A critique on complementary and alternative medicine.

Modern medicine regularly uses the products of science to improve health. Until recently, however, medicine itself has not been practiced in a scientific manner. The growth of evidence-based medicine is predicated upon the concept that insofar as possible, all aspects of medical care ought to be examined with regard to the evidence. All forms of treatments and preventive strategies should be subjected to assessments of efficacy and effectiveness. Efficacy is demonstrated in the day-to-day practice of medicine. An evaluation of effectiveness may lead to one or more randomized clinical trials, where the results of these randomized clinical trials may be necessary to maximize effectiveness. From a health care perspective, safety must be assessed, not only with regard to adverse effects of the particular intervention, but also in the context of a comparison to alternative treatments. If evidence demonstrates the efficacy and/or effectiveness of a particular intervention, it may be unsafe to select a treatment for which evidence of efficacy or effectiveness is lacking. Certainly patients should be fully informed of the evidence that is available for making rational choices. Alternative and complementary modes of medicine should be subject to these principles. The history of digitalis glycosides provides an interesting example of an important treatment arising from herbal medicine, by which many of these elements can be exemplified.

Challenges facing academic health centers and major teaching hospitals.

To understand the unique and complex challenges facing healthcare providers, the author discusses present and projected changes occurring in the healthcare system. Reflecting on their impact on clinical care, education and research, he discusses some ways in which academic health centers around the country are responding to these changes. He concludes by discussing strategies to address some of the issues facing us.

Low-cost technologies and public policy.

The evaluation of low-cost technologies is complicated by the difficulty of understanding what is meant by "low" cost. Low unit costs may lead to the widespread use of a technology that results in high aggregate costs. It is often more useful to consider the value than the cost of a technology, recognizing that this value may change, depending upon the group to whom it is applied as well as the factors that are measured. Public policy should attempt not only to control costs but also to obtain the greatest value for expenditures in health care by supporting the development of methodologies to define value, reimbursement strategies that emphasize cost-effectiveness, and clinical guidelines that can reduce variation in practice.