Ontario college beats retreat on alternative therapies.

Surgeons of Ontario has retreated on a controversial draft complementary medicine policy after substantial backlash from physician groups who feared it would require them to advise patients about quack therapies. The updated Complementary/Alternative Medicine policy statement reaffirms the primacy of physicians’ duty to act in their patients’ best interests and only recommend therapeutic options “informed by evidence and science” (www.cpso.on.ca/uploadedFiles/policies /policies/policyitems/complementary _med.pdf). “The College focused on ensuring the new policy is congruent with the core expectations of professional conduct that are applicable to all members of the medical profession, and addressed the perceived frailties of the existing policy (i.e., that it was too permissive and did not explicitly prohibit unacceptable conduct),” Kathryn Clarke, the college’s senior communications coordinator, writes in an email. Physician groups balked at the lower evidentiary bar an earlier draft of the policy had set for measuring the safety and efficacy of complementary therapies, arguing that its requirement that physicians propose complementary and alternative medicine (CAM) options would force them to breach their duty to provide patients with the best possible care (www.cmaj.ca/lookup/doi /10.1503/cmaj.109-4004). That requirement has been axed in the updated policy, which gives precedence to the expectation that physicians act in their patients’ best interests, whereas the original gave first rank to respect for patient wishes, “even those which physicians deem to be unfounded or unwise” (www.cpso .on .ca /uploadedFiles /policies /consultations /non-allopathic -consultation-draft.pdf). A stipulation that physicians “must refrain from expressing personal nonclinical judgments” has also been removed, and “new language has been added to make it clear that we expect physicians to demonstrate respect for patient choice but also to comply with their professional obligations,” Clarke writes. To wit, the updated guidelines now affirm that “it is a principle of good practice that physicians provide their professional opinion in an accurate and objective manner, substantiated by fact and sound clinical judgment. Clinical concerns must always be highlighted.” Moreover, “the explicit expectation that decision-making and physician practice must be informed by evidence and science has been interwoven into the policy in a number of key areas, for example: in the introduction, and in the section relating to expectations of physicians when practicing CAM (i.e., when physicians are performing clinical assessments; reaching a diagnosis; presenting therapeutic options; and obtaining informed consent),” Clarke writes. The updated policy states that “all patient assessments and diagnoses must be consistent with the standards of conventional medicine and be informed by evidence and science,” and that “any CAM therapeutic option that is recommended by physicians must be informed by evidence and science.” It also requires that alternative therapies proposed by physicians must: • “Have a logical connection to the diagnosis reached; • Have a reasonable expectation of remedying or alleviating the patient’s health condition or symptoms; and • Possess a favourable risk/benefit ratio based on: the merits of the option, the potential interactions with other treatment the patient is receiving, the conventional therapeutic options available, and other considerations the physician deems relevant.” The earlier iteration of the guidelines had only required rigorous evidence for alternative therapies “that pose greater risks than a comparable allopathic treatment or that will impose a financial burden.” Vague terminology, such as the use of News CMAJ