Regular readers of this blog know that I have been becoming increasingly disturbed by what I see as the infiltration of non-evidenced-based “alternative” medicine into academic medical centers. Indeed, about a month ago, I went so far as to count the number of medical schools that offer some form of “complementary and alternative medicine” (CAM) in their curricula. (What a fantastic marketing term for what are in the vast majority of cases therapies without a plausible scientific basis or compelling clinical evidence for efficacy above that of a placebo!) The end result was the Academic Woo Aggregator, a post that, less than a month after its creation, already requires updating to include a few programs of which I’ve become aware that I didn’t know about then. As I’ve said time and time again, I’m all for teaching a critical, evidence-based evaluation of CAM in medical school. After all, lots of people use these therapies, and any good physician should know what they are and what the evidence supporting (or, far more frequently, failing to support) them is. Unfortunately, that’s not what usually happens. (More about that below the fold, along with the justification of including the Blogging About Peer-reviewed Research icon.)
Worse, one outcome of so much credulous teaching of treatments with no good basic scientific or clinical evidence allows credulous boosters in the media like the Chicago Tribune‘s chief antivaccinationist twit and cheerleader for quackery, Julie Deardorff to crow about how CAM is now “respected”:
Is it time to try acupuncture, hypnosis, meditation, guided imagery and massage?
Surprisingly, even the most conservative mainstream research hospitals now answer “yes!”
Twenty years ago, the mind-body connection was largely dismissed by U.S. doctors as a wacky concept in healing. Today it’s a staple of integrative medicine, the discipline that blends complementary and alternative medicine (CAM) with conventional treatments and places more emphasis on treating the whole person.
About 75 percent of medical schools now have some CAM courses in the curriculum, and the Consortium of Academic Health Centers for Integrative Medicine includes 39 academic health centers, including the Mayo Clinic plus Harvard, Stanford, Columbia, Duke and Yale Universities.
Coincidentally enough, 39 is the number of centers in my first iteration of the Academic Woo Aggregator. Deardorff goes on to discuss these modalities, which were apparently the topic of a conference at the Drake Hotel in Chicago last week. The truly ridiculous thing about all of this is that the vast majority of the interventions claimed at this meeting to have efficacy are dietary or herbal remedies, not hardcore woo like homeopathy. For example:
A Mediterranean-style diet is the best eating plan for patients with coronary heart disease. It includes fruits and vegetables, at least two servings of fish per week, the use of liquid vegetable oils, such as flaxseed, and a decreased intake of saturated fat, said Matthew Sorrentino, a non-invasive preventive cardiologist at the University of Chicago. A Mediterranean diet in conjunction with statin therapy has been shown to be more effective than statin therapy alone.
Since when did using dietary interventions as medical treatment for heart disease become “alternative,” CAM, or integrative, rather than just medicine? Forgive me, but most of this is nothing more than mainstream medicine repackaged as CAM to sell it to a credulous public. True, such “soft” interventions as hypnotism, relaxation, acupuncture, and massage are included, but most of the interventions discussed would not be out of place in the paradigm of “conventional” medicine, which makes me wonder why they are called “alternative.” In reality, what bothers me about the whole concept of CAM is that it’s basically a Trojan horse through which some therapies that might be evidence-based and could easily be integrated into our standard armamentarium of medical therapies are the “foot in the door” behind which hardcore woo lumped together as CAM follow, woo such as homeopathy, craniosacral therapy, reiki, and even reflexology, all of which I have encountered on wepages for academic centers devoted to CAM.
That’s why I’ve been in agreement with Dr. Robert Donnell, who, as part of a Roundtable Discussion entitled Should Medical Schools Teach “Integrative Medicine?, recently penned an excellent editorial for Medscape entitled Abraham Flexner May Be Turning Over in His Grave. A key quote:
Let’s make a distinction. Doctors need to know about the alternative treatments that patients are seeking so that they can recognize herb-drug interactions, engage patients in discussions about alternative treatments, and appreciate cultural differences that may lead patients to seek such treatments. Medical schools should equip students in these areas. However, they should teach an appropriately critical and scientific view of alternative theories.
For many medical schools today, that’s the rub. Academic leaders, in fact, are suggesting that alternative modalities should be presented “in the context of their own philosophies and models of health and illness.[4]” Survey data from both MD- and DO-granting schools confirm this trend.[5-7] In other words, dubious claims are being promoted to students in an unscientific, uncritical manner. If you need more evidence, browse the Web sites of academic medical centers to see what’s going on and note their promotions of therapeutic touch, homeopathy, Ayurvedic medicine, shamanism, chakras, and more.
So, you may say, what’s wrong with combining other healing traditions with scientific methods? Plenty, because it results in an eclectic mix of diverse theories with no common basis. It leaves medicine without a consistent scientific framework upon which to evaluate treatments.
I would go even further and say that it blurs the line between science and pseudoscience, between medical science and the religious beliefs that underlie so many CAM therapies, such as reiki, shamanistic practices, or acupuncture. This is something medicine most definitely does not need. Indeed, Dr. Nick Genes, organizer of the Grand Rounds medical blogging carnival, while arguing that evidence-based medicine is the future of medicine, not CAM, inadvertently gives a good indication why the infiltration of woo into medical schools is so disturbing. Genes argues that, even after the Flexner report, medicine remained quite dogmatic and that only now is evidence-based medicine supplanting teaching based on the authority of long-dead “gods” of medicine and tradition. Although I think he is exaggerating a bit, he does have a point about how medical education can at times be dogmatic. He also has a point that evidence-based medicine is finally coming to the forefront in medicine and medical education, after years of lip service being paid to it but little being done with it. Unfortunately, though, that’s exactly why the infiltration of CAM is so disturbing. Medicine has finally, after over a hundred years, evolved to the point where it can actually become truly scientific and evidence-based. From my perspective, the growing uncritical acceptance of CAM in academic medicine is a major threat to the continuation of that evolution. Indeed, Dr. Roy Poses of the Health Care Renewal blog, who wrote another article for this roundtable, tells me just how bad the problem is becoming:
By 2002, most US medical schools (98 out of 126) were teaching about CAM practices in 1 or more required courses.[15] The material that was being taught was mostly uncritical: Less than one fifth of CAM courses included “critical evaluation of the scientific literature,” and almost four fifths were taught by a “CAM practitioner” who was likely to be an enthusiast, not a critic. Many of the modalities being taught had little scientific justification. These included homeopathy (taught in 58% of courses); ethnomedicine, including Ayurveda and Native American medicine (48%); therapeutic touch (38%); naturopathy (36%); and energy medicine, including manipulation of electromagnetic fields and magnet therapy (12%).
[…]
Medical schools’ often uncritical embracement of CAM sadly contrasts with their often lukewarm support of EBM. As Paul Glasziou put it, “evidence-based medicine (EBM) is like safe sex: talked about a lot, preached (taught) a little and practiced infrequently.[19]”
One thing for which I’m grateful is that this roundtable brought to my attention to a couple of articles that suggest just how much woo is infiltrating the curriculum of most medical schools:
- Brokaw JJ, Tunnicliff G, Raess BU, Saxon DW (2002). The teaching of complementary and alternative medicine in U.S. medical schools: a survey of course directors. Acad Med. 77(9):876-81.
- Saxon DW, Tunnicliff G, Brokaw JJ, Raess BU (2004). Status of complementary and alternative medicine in the osteopathic medical school curriculum. Am Osteopath Assoc. 104(3):121-6.
The first article polled the course directors of medical schools, while the second article looks at osteopathic medical schools. Both of them paint a depressing picture. Again, I emphasize that I strongly support teaching an evidence-based approach to CAM. The problem, if these articles’ conclusions are accurate, is that this is not what’s happening. The good news is that teaching of CAM, as of five years ago, was still a relatively small part of the medical school curriculum in most medical schools, although it was found that some medical schools dedicated 60 or more contact hours to it. The bad news is that it’s growing:
The growing popularity of CAM is beginning to have an impact on medical education. In their 1997-1998 survey of all 125 U.S. medical schools, Wetzel et al. found that 64% of the 117 responding schools were teaching CAM topics either as stand-alone elective courses or as part of required courses. This is almost twice the number of institutions found offering CAM instruction in a 1995 survey (34% of 97 responding schools),8 which underscores the rapid acceptance of unconventional therapies in U.S. medical schools. Canadian medical schools have likewise incorporated CAM into their curricula–as of 1998, 81% were teaching CAM topics.
Given this background, Brokaw et al (quoted above) did a study looking at what is taught in medical school by polling course directors. What they found about how CAM is taught in most medical schools where it is taught should give any maven of evidence-based medicine pause:
The topics most often being taught were acupuncture (76.7%), herbs and botanicals (69.9%), meditation and relaxation (65.8%), spirituality/faith/prayer (64.4%), chiropractic (60.3%), homeopathy (57.5%), and nutrition and diets (50.7%). The amounts of instructional time devoted to individual CAM topics varied widely, but most received about two contact hours. The “typical” CAM course was sponsored by a clinical department as an elective, was most likely to be taught in the first or fourth year of medical school, and had fewer than 20 contact hours of instruction. Most of the courses (78.1%) were taught by individuals identified as being CAM practitioners or prescribes of CAM therapies. Few of the courses (17.8%) emphasized a scientific approach to the evaluation of CAM effectiveness.
In other words, slightly more than one out of six medical schools actually do what they’re supposed to do and teach these modalities using a scientific viewpoint, which is, after all, what medical schools do for virtually every other therapy. However, apparently CAM modalities are otherwise given a pass in most cases when it comes to being taught from an evidence-based, scientific perspective. Indeed, only around one in twelve actually specifically emphasize that they use evidence-based techniques to teach CAM in their courses, while nearly 80% of the teachers are CAM practitioners:
…we find it troubling that so few of the respondents (17.8%) appear to have emphasized a critical perspective in evaluating CAM treatments and claims of therapeutic efficacy. In fact, only 8.2% of the respondents specifically mentioned that they included topics about evidence-based medicine in their courses. This may reflect the fact that most of the courses (78.1%) were taught by practitioners or prescribers of unconventional therapies. Although an instructor’s use of a CAM therapy does not necessarily imply uncritical advocacy, it does imply that he or she believes a particular CAM treatment modality to have genuine merit. In this situation, then, the instructor may be less inclined to impart a critical perspective based on accepted standards of scientific evidence. Whether our findings truly reflect the state of CAM instruction nationwide is uncertain, but the apparent lack of a critical approach by most of our respondents is cause for concern.
Indeed it is. In essence, what we have are practitioners of non-evidence-based medicine teaching the next generation of medical students uncritical acceptance of their favored woo. If Saxon et al (the second paper) are to be believed, the situation is even more disturbing in osteopathic medical schools:
Although we found that CAM instruction at osteopathic and allopathic medical schools was on the whole similar, there were a few notable differences (Table 2). For example, courses with CAM content were twice as likely to be required at osteopathic medical schools than at allopathic medical schools. This may indicate a greater commitment to CAM education at osteopathic medical schools, but could just as easily reflect the incidental inclusion of CAM topics into several required courses of the traditional osteopathic curriculum. Another difference is that most CAM instruction at osteopathic medical schools occurred during the first 2 years, whereas CAM instruction during the third and fourth years was relatively uncommon. By contrast, the teaching of CAM at allopathic schools was substantial during the third and fourth years.7 In general, these data suggest that students at osteopathic medical schools are more likely to be exposed to CAM in required coursework during the preclinical part of their training, whereas students at allopathic medical schools tend to learn about CAM in elective coursework taken during the clinical years.
Sadly, this teaching seems to be having an effect. There is at least some evidence that far too many medical students appear to be enthusiastically embracing non-evidence-based CAM therapies, as was reported by Chaterji et al in 2007, in which they found that 91% of medical students agreed that “CAM includes ideas and methods from which Western medicine could benefit.” (I wonder what ideas those are. The concept of qi, the magical life force that, it is claimed, various therapies can manipulate to therapeutic intent, perhaps? But that’s just the nasty skeptic in me speaking.) Even taking into account the journal in which this study was published, which is an “alternative medicine” journal, its conclusion is worrisome:
Interest in and enthusiasm about CAM modalities was high in this sample; personal experience was much less prevalent. Students were in favor of CAM training in the curriculum to the extent that they could provide advice to patients; the largest proportions of the sample planned to endorse, refer patients for, or provide 8 of the 15 modalities surveyed in their future practice.
I fear that this conclusion may well be fairly close to the truth.
What I fail to understand is why there is even the concept of CAM to begin with. I view the distinction between “conventional” medical therapy and “alternative” medical therapy to be a false dichotomy used as an excuse to give an appearance of respectability and scientific validity to therapies that have failed to earn either the same way “conventional” medical therapies have to earn them, through science and clinical trials. The real dichotomy is between therapies that have scientific evidence to support their efficacy in treating specific disease and those that do not. As a supporter of evidence-based medicine, I would be perfectly happy to embrace any therapy for which there was compelling scientific and clinical evidence for efficacy. Believe it or not, I’d even embrace a concept as ridiculous as homeopathy appears to be now if compelling evidence in well-designed clinical trials showed that it had an effect over that of a placebo. In other words, I do not accept the concept of “alternative,” “complementary and alternative,” or “integrative” medicine. In fact I reject them. To me there are only two types of medicine. There is medicine that is not evidence-based, and there is medicine that is. I choose the latter. Unfortunately, medical schools seem to be becoming all too receptive to promoting the former, and, if the discussion after the articles is any indication, a depressingly large number of medical students are lapping it up.
