This paper examines the views and policies of medical journal editors with respect to word use and semantics relating to the subject and methods commonly termed “alternative medicine” (altmed).

With any change in conceptual approaches in science and medicine comes the necessity to develop language changes to express those concepts. Some changes use words in traditional definition (eg, nuclear transfer); sometimes new words have to be invented or synthesized (eg, clone, ribonucleic acid, hertz); sometimes standard words are used with transformed meaning (eg, alternative, integrative); and some words are dropped from common use for social consensus, legal, or political reasons (eg, quackery). Some of the words are used with differing meanings in differing contexts (eg, alternative). In some instances, proponents and writers seemingly apply words in previously unused ways to convey new or different meanings and to elicit desired emotional responses, or use euphemisms to preclude emotional responses in readers. All of this may be normal language development for which the altmed movement is no exception.[1–6]

However, word use and semantics are of importance to teachers, writers, editors, librarians, semanticists, and historians as well as to workers in the field, physicians, and patients.[3,7–9] Some advocates and workers have even conferred, under the auspices of the US National Institutes of Health, to define alternative and related descriptors.[10] Others (eg, the former US Office of Technology Assessment) have invented their own terminology when referring to anomalous cancer treatments as unconventional.[11]

As a prelude to the present study, the authors had informally surveyed the medical literature and found no consistency of use; rather, there appeared to be an attempt to form a new set of definitions by workers in the field. Literature on the use of altmed methods published over recent years illuminates changing terminology in the field.[12] However, although numerous surveys of altmed use exist, we have found no published surveys that examine terminology.

Proponents of altmed have encountered major difficulties in achieving acceptance of their methods by the medical community. Such difficulties remain pervasive because many rationales, bases, and claims for alternative approaches conflict with the logicoscientific foundations of medicine. Faced with this fundamental problem, a tempting solution for proponents of altmed is one of semantics: alter the words but not the substance.

Such semantic turns have already occurred. The most obvious examples concern the descriptive language applying to altmed as an entity. The term “alternative” immediately appears to set such therapeutic approaches apart from mainstream medicine. While this may satisfy proponents who are ideologically wedded to alternatives to modern medicine, it is likely to alert many others into wariness. Thus, sectarian medical proponents now frequently employ the word “complementary” in place of, or in addition to, the word “alternative,” as in complementary medicine, complementary therapies, complementary and alternative medicine (CAM). The term “complementary” in this context implies a positive contribution to healthcare, one that is in harmony with established medicine, as opposed to serving as an alternative to it. A more recently deployed synonym is integrative, as in integrative medicine and integrative therapies. The term “integrative” in this context implies approaches that are somehow incorporated into established medicine – even without adequate efficacy proof. Some altmed advocates have proposed using language change as a tool for swaying public opinion, with the intent of changing laws, presumably to legalize methods and practices now or previously considered illegal.[3]

The purpose of our study was to investigate the views, practices, and policies of medical journal editors on the use of words and phrases present in altmed manuscripts submitted for publication. A survey was used to measure, in a simple and brief way, the awareness of medical editors about the problem of invented language use in the formation of medical knowledge. We hoped to be able to provide answers to the following questions:

• To what degree are medical journal editors paying attention to this issue?
• Are the stances and practices of editors likely to carry implications for the knowledge base of medicine and altmed?

We conducted a postal survey of editors of medical and closely related journals. We selected 56 journals from the following Institute for Scientific Information (ISI) categories: [a] Integrative & Complementary Medicine (10); [b] General & Internal Medicine (16); [c] Research & Experimental Medicine (15); and [d] Nursing (15). On the basis of ISI 2002 citation scores, journals in [b-d] were selected to represent high-ranking and low-ranking journals. The rationale for selection was to take the 10 top-scoring and the 10 lowest-scoring journals in each category. This gave the following mean score values: [b] high ranking: mean score 11.6 (10); low ranking: mean score 0.2 (6); [c] high ranking: mean score 8.3 (9); low ranking: mean score 1.1 (6); [d] high ranking: mean score 0.9 (10); low ranking: mean score 0.4 (5). A low spread of ISI citation values, coupled with nonavailability of scores for several journals, precluded a high/low ranking being applied to journals in [a]. A lack of ranked journals necessitated the use of a smaller sample size for the low-ranking group of journals in [d]. Note that ISI scores for individual journals have been removed from the tabulated data presented in this paper to preserve journal anonymity.

The questionnaire sent to editors comprised an explanatory tract followed by specific questions. The explanatory tract closely matched the words of the Introduction section of this article. There were 6 questions, as follows:

• Does your journal have a policy on the definition and use of words and phrases relating to the subject and methods commonly termed “alternative medicine”? (If so, we would appreciate details of your policy.)
• If your journal has no policy, has the subject been discussed among your staff?
• Does your staff plan to discuss the matter or introduce/improve guidelines?
• Have you discussed the question with other editors?
• Do you personally consider the matter to be a problem?
• In papers published by your journal, have you changed wording relating to the alternative medicine field, or have you had a reviewer suggest a change in wording?

The letter stated: “We will collate answers, evaluate and publish the results. We hope the survey will eventually result in more attention given to the issue. Answers will not be identified by journal name or editor name, but simply listed by number.”

Initial letters were sent out in March 2004. Reminder letters were sent to all nonrespondents in December 2004. Final reminder letters were sent to the remaining nonrespondents in April 2005.

Data from the returns were collated and are summarized in the following section (Table). Because of the qualitative nature of the research approach, statistical analysis of the numerically represented results would have been inappropriate and has therefore not been conducted.

Table Survey Results

In terms of journal category, the response rates (in descending order) were as follows: Nursing, 86.7% (13/15); General & Internal Medicine, 75% (12/16); Integrative & Complementary Medicine, 50% (5/10); and Research & Experimental Medicine, 33.3% (5/15). The differences here may well be the result of the differential focus of the journal types, and thus the nature of the types of papers received or published by them. One would expect general medical and nursing journals to receive more submissions on altmed topics than would experimentally focused journals because altmed claims infrequently reside in the domain of experimental biomedicine. It is, however, surprising that only 50% of editors of journals in the Integrative & Complementary Medicine category responded, considering that such journals presumably deal exclusively with altmed manuscripts.

In terms of ranking, no clear pattern of response rate is discernable. In other words, we found no evidence that ISI citation scores were associated with the willingness or otherwise of editors to respond to the survey.

Noteworthy comments made by the editors are reproduced below. Some comments provided, especially those associated with individual questions, contributed nothing significant beyond what had already been said (for example, simply restating a yes answer); such comments are not listed below.

There were 2 affirmative responses from 34 clear answers. Thus, 5.9% of the responding journals had a policy on word use in respect of altmed. The 2 affirmative responses were from journals in the following categories: [a] General & Internal Medicine (high ranking in terms of ISI impact factor data); and [b] Nursing (high ranking). Both of the affirmative responses were accompanied by comments, as follows: [a] “Our house style book says: alternative medicine – prefer complementary medicine”; and [b] “We do try to use the term “healthcare” in place of “medicine” in any context.” Thus, only one of these two comments appears to clearly relate to the issue of altmed terminology. However, it is worth noting that the reclassification from medicine to healthcare in this nursing journal suggests that more than casual consideration was directed toward word meaning and usage.

Of the negative responses, 2 were accompanied by specific comments, namely: “We do not have a policy on the definition and use of words relating to this field of inquiry largely because definitions are provided by authors depending on the topic under discussion – for instance a macro-analysis may address Western medicines as an alternate form of healthcare if a paper comes from a different culture” (from a journal in the Integrative & Complementary Medicine category); and “We would expect authors to provide their own definitions and meanings, which is a general expectation of scholarly work” (from a journal in the Nursing category).

There were 4 affirmative responses from 31 clear answers. Thus, 12.9% of the responding journal editors had discussed the subject with their staff. The 4 affirmative responses were from journals in the following categories: [a] Integrative & Complementary Medicine, 3; and [b] Nursing (high ranking), 1. The latter journal supplied a specific comment for this question, namely “Discussed informally in the editorial team.”

There were 2 affirmative responses from 27 clear answers. Thus, 7.4% of the responding journal editors planned to discuss the matter or introduce/improve guidelines. The 2 affirmative responses were from journals in the following categories: [a] Integrative & Complementary Medicine; and [b] General & Internal Medicine (low ranking). A long comment was provided from the editor of the former journal, as follows: “Terminology is continuously discussed from various stances, eg, phemenological, ethnomethodological, philosophical, and sociological perspectives. The nature of social trends and social change play a large part in shifting definitions in this country and are also culturally specific – an “alternative” therapy in one country may well be the primary form of care in another. In the UK, the sociological professionalization of “alternative medicine” has resulted in a terminology reflecting social and medical acknowledgement of the impact of certain therapies upon healthcare and Western medicine. Thus terms such as integrated or integrative medicine are appearing more frequently – in the future it is hoped there will simply be good medicine with no social distinction made between healthcare therapies.”

Of the negative responses, one editor provided a comment, as follows: “We do not expect to discuss introducing guidelines along this line – our general expectation for all terms that may have alternate meanings is for authors to anchor their meanings with their own definitions” (from a journal in the Nursing high-ranking category).

There were 5 affirmative responses from 28 clear answers. Thus, 17.9% of the responding journal editors had discussed the subject with other editors. The 5 affirmative responses were from journals in the following categories: [a] Integrative & Complementary Medicine, 3; [b] Research & Experimental Medicine (high ranking), 1; and [c] Nursing (high ranking), 1. Various comments were given in conjunction with the affirmative responses, namely: “The issue has been at best only informally brought up”; “We have kind of wondered about it”; and “informally.” These comments suggest a degree of tentativeness in the affirmative answers.

No noteworthy question-specific comments were provided for the negative responses.

There were 3 affirmative responses from 30 clear answers. Thus, 10% of the responding journal editors personally considered the matter to be a problem. The 3 affirmative responses were from journals in the following categories: [a] Integrative & Complementary Medicine; [b] General & Internal Medicine (low ranking); and [c] Research & Experimental Medicine (low ranking). Comments were: “Yes, but not a serious problem at this point”; and “Potentially a problem if incorrect meaning conveyed.”

Several of the negative responses were accompanied with noteworthy comments, as follows from 2 Integrative & Complementary Medicine journals: “No – a matter of intellectual curiosity”; and “Not particularly – the peer review process serves us extremely well.” From 3 General & Internal Medicine (high-ranking) journals: “It hasn't been. We've published a lot of CAM articles”; and “Personally I don't see a problem for any “accepted usage” if the “accepted definition” is clear. It's the connotations that usually cause the problem. Perhaps influenced by my immersion in (my journal's) style, I'd use “complementary” as a matter of course.” From a Nursing (high-ranking) journal: “No – careful conceptual clarification is required in all papers.”

There were 9 affirmative responses from 28 clear answers. Thus, 32% of the responding journal editors had changed altmed wording or had a reviewer suggest changes. The 9 affirmative responses were from journals in the following categories: [a] Integrative & Complementary Medicine, 1; [b] General & Internal Medicine (both high ranking and low ranking), 4; [c] Research & Experimental Medicine (low ranking), 1; Nursing (high ranking), 3. Several of the affirmative responses were accompanied with noteworthy comments, namely: “Yes, frequently (the reviewer suggesting a change in wording) which is of course ultimately up to the authors” (from a journal in the Integrative & Complementary Medicine category); and “We do change wording if the meaning/sense is going to be unclear to nonspecialists” (from a journal in the General & Internal Medicine [high-ranking] category); and “I have asked authors to define clearly how they used the term and how it was operationalized as a variable” (from a journal in the Nursing [high-ranking] category.

Two of the negative responses were accompanied with noteworthy comments, as follows. “We do not change wording in an author's work. Reviewers sometimes ask the author to clarify meanings of ambiguous terms and concepts of any term or concept that is not used consistently or the meaning of which is not clear” (from a journal in the Nursing [high-ranking] category; and “Generally, our authors define what they mean by the term, but since this is a nursing journal, the term “alternative medicine” is rarely used; more often the term “alternative and complementary therapies or modalities” may be used” (from a journal in the Nursing [low-ranking] category). It is notable that this nursing journal editor chooses to change from medicine to therapies or modalities yet appears not to see a problem with altmed euphemisms.

From 2 journals in the General & Internal Medicine (high-ranking) category:

“The problem is that I cannot answer your questions simply. Suffice it to say that (this journal's) “policy” re “alternative medicine” is much the same as any other complex issue. We handle each paper/submission as appropriate for the specific issues involved.”

“(This journal) does not have a specific policy on the definition and use of words and phrases relating to “alternative medicine.” We do allow authors to use this term, which seemed to be the preferred term in the early 1990s, when the National Institutes of Health established the Office of Alternative Medicine. In 1998, it was replaced by the National Center for Complementary and Alternative Medicine. Our authors have occasionally referred to “alternative or complementary medicine” or “unconventional medicine,” and we have not changed these terms.”

From 2 journals in the Nursing (high-ranking) category:

“There are several issues: 1. USA authors often refer to CAM – complementary and alternative medicine – as a unitary concept, whereas to me they are not the same. 2. Complementary and alternative are different in this context, ie, in addition to or instead of, respectively. 3. Medicine – as this is a nursing journal I change this to therapy or care if appropriate. So my most usual formulation is ‘complementary therapy/ies’ or ‘complementary care’.”

“I do not see authors using that term. The journal has no policies about it, but the more acceptable term now appears to be “complementary medicine.” The word “alternative” has the connotation of fringe. I have not received manuscripts recently with either wording so I have not faced whether to ask authors to revise terms.”

From a journal in the Nursing (low-ranking) category:

“I would check with authors if they would agree to “complementary medicine” but they tend to be sensitive to changing language anyway.”

This study involved a wide range of journals and had a high overall response rate. However, nonresponding editors' views cannot be known, and it is possible that their hidden views, if known, might alter the percentages to some extent. However, there are no strong reasons to suppose that systematic bias would likely undermine the fundamental conclusion, expressed above, that editors do not in general recognize the use of words in altmed as being an issue of special significance. Systematic bias in this study, if it exists, is likely to have operated in the opposite direction: the set of editors who chose not to respond may be assumed to include a particularly high proportion of those who view the issue as having little importance or relevance to them. The data from this study cannot formally determine whether this is the case; however, we suggest that this assumption is reasonable and sound.

Given that the data from this study were collected from the years 2004 and 2005, it is possible that the situation may have changed since that time. In practical terms, one may view the relation between sectarian medicine methods (altmed) and medicine as one with both opposing and complementary features, the border between them shifting with knowledge and time. This process is likely to affect all agents involved in medicine and healthcare, including journal editors and policies. For example, viewpoints of extant editors may be swayed in one direction or other, and new editors may arrive bringing with them fresh perspectives. It would therefore be useful to repeat this study in the near future to investigate the existence, direction, and extent of any such shifts in editorial stance. The work might also be extended by including semistructured interviews as a means to enhance information gathering.

The foregoing data indicate that among editors of medical and related journals there exists a general lack of policy or discussion on the use of words in altmed papers. This is evidenced by the finding that fewer than 1 in 4 of the responding editors had a policy, or had discussed with staff, or planned to introduce/improve guidelines on this issue. This lack of policy and discussion is in harmony with the associated findings that fewer than 1 in 5 of the editors had discussed the issue with other editors, and only 1 in 10 considered the matter to be a problem. Taken together, these findings lead to the conclusion that editors of medical and related journals do not in general recognize the use of words in altmed as being an issue of special significance.

We suggest that the lack of special significance accorded by editors to altmed terminology is of significant importance.

As described in the introduction to this paper, altmed proponents frequently use the word “complementary,” as in complementary medicine, complementary therapies, and complementary and alternative medicine or CAM. Similarly, the word “integrative” is frequently used, as in integrative medicine, integrative therapies, and integrative healthcare. Another term now in use is “unconventional.” The use of terms such as “complementary,” “integrative,” and “unconventional” in the context of altmed represent new word usage. Language used only 3 to 4 decades ago differs markedly from that used today: perusal of medical journals indicates that there were no references to alternative medicine until the 1970s; references to complementary appeared in the 1980s; and references to integrative began only 10 to 15 years ago. Previously, terms such as “quackery,” “health fraud,” and “sectarian” were commonly used to describe methods lacking a logicoscientific basis.

Going beyond the semantics of describing altmed per se, there are many other terms commonly used in altmed discourse that require more than an unquestioned acceptance. Some words have had their established etymologic or common meanings distorted or ignored, becoming largely platitudes (eg, harmony, holistic, transformational), and scientific or technical terms have been used inappropriately (eg, energy, evidence, and immune system).

The choices and definitions of words used to describe altmed methods and modalities have been determined by altmed practitioners and advocates, not by independent and objective individuals. Most importantly, the language changes did not follow a natural course of language evolution, but were introduced by intention.

Of course, it is true that some genuinely alternative or complementary methods exist and have value. Examples include some forms of meditation, relaxation, massage, and music. Such methods may relax the patient, reduce symptoms, and provide psychological support. To give a specific example: for an individual with an anxiety disorder, massage or music may reasonably be used as an adjunct (or in some cases as an alternative) to standard medical approaches such as anxiolytic medication and cognitive behavioral therapy. Moreover, there exist two alternative or complementary methods that can improve health in many circumstances, these being exercise and standard nutritional advice. For example, both exercise and dietary alteration are clearly beneficial for individuals with type II diabetes and are indicated as an adjunct to conventional medical management of the disorder – and in some milder cases may represent a genuine alternative to medical therapy. However, most physicians would regard these not as alternative or complementary but as standard components of medicine for many decades.

The difficulty here is that the definition and scope of altmed methods are often loosely determined or not determined at all. Some authors include some of the above genuinely efficacious methods, particularly exercise and standard nutritional advice, within their definition of alternative medicine or complementary therapies because their inclusion enables the authors to say that some altmed methods work.

The present lack of definitions and scope of altmed methods is thus a problem for medical journal editors. We suggest that editors should, ideally on a collective basis, endeavor to define key altmed terms and carefully examine their scope.

We suggest that, as the gatekeepers of medical knowledge, editors should be aware of the special semantic problems surrounding altmed, and act accordingly with respect to manuscripts dealing with altmed. We suggest that failure to do so is likely to result in selection and printing of articles that may contain subtle unfounded characteristics for dubious scientific propositions masked by distorted language. Such accidental publication bias is liable to incur several negative effects, including misleading readers and obscuring the meaning and context of research findings. Editors who are unaware of the semantic issues may risk publishing manuscripts that can be inappropriately cited as evidence.

Kevin R. Smith, School of Contemporary Sciences, University of Abertay, Dundee, Scotland, United Kingdom Author's email: k.smith/at/tay.ac.uk.

Wallace Sampson, Stanford University, Stanford, California; Division of Hematology and Oncology, Department of Medicine, Santa Clara Valley Medical Center, San Jose, California.