illegal for them to do so in many jurisdictions. Furthermore, some CAM practitioners, such as naturopathic, chiropractic and TCM physicians are trained in both Western medicine and alternative
systems of diagnosis, and thus might approach the same condition from two or more very different perspectives. In addition to differences in philosophical underpinnings, CAM therapists have widely disparate levels of education and training. Education can vary in terms of duration and intensity as well as in terms of diagnostic and treatment focus. Many therapists have received some training in Western conventional medicine and are educated in the basics of anatomy, physiology, and pathology; however, the time spent, quality of education, and attention given to the basic sciences are highly variable. Without grounding in the basic sciences and clinical exposure to patients, it is inevitable that Western-based diagnostic skills will suffer. High-quality didactic and clinical education is required to develop a good diagnostician. This applies to any system of medicine regardless of approach; however, given the extensive specialist terminology and knowledge base required for Western diagnosis, an excellent education is a necessity for competence in this area. CAM practitioners also exhibit diversity in their training in the use and interpretation of Western-based diagnostic tools. This aspect is described in Grace et al.’s paper (pp. 695–700) via detailing the frequency of both training and use of specific “Western medical diagnostic techniques.” More than 50% of respondents indicated that they had been trained in and used Western medical case history, palpation, blood pressure reading, postural, and orthopaedic assessments. However, a minority of respondents claimed to have training or use such important diagnostic tools such as auscultation, otoscopy, spirometry, and neurologic testing. It is interesting to note that, in this study, the diagnostic tools for which use is substantially higher than training level occurs in the interpretation of pathology test results, radiographs, computed tomography scans, and perhaps other tools provided by a conventional medical doctor or specialist. A viable interpretation of this result is that some CAM practitioners are utilizing and interpreting diagnostic tests without adequate training.
Department of Clinical Epidemiology, The Canadian College of Naturopathic Medicine, North York, Ontario, Canada.
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702 Whether or not a CAM practitioner is offering primary care to patients is a critical point in this discussion. Primary care requires a higher level of competence, training, and responsibility on the part of the practitioner so that referrals can be made accurately and efficiently. More importantly, primary care must provide an effective public screen so that serious pathologies do not go undiagnosed or misdiagnosed. For CAM practitioners to provide a valuable role in primary care and be part of a system of referral, their diagnostic skills must be at a high level of proficiency. Efficient and effective integrated care can only be achieved through good communication between practitioners wherein mutual understanding of a disease’s pathophysiology and diagnosis is present. Unfortunately standardization, and ultimately cohesion, is often lacking within the CAM arena. Providing a high standard of health care is not trivial. Misdiagnosis or avoiding diagnosis have probably resulted in countless deaths. Just because CAM has different explanations of disease does not exclude the need for appropriate diagnosis to understand prognoses. It is encouraging that there are groups of practitioners who receive accredited education with a clinical exposure component, are regulated, and have well-defined scopes of practice. Often, however, many CAM practitioners have variable levels of training with no exposure to supervised clinical training, have undefined scopes of practice, and function entirely without regulation. Patients are often left to themselves to determine practitioners’ credibility and sometimes are misled, leading to negative consequences. Given the finding by Grace et al. (pp. 695–700) that
SEELY AND MILLS “[a]pproximately one third (34%) of respondents estimated that their clients had only ‘occasionally,’ or ‘never,’ been assessed by a doctor before presenting for CAM treatment,” a finding consistent with a prior study,1 it is clear that there are a number of people who are receiving “primary care” from CAM practitioners. Considering the deficiencies in many public health care systems around the world, this should come as no surprise. Rather, this should provide a “wake-up call” about the need to achieve greater standardization and regulation of CAM therapists who are in such a role. The realization of such a goal would provide more consistent care to individual patients and ultimately benefit the public health care system as a whole.
REFERENCE 1. Chow R. Complementary medicine: Impact on medical practice. Curr Ther 2000;41:76–79.
Address reprint requests to: Dugald Seely N.D. Department of Clinical Epidemiology The Canadian College of Naturopathic Medicine 1255 Sheppard Avenue, East North York, Ontario, M2K1E2 Canada E-mail:
[email protected]
