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Philosophy

The practical difference between conventional and alternative medicine

Artofmedicine
I am a Doctor. I do not take sides whether I am an allopathic doctor or a holistic/alternative doctor. I am just a doctor, and I try to be a good one. 
 
There is a lot of discussion about the differences between “conventional” and “alternative” medicine. Most arguments are abstract straw man arguments formed by the “opposition”. A classical divide would look like this :
 
Conventional medicine : treats the symptom; Alternative medicine : treats the disease
Conventional medicine : concerned with matter; Alternative medicine : concerned with energy
Conventional medicine : treats the lab; Alternative medicine : treats the patient
Conventional medicine : sees the body as a machine; Alternative medicine : sees the body as a microcosm
Conventional medicine : reductionist approach; Alternative medicine : systematic approach
 
You can find these divisive tables all over the internet and recited by many alternative practitioners. But its simply not true. Sometimes alternative practitioners treat the symptom, while conventional medicine treats the disease. Sometimes conventional medicine uses insights from system biology more effectively than alternative medicine. And sometimes alternative medicine treats the body as a machine. 
 
 

So what are some real practical differences?

 

Defining the OUTCOME 

 
I am deeply involved in both perspectives. I have had traditional medical training where I experience the bashing of „alternative“ approaches on a daily basis, and I have many certificates from „alternative“ institutions, which also have their fair share of critique towards „conventional“ medicine. I am in between and feel like a child with divorced parents. Just get along you two!
 
The funny thing is that practitioners of „Alternative Medicine“ do not like being called „alternative“. They consider themselves to be just good therapists. It is the „conventional“ doctors that call the „other“ doctors „alternative“. On the same token any „conventional“ doctor, would not call himself „allopathic“. It is the „alternative“ doctors that basically invented the term „allopathic medicine“ to refer to „conventional“ doctors. Jeez it gets confusing already, right? So whats the actual difference, if any?
 
I received traditional medical training in Germany. It is an evidence-based medicine which is focussed on measurable outcomes. The strategy that has the best evidence of improving a patients outcome is usually the preferred strategy. Scientific measures of outcome in this form of medicine have something to do with the survival of the patients. So the type of medicine I learned there is really really really good at keeping people alive. It is a system that is, through scientific endeavour, constantly self-optimising to improve survival of patients. If you want a strategy to improve your chance of survival from any form of disease or trauma, then you should get your advice from a doctor with traditional medical training in Germany, USA, Canada, or really any other first world country.
 
The thing is though, when survival is secured, people usually want more than bare survival. They might want well-being. They might even want to be able to move without pain, laugh without regret, and think clearly. They might want performance. 
The type of medicine I learned at University in the United States and Germany usually does not employ strategies that improve the outcome of performance. Like I said earlier, almost all their self-optimising strategies focus on the outcome of survival. 
 
 
To be able to identify and develop strategies to improve the well-being or health (beyond bare survival) of patients, an evidence-based approach is needed where the outcome is not survival, but the outcome is defined by measures of performance. Measures of well-being. Measures of emotional, mental and physical capabilities beyond survival.
 
 
We can find these scientific endeavours in sports science. I had a background in sports science even before I started medicine, thats why I was always so confused that medicine did not care too much about measures of performance, and instead only cared about survival. That was deeply troubling to me. During my medical training I was always close to sports science for that reason. It was a welcoming add-on to my repertoire. During medical training I learned how to optimise survival and when I was involved in sports science I learned how to optimise well-being and performance. 
 
Luckily there is this emerging trend in medical research to broaden the scope of „optimal outcome“ by not only looking at survival, but also at well-being and performance. This emerging trend in science is not picked up by clinical practice unfortunately. And there are two simple reasons behind this. And this is what gets us to the real differences between „survival medicine“ and „performance medicine“.
 
 
There are also practitioners that completely reject the evidence-based approach of using critical thinking, observation and experimentation to gain scientific insight into the true nature of reality. I do not consider anybody who rejects this approach a medical practitioner. Anybody who rejects this general approach is in my opinion a plain idiot and a quack. The scientific method is a necessary foundational system of self-optimisation. Without that it is impossible to improve as an individual, as a profession, as a craft or as an art. 
 
 
 
 

Upstream vs. Downstream Interventions

 
When you have a wet wall at your house. What do you do? Do you dry and re-paint the wall? Or do you fix the roof?
It is a very populistic example, because on first instinct most people would say they would fix the roof. But lets look at the reality of it!
Drying the wall takes about 3 days. All you need to do is rent an air dryer, leave the room alone for 3 days, and then re-paint the wall. It costs you 3 days, and a total of maybe 200$. Will the wall get wet again? Well maybe. No one knows. It might. But it might also be just fine and never be wet again. 
How about fixing the roof? For starters you will have to bring someone over to check out the roof. That might take a couple of days to find someone good for that. He might find something wrong with the roof, or he might even say he can’t find anything. When he found something it will take weeks to get the roof fixed. It will costs several thousands of dollars. It will be incredibly loud for weeks. The house might not be inhabitable for weeks on end. Okay, and what happens to the wall if the roof is fixed? You will probably still have to dry it and re-paint it. 
So again, what would you do?
 
Lets take an example from medicine. Lets say you suffer from Multiple Sclerosis. Lets say you get a fairly late diagnosis. There are already multiple spots in your brain scan. The eyesight in your left eye worsened a lot in the last 6 months and your right hand feels like it does not belong to you. You increasingly lose control over your right arm, and your gait starts to worsen as well. It is painful.
Now it is important to know that MS is at its base an inflammatory disease.
 
Inflammation is an incredibly complex, but well researched phenomenon that is controlled by our immune system. Inflammation is like a cascade, it is like a riverbed that keeps splitting up in finer and finer details. Not all forms of MS are the same, because not all forms of inflammation are the same. 
 
Current therapies for MS target as far downstream as possible. At the finest details we could scientifically uncover. These so called „biologicals“ are high-potency drugs, that are extremely effective at reducing the symptoms of MS when they are being used for the right type of MS/Inflammation, and the right downstream riverbed. So thats a definite plus. They relieve the patient of symptoms fast! So if you are in that situation I just described then you would want the medicine that helps you feel normal again as fast as possible. That is where that downstream approach comes in very useful.
 
 
 
Another strategy in MS (or any other inflammatory disease) that targets one level more upstream is cortisone. Cortisone is a powerful anti-inflammatory. In our metaphor of the riverbed it is a big dam that is big enough for medium-sized rivers. This is a good strategy in MS when we are not quite sure yet exactly WHICH biological might be helpful. 
 
 
We can also target inflammation another level more upstream by immune resource management. When the immune system runs out of substrates to regulate the immune response, the inflammation can get out of hand. Giving the immune system the resources it needs to manage the inflammatory response can be one strategy to reduce the impact of inflammation on disease processes. Strategies can include Vitamin D, Curcumin, or Omega-3 therapy.
 
 
Another step more upstream involves the question of how this overreactive immune system with its inflammatory response came about. WHY is the immune system so pissed? Answers can involve toxicity from heavy metals, from fungi, and in some cases it is because of a leaky gut-blood barrier in the intestinal tract. When the barrier between the outside world and our blood (our intestinal lining) is not intact, our immune system will have to guard this area and regulate it with inflammation. Intervening to modulate or even remove the cause of the overactive immune system, by removing the toxin, or improving the integrity of the intestinal lining will be constitute this fairly upstream therapy.
 
 
 
And ultimately the most upstream we can get in my opinion is the modulation of all of our INPUTS (Food, Environment, Thoughts, Interactions, Movement, Stress).
 
 
Can we treat MS with biologicals alone? Well this is the same answer to the question : „Is it enough to dry and paint the wall?“. Yeah it might be. Biologicals might be the answer for some patients. But what if the water of the river finds another way? We might have to look one level more upstream. Or even another level even further upstream. 
 
Lets ask the opposite question? Can we treat MS with the modulation of lifestyle alone? Or with the improvement of gut integrity alone? Yeah we might be. It might take a lot longer, but it might be the safer and more complete approach to health. 
 
In my opinion we need both. We might need to fix the roof and the wall. We just have to decide whats the best situation for which intervention. We need to decide that together with the patient. Sometimes we need to just paint the wall (downstream treatment). And when the patient is relieved of symptoms and wants to go deeper into the cause of his situation, well then we need to work our way upstream.
 
Conventional medicine works from downstream towards upstream, from targeted pharmaceutical therapy towards lifestyle interventions. „Alternative“ medicine approaches work from upstream towards downstream. I haven’t clearly identified which perspective is better for health or performance, or if it even matters which one is better. All I know is that ONLY working downstream or ONLY working upstream is not beneficial for the patient or athlete.
 
 
So when there is a doctor who ONLY works downstream I would stay away, and if there is a therapist who ONLY works upstream, well then I would really ask myself if he knows about the mechanics of the disease. Where you start might be a matter of patient preference, but a good doctor integrates both approaches sooner or later.
 
 

This brings us to the second key difference in my opinion.

 

Treatment Intervals

Starting downstream, starting with the specific pharmaceuticals, is a quick way to start. It requires little to no investment of time, energy, money or emotion by the patient. Just take the pill. It can quickly take the edge off and relieve the patient of symptoms. But it also bears the risk of many side effects, especially long term. When we stick to the metaphor of the river it is easy to imagine that the water will find an alternative way. Inflammation will find an alternate route. 
So this means a patient might come months later for a different symptom. Maybe high blood pressure. Then this symptom is treated with another substance. Then another two months later he might develop kidney stones. Another pill on the list. 
So what I am saying is that while the downstream approach might improve symptoms quick in the beginning and can start with little time, the costs of this approach will increase over time. Patient visits per month will increase over the years, pills taken will increase over the years, medical costs will increase over the years, time and emotional energy invested by the patient will increase over the years.
This does not have to be the case if a medical practitioner starts downstream and then works upstream, but it is certainly my experience that this is the typical trajectory if treatment is only targeted downstream.
 
 
On the other hand starting upstream will take A LOT of investment by the patient in the beginning. It will cost money, it will cost time, it will put the patient in an uncomfortable position, where he will have to step out of his comfort zone, he will have to face things he does not want to face. He might need to restructure his life, his diet, his environment, maybe even his relationships. And the worst thing is : He might not get immediate improvement. He might do all this restructuring without any immediate benefit. It is a tough process. He might ask himself several times along this route why he is doing all that. Yeah, some patients receive instant benefits. They feel better immediately. But thats certainly not true for all patients.
 
This approach needs a therapeutic partner that is more than just a doctor who gives medical advice. The patients needs a therapeutic partner that helps him psychologically, emotionally and physically create lasting change. This skillset is not something the traditional doctor possesses. That is where health and lifestyle coaches come in. Some doctors form a therapeutic partnership with qualified health coaches just for that purpose. 
The benefits of this approach on the other hand are self-efficacy. The patient will become less and less reliant on the medical professional. The patient will take back control of his own life. Over the years he will see the doctor less and less, he will use less and less pills, and he will have to invest less and less money.
 
 
So only working downstream tends increase the dependency of the patients to the doctor, while the upstream approach tends to decrease the dependency of patients to their doctors over the long run. 
 
I am not advocating either/or. I myself start upstream, but will integrate downstream approaches intermittently to make upstream modifications easier. My first goal is to relieve symptoms. But I educate patients that the relief of symptoms is usually not equal to healing, because
 
 

May the FLOW be with you!

 
Gerrit Keferstein, MD

Gerrit Keferstein is a Medical Doctor specialised in Performance & Functional Medicine. He is most known for his work on the optimisation of recovery and adaptation in elite athletes.

Tags : inflammationconventional medicinemedicinealternative medicineallopathic medicineholistic medicinefunctional medicinedownstreamupstreammultiple sclerosistargeted therapyimmune modulationleaky gutperformance docperformance medicine

2 Comments

  1. Nice article, Gerrit. Isn’t this a very vigorous distinction between conventional and alternative medicine? In my experience as a Physio- and Manual Therapist and current medical student I understand the difference between these two more like “proven by research” and “not proven by research”, and therefore the “alternative to the proven treatment”. Conventional medicine SHOULD take the upstream approach into account, in my opinion it is more the fact that most doctors do not treat the person as a human being that interacts with his environment, but as a bio-medical problem. Shouldn’t the bio-psycho-social approach to diagnosing and treating people – I know it’s not standard of practice in the real world yet – fix just that? And this is proven by reasearch and therefore (at least to my distinction) not considered alternative medicine.

    When I look at the research concerning acute and chronic low back pain, there has been a shift in the last years away from subgrouping people to different treatment strategies for the “mechanical” or “biological” problem (manipulation vs. transverse abdominis “core” training i.e.), towards more treatment options like pain education, graded activity and graded exposure. These are intended that the patient gets back his self-efficacy and “control” over his body and health.

    What are your two cents on that?
    Keep up the good work!
    Julian

    1. Hey Julian!
      you hit a lot of points man 🙂
      My first main point here is that ALL treatments that consider themselves medicine should follow the principles of the scientific method, which is test-intervene-retest. This is the way to not fool ourselves or patients.
      The scientific method is NOT the same as academic research. I can do the scientific method one-on-one with my patient. And thats what we do in medicine A LOT. We do Try & Error. And that is completely fine and necessary!
      I believe that modern medicine is founded on strong principles, which I completely stand behind. One of them is Evidence-Based Medicine. Evidence-Based Medicine is made up of THREE components. 1) Clinical Expertise, 2) Patient Preference, 3) Academic Research. The current reality, is that the practice of medicine is departing from two of these principles. Academic Research becomes synonymous with Evidence-Based practice and I believe that is horrible.

      My second main point is that downstream treatment is a good way to start. It gives relief, it improves patient-doctor trust, and it is cost-efficient. But for TRUE healing, we need upstream treatment. Upstream treatment has two problems. Big investment by the patient needed (esp. emotionally), and Big initial time investment by doctor needed.

      The current conventional medical system has no place for upstream treatment. No financial models, no doctor incentives, no patient-preference, and no medical education for upstream treatment. That is why “alternative” medicine is booming. But really, it is NOT an ALTERNATIVE to medicine. It is just good upstream medicine. And for the alternative medicine quacks that deny the scientific method : They dont do medicine.

      May the flow be with you brother!
      G

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