leaves (compare Joe’s remarks in the opening quote to the chapter). Other
aspects of a regimen may be important such as changing the leaves frequently
to maintain a ‘cooling’ action, which may well provide comfort and a feeling
of relief; an active role by patients in any therapy is often recognised as helpful.
Step 3
Step 3 is not always necessary and runs on from step 2. Occasions arise when
differences of opinion between patient and practitioner need to be brokered
so as to develop or maintain an effective relationship. This is facilitated,
partly through background knowledge (step 1), both by uncovering and
understanding a patient’s own circumstances and beliefs towards non-
conventional approaches, and by critically evaluating published information.
A three-step strategy implies one step after the other; however, this may
change in practice depending on a particular situation (e.g. a patient’s level
of education and knowledge), and shortcuts may be taken. Moreover, the
understanding of a specific concept (step 1’s preparation) may need to be
revisited or learned for the first time after a case history has been taken (step
2). In this situation, admitting lack of knowledge to a patient is often appro-
priate. Although this is problematic for many practitioners, they can be reas-
sured that patients accept practitioners’ frank statement that they need to
research a topic outside their customary practice before giving advice. The
three-step strategy is therefore intended primarily to ensure that all relevant
information is considered when responding to issues of efficacy and safety
in the context of cultural sensitivity.
The strategy for evaluating remedies used empirically
Practitioners (and nowadays many patients) want ‘scientific’ evidence to
support effectiveness and safety. Indeed, it is noteworthy that some aborig-
inal peoples are backing scientific research in the hope of marketing their
traditional medicines.^11 As already indicated, the currently accepted stan-
dards for robust evidence should meet the principles of EBM. However, just
what this means needs reflection because there are tendencies to stereotype
EBM as the application of clinical trial data to patients as if one medication,
one regimen, fits all. In fact, EBM should be viewed as it was by its early
pioneers, namely: ‘EBM is the integration of best research evidence and clin-
ical expertise and patient values.’^12 For this reason, many practitioners prefer
the term ‘evidence-informed practice’ to make clear that it focuses on the
needs and situation of each patient; this may mean that a practitioner –
depending on the values and wishes of a patient – supports the trial of a
therapy (perhaps an aboriginal practice) even though the evidence for effi-
cacy is relatively low in the hierarchical levels that have become part of the
EBM movement.
48 |Traditional medicine