Can teaching CAM improve the doctor-patient relationship?

My recent post (coupled with similar posts by Dr. R. W. and Abel Pharmboy) about the American Medical Student Association (AMSA) and its credulous promotion of non-evidence-based alternative medicine while posing as being “skeptical” of big pharma brought this rejoinder from Joseph of Corpus Callosum, in which he took issue with one aspect of my suspicion of the promotion of woo in medical schools by AMSA. I have to strenuously disagree with nearly all of his points. Here’s the first, and most easily dismissed:

They [Dr. R.W., Abel, and I] raise some valid points, although I would not be quick to be entirely dismissive of ASMA’s efforts. There are several reasons for that.

For one, kids will be kids. While medical students are not exactly kids, probably most of them did not get to be very rebellious during their teenage years. Maybe they need to get it out of their system.

As a fellow physician, I’d say: So what? Being a doctor is serious business. Medical students are preparing for a profession in which they will literally be responsible for people’s lives and well-being. If a medical student feels the need to “rebel” by trying to get non-evidence-based medicine introduced into the curriculum, then maybe that medical student doesn’t belong in medicine. Harsh? Judgmental? Hell, yes! Medicine isn’t a game. Responsible physicians know what they are responsible for. For medical students, “kids will be kids” doesn’t bother me as far as playing pranks on each other (and, yes, a fair amount of that does go on during medical school) or dabbling in left wing politics, but I draw the line at anything that compromises patient care. The cardinal rule of medicine is, “First, do no harm.” In some cases, pitching woo may do no harm, but in many cases it does. (Just ask the Orange Man.) Maybe it’s just my specialty (surgery), where the therapies we use can do real harm when misapplied (and sometimes even when applied properly). Consequently, my attitude is not so forgiving towards actions that I perceive as potentially compromising the standard of care, and, I argue, the unabashed credulous promotion of woo by AMSA has the potential to do just that.

Joseph’s main objection to my thesis, in contrast, is not quite as easily dismissed, although I believe he is mistaken about this as well. After pointing out that AMSA is probably not pushing this woo as a replacement for evidence-based medicine (EBM), but rather something to be used in addition to EBM (probably true, for the most part, at least now), he makes the argument that understanding complementary and alternative medicine (CAM) can have a benefit:

However, looking at it from a biopsychosocial perspective, I am not confident that there is zero benefit [from a physician understanding CAM]. In fact, I think there is a benefit. What I am not clear about is how big the benefit is. I suspect that it helps some doctors, but not others.

Traditional medicine tends to focus or preventing or curing disease. It is hard to find fault with that. When the disease cannot be prevented cured, the focus shifts to stopping or slowing the progression. When that cannot be done, the focus shifts to minimizing the impact of the disease, by assisting with adaptation.

Patients, of course, want to be cured. Sometimes that is not possible, so the best thing for the physician to do is to help the patient accept the shift in focus. ICAM probably has a lot to offer in that area.

Again, I disagree. For one thing, CAM tends to do exactly the opposite. I argue that it actually impedes such a shift in focus. CAM therapies often promise the impossible: curing diseases that “conventional” medicine can’t cure, in particular. The patient often seeks alternative medicine because he believes that conventional medicine can’t help him or that it will cause too much discomfort or pain in doing so (patients who reject chemotherapy for tumors known to respond to it in favor of “less toxic” natural therapies that have no evidence to support their efficacy, for example). Even though most of us think that we are immune to it, physicians who begin to use CAM take the very real risk of falling into the same mindset as practitioners of woo who practice outright quackery. I’d be willing to bet that, for instance, Dr. Roy Kerry, the physician whose use of chelation therapy for autism killed a five year old boy, started out practicing EBM but now genuinely believes he is helping his patients when he gives them EDTA for their autism. No, in actuality, much of CAM shifts the focus of patients with incurable disease or chronic conditions that are not likely to change in exactly the wrong direction: towards a false hope that their condition can be cured, rather than simply managed or palliated.

Joseph’s other argument is that learning about woo can improve a physician’s bedside manner by helping him to understand what the patient’s conception of disease is:

The other area of potential benefit is a bit more obscure, more difficult to understand. Patients come to the clinic with a conception of what is wrong. To them, their conception of the disease is what defines the problem. usually, their concept of the disease is quite different from that of the physician.

In order to have the best chance of helping, it is necessary for the physician to make recommendations that are consistent with the patient’s concept of the disease. Education in ICAM can, at least potentially, help broaden the physician’s ability to understand the patients concept of the disease. This could facilitate communication, and the development of a therapeutic alliance.

Now, I am aware that the idea of a therapeutic alliance is pretty much restricted to psychiatry and allied disciplines. But the idea is an old one: every doctor knows about the concept of bedside manner, which is probably the single most important skill to have.

In fact, over the entire history of medicine, various concepts have come and gone. Probably the one concept that has endured over the entire history of medicine, is that of the centrality of the physician-patient relationship.

Part of the skill of bedside manner is the ability to understand the disease from the perspective of the patient. Increasingly, patients are coming in, having conceptualized their illness in terms borrowed from a variety of sources. Sometimes these are concepts from ICAM, sometimes they are from drug company ads, or Oprah, or Reader’s Digest; sometimes they are idiosyncratic. But whatever the origin, the doctor has to listen and understand.

Fair enough, but my rejoinder to this is that a doctor doesn’t really need to have more than a general understanding of what these concepts are order to accomplish exactly what Joseph considers important above. For example, a medical student does not need to take a series of courses as extensive as the courses at the University of Michigan to which Joseph referred. (Indeed, I’m actually quite disturbed to see my old undergraduate and medical school alma mater engaging in this woo, but that’s another matter. Suffice it to say that It’s unlikely that U. of M. will be getting any donations from me for the foreseeable future unless I can be somehow assured that they won’t go to help fund woo.)

My objection to Joseph’s argument is this; Just because medical schools have traditionally not been that great at teaching bedside manner, resulting in many doctors with less than stellar communications skills, is not a valid reason to teach them woo even if doing so would improve their communication skills with patients. ICAM and bedside manner are separate issues, and they do not have to be conflated to teach future doctors to learn how to forge a better therapeutic alliance with the patient. Just because, as Joseph correctly points out, the doctor-patient relationship can never entirely be evidence-based (being an interaction between two human beings) does not mean that practicing evidence-based medicine precludes the “human touch.” (Indeed, I’ve seen this in action at my own institution by oncologists with whom I work time and time again.) Joseph may have a point that it is useful for physicians to be familiar with multiple models of disease, but most CAM programs in medical school (and certainly AMSA’s credulous promotion of woo and even U. of M.’s program) go far beyond making students “familiar” with the tenets of CAM, which are numerous and often contradictory, depending upon which system.

Perhaps Joseph’s worst mistake, though, is this one:

Another potential benefit to inclusion of ICAM is that it provides opportunities to teach critical thinking skills. It is important for physicians to be able to critically evaluate the evidence supporting each treatment modality, regardless of whether it originated in New London or in Tibet.

In theory, yes, teaching CAM could provide opportunities to teach critical thinking skills. However, I’m afraid that in practice this is the last thing that CAM programs are generally good for. Indeed, as Dr. R. W. has so ably documented on his blog, critical thinking skills are most definitely not a primary concern in the vast majority of these programs, most of which teach credulous, nonjudgmental treatments of the major alternative medicine therapies and do not present much in terms of teaching what evidence there is or is not to support the use of these therapies. I note that even the program at the University of Michigan does not seem to provide much in the way of evidence-based teaching of CAM until the fourth year curriculum, and only then as an additional elective. (Heck, U. of M. even offers an elective that includes teaching on the utter quackery that is homeopathy! I could teach homeopathy in less than a half hour, with an explanation of the “law of similars” and “homeopathic dilutions,” followed by pointing out that homeopathy violates the laws of chemistry and physics and that there is no evidence that it does anything beyond a placebo effect. You can bet that U. of M. almost certainly doesn’t treat it that way.)

Also, my experience observing the proliferation of these programs is that they start out with good intentions of presenting an evidence-based approach to these modalities but then over time degenerate into credulous acceptance. I rather suspect that much of this is market-driven. Patients want CAM; to compete, medical schools introduce it into their hospitals and curricula. There is no real incentive other than good intentions to keep the programs strictly evidence-based, and the result is, all too often, a descent into woo. In short, woo sells, and medical schools are becoming all too willing to overlook the lack of sound scientific evidence for the vast majority of alternative medicine. I don’t have that much trouble with the teaching of herbal medicine, for instance, but when I start seeing Reiki, homeopathy, reflexology, and qi gong showing up in medical school, I become very alarmed indeed.

I rather suspect that Joseph doesn’t view the teaching of CAM in medical school to be as pernicious as I do because, unlike me, he perceives a mild benefit, no matter how ephemeral, and his perception of the cost to realize that benefit differs greatly from mine. One area where he and I agree is that teaching these modalities in medical school is “the potential to give certain treatment modalities more credibility than they deserve.” From my perspective that potential is very high–unacceptably high. When medical schools start teaching woo alongside EBM, it falsely elevates the woo as being on par with scientific medicine, and, worse, it takes time away from subjects that medical students actually need to know, to the potential detriment of their future patients. As far as I’m concerned, there should be no such thing as “alternative” medicine. There should medicine for which there is good scientific evidence of efficacy (it doesn’t matter where it came from or whether it was once considered “alternative” or not), and there is everything else that either doesn’t work or has no evidence to support that it works. Doctors-to-be should not waste too much time learning the latter.