Focus on Alternative and Complementary Therapies
www.pharmpress.com/fact
Focus Alternat Complement Ther©2005 Pharmaceutical Press
Focus Altern Complement Ther 2005; 10: 101–3
David Colquhoun
CAM is big business, and many patients are interested in it, so medical students must know something about it. They should be taught about CAM in exactly the same way as they are taught about all the other subjects they must master: the aim in all of them must be to enable the student to distinguish between truth and fiction. That is not as easy as it sounds because medicine as a whole has a long and distinguished record of the propagation of fictions. Within my lifetime ‘tonics’ (often with nux vomica, i.e. strychnine) and ‘demulcents’ were widely prescribed. Now the very categories have vanished.
It is unimaginable that, 400 years after Galileo, we should find it necessary to have departments of evidence-based physics. The idea is quite laughable. Yet it has been necessary to found departments, and journals, of evidence-based medicine, as opposed, presumably, to myth-based medicine. This, I take to be a residual sign of the recent time when medical people were commonly as authoritarian as Cardinal Bellarmino about what was true. Let us assume, though, that this age is passing. The generous view is that the backwardness of medicine in distinguishing truth from fiction is because it is surprisingly difficult to do so (and can sometimes be hindered by the suppression of relevant data for financial reasons). Vigorous arguments still rage about whether or not serotonin reuptake inhibitors are really much good as antidepressants, despite considerable efforts to find out. Much of the lore of physiotherapy is as untested as homoeopathy. And if it is hard to find out whether or not conventional medicines work, where real efforts are made, it is much harder to know whether or not CAM treatments work, where rather fewer efforts are made to find out. It is not as though we did not know what to do. A House of Lords report said clearly what should be done, the government gave some money to do it, but sadly the Department of Health allowed the money to be hijacked for other purposes.1
Thus, the first thing that medical students need to be taught is that it is very hard to assess whether or not any sort of treatment is really effective. They must also be told that the efforts made by CAM practitioners to tackle this difficult problem have been wholly inadequate. For this reason, teaching about CAM cannot be done by those who make a living from it; their vested interest is too great, and their knowledge of statistics almost always too small.
The second thing that medical students need to be aware of is the dilemma that is posed by placebo effects. It seems very likely that patients with terminal cancer do indeed feel better after reflexology treatment. From the point of view of the patient, it does not matter a damn whether it is a placebo effect or not. Of course it is very likely that any old foot massage, or just a good chat, would be as effective. But, guess what? Nobody knows. The placebo effect may not be a problem for the patient, but medical students must realise that is a big problem for them, and for universities. In susceptible patients it would not be surprising if the size of the placebo effect were maximised by incorporating as much mumbo jumbo into the treatment as possible. But mumbo jumbo means lies, and that is contrary to all the admirable efforts that have been made recently to make the medical profession more open, more honest and less authoritarian with their patients. Yet, the more lies, the better the placebo effect. That is a dilemma that has not yet been resolved. Indeed it is now considered unethical for a medical practitioner to knowingly prescribe a placebo since patients must give informed consent to treatment. Informing the patient that a prescription is a placebo would tend to destroy the placebo effect (a blinded clinical trial is different because the patient does consent to the chance of receiving a placebo). Of course there would be no dilemma if proper experiments had been done, but by and large they have not. If, as one might guess, foot massage or chat is as good as reflexology, then we should provide foot massage or chat. Without knowing what is true, we risk telling lies to patients, and we risk universities being pressurised into teaching degrees in the mediaeval mumbo jumbo of reflexology. That is why I think it is quite wrong for Peter Fisher2 to say (in a report on the ineffectiveness of a homoeopathic treatment for rheumatoid arthritis) ‘It seems more important to define if homeopathists can genuinely control patients’ symptoms and less relevant to have concerns about whether this is due to a “genuine” effect or to influencing the placebo response.’ Truth does matter.
CAM advocates are fond of portraying themselves as being persecuted by an intolerant establishment. While it is perfectly true that a few great ideas have been denounced as crackpot when first suggested (before the evidence became compelling), it is also true that the vast majority of crackpot ideas are simply crackpot. ‘Alas, to wear the mantle of Galileo it is not enough that you be persecuted by an unkind establishment; you must also be right.’ (Robert Park, of the American Physical Society).
Marja J Verhoef
Without hesitation, I advocate that medical students should be taught about CAM. This recommendation, however, is not novel and there is substantial information to support it, including:
It is obvious that public demand for CAM cannot be the primary factor that drives the kind of care physicians provide to their patients. Nevertheless, the lack of physician knowledge about CAM (and sometimes lack of willingness to discuss CAM with their patients) reflects and perpetuates a communication breakdown in an area where communication is vital to appropriate healthcare provision. Thus, it is critical for physicians to acknowledge and respond to their patients’ healthcare questions and decisions in an appropriate and non-judgemental manner. However, concern has been expressed that the presentation of information about CAM in medical school courses may be construed as an endorsement of the use of CAM therapies.9 In light of this and other issues, I would argue that the debate is not about whether or not students should be taught about CAM, but rather what should medical students be taught about CAM, who should teach medical students about CAM and how should CAM content be introduced into existing undergraduate medical curricula in an unbiased way?
In the English published literature, there are reports that many medical schools in the USA,10 Canada,11 and the UK12 currently offer CAM teaching within their undergraduate medical education (UME) programmes. It is likely that the current numbers of schools providing CAM education are higher. There is ample literature documenting ‘practical steps toward the inclusion of CAM’ in UME13 as well as medical school websites documenting their CAM programmes.14 While there is still considerable variability in the depth and breadth of CAM teaching at different medical schools, most provide students with information that will help them (i) understand why many patients choose CAM and (ii) prepare for discussions of CAM use with patients.
The general guiding principles for a nationally based project in Canada to develop CAM curricula for UME15 include:
The intent is not to present a wholesale endorsement of CAM in general or of any specific CAM products and practices or not to teach medical students how to practice any specific therapies.
Medical school curricula are continually being expanded and restructured to reflect changes in the current state of evidence, and in the philosophy and principles guiding the planning and delivery of health services. In order to make medical education and medical practice relevant to the needs of the population, medical schools must recognise the range and diversity of health services and health-related practices that are being used.
In order to incorporate CAM teaching within medical school programmes, many logistical challenges need to be overcome, including establishing (i) administration approval, (ii) time in the curriculum, (iii) valid teaching resources and (iv) knowledgeable instructors. However, these barriers are not insurmountable. It is essential that medical school faculties trying to incorporate CAM education into their curriculum look closely at the pedagogical philosophy and course content as well as the evidence base on specific CAMs to see how they can best be integrated.
In closing, in order to ensure patient safety, the medical education system (and regulatory system) needs to acknowledge and confront the reality of CAM use; an obvious, albeit challenging start is to target the beginning of medical education (i.e. undergraduate medical education). Medical schools need to be socially accountable to the values, attitudes and health concerns of the general public, a point that has been recently expressed by the WHO and underscored by the Association of Faculties of Medicine of Canada and Health Canada.16 The introduction of CAM-related content into medical school curricula is an important step towards this goal and in the evolution of medical education.
