During the past academic year, I have written about CAM on campus for my student newspaper and fancy myself now somewhat notorious among the students who care about the issue. My article in the fall issue was a review of a homeopathy lecture that I described in detail for my first SBM post. In the winter issue I discussed two dueling WSJ opinions and the silliness of the “4 in 10 Americans use CAM” argument, channeling Drs. Gorsky and Crislip. I had a piece planned to wrap up the series, but sadly the spring issue has been canceled because the rest of the editorial staff is studying for USMLE Step 1. This is life at medical school, probably not just mine but universally: huge stresses and time obligations often crowd out extracurricular activities.
I began imagining this essay, an open letter to the campus CAM advocates about how I would direct their programming, just before my run-in with a pair of students unhappy about an SBM post. Before the accusations of unprofessionalism began flying around, I was thinking about how we could find common ground. Are there aspects of CAM that even a self-described skeptic can support? Clearly everyone on campus cares firstly about providing the best possible care for patients. Could the CAM advocates and I be collaborative rather than antagonistic? Some disagreement is inevitable given that I have classmates who have taken coursework in homeopathy and integrative nutrition, but I wondered if I could offer constructive advice on improving the CAM club rather than simply dismissing it as having no place on campus.
Since the newspaper pressess are stopped until the fall, I am posting the letter here, stripped of identifiers as I remain coy about my university’s identity on this site. Please give me feedback! I am interested in your thoughts about engaging with CAM advocates beyond publically disputing their claims.
How I would teach alternative medicine
An open letter to campus CAM advocates
Labels matter. One of my issues with alternative or complimentary or integrative medicine (for ease, CAM) is that these names are not very informative. What, precisely, is being integrated? Many beliefs and practices, from herbalism to homeopathy, seem to be included under the umbrella of CAM even if their central tenets contradict each other. When such disparate modalities as acupuncture, prayer, aromatherapy, and chiropractic are lumped together and presented as “CAM,” many of us may either accept or reject CAM in total, which is inappropriate. If I were to direct campus CAM programming, I would classify CAM modalities into four (overlapping) groups: cultural beliefs, lifestyle interventions, nonstandard drugs, and alternative ideologies.
Cultural beliefs would be the easiest of my four to address and the most immediately useful to medical students. Our clinic serves patients of diverse nationalities and religions, and we would be well served by a club that taught us what traditions to expect. A lecturer on Indian or Brazilian or Haitian folk remedies could tell us which are potentially dangerous, which might cause drug interactions, and which are generally safe or efficacious. A panel on religious health beliefs could discuss how patients of various faiths interact with health care providers. Culturally-specific practices like Traditional Chinese Medicine should be explained, not so that medical students will believe in chi, but because we must be prepared to accommodate such beliefs when treating patients who hold them.
By lifestyle interventions I mean non-drug therapies related to relaxation, exercise, nutrition, and such. These practices are often included in CAM because physicians may have historically underutilized them, a point worthy of discussion. Also, given the unfortunate way physicians are reimbursed in this country, a counter-balance to the financial incentives for pharmaceutical, surgical, and radiological interventions seems appropriate. The important pitfall to avoid is basing recommendations on feel-good, New-Age, Oprah-style sentiments rather than on scientific evidence. For example, an anonymous writer in the previous issue of the campus newspaper decried our cafeteria Burger King as incompatible with our mission to improve patient health, as if removing the fast food option in the hospital would have a meaningful impact on patients’ weight control. (The writer did not demonstrate a “holistic” approach, to use the language of CAM, as he ignored socioeconomic reasons one might choose Burger King and did not consider the challenge of providing hot food to visitors and employees at very late hours.) Consider, however, a February report in The New England Journal of Medicine showing that even intensive dietary interventions had disappointingly small effects on long-term weight loss. Of course we should promote drugless medicine and public health initiatives, but only when they convincingly work in a cost-effect manner.
Herbal preparations and non-vitamin, non-mineral supplements are essentially nonstandard drugs. The difference between, say, echinacea and aspirin is simply a matter of processing and regulation; both are ultimately derived from plant products, but only one features a reliable dose of a well-characterized active ingredient. The scientific study of medicinal herbs is called pharmacognosy, and medical students would benefit from lectures by researchers in this field. Just as our pharmacology professors strive to give us PHARMA-independent drug information, the academic pharmacognosists could help us navigate the labyrinth of nonstandard drugs in the market. We need to learn which nonstandard drugs are efficacious, which are harmful, which have no activity, and—most importantly—how we can investigate for ourselves when presented with a new product. (How many of us have been offered Airborne by a family or friend and had little idea how to respond?) Conversely, a presentation by a naturopath who has both financial and ideological bias in favor of nonstandard drugs is less than helpful.
“Alternative ideologies” is my name for theories of health incompatible with modern medicine. Examples include chiropractic, homeopathy, iridology, Reiki, and anything involving chi. These ideologies all have a central tenet that must be held by faith, either a metaphysical claim like vitalism or a flat contradiction of science like homeopathic dilutions. To be fair, the practitioners are often masters of the therapeutic relationship, but this skill only raises the likelihood that many of their observed effects are placebo. Useful lectures on alternative ideologies would identify those that are frankly dangerous (e.g., anti-vaccine propaganda, autism chelation), those that are directly harmless (homeopathy, therapeutic touch), and those that can be useful albeit not for the reasons adherents believe (chiropractic for low back pain despite no “vertebral subluxations”). However, inviting an acupuncturist or Reiki master to lecture on the philosophy that guides his profession is like inviting a Merck representative to talk about a new use for Vioxx; such conflict of interest hinders critical examination of controversial claims.
A careful treatment of CAM must distinguish and critique its different components. In my observation of campus programming, faculty and student advocates of CAM speak about such critical evaluation yet paradoxically seem supportive of even the most implausible claims (e.g., homeopathic preparation of duck liver to treat influenza). As physicians-to-be, we are compelled by professional ethics to be both curious and discerning in the investigation of therapeutic interventions. Perhaps I am criticized as being too skeptical, but I worry that some campus CAM proponents are too open-minded, and neither extreme is in the best interests of our patients.
End of letter.
P.S.: I am excited to be attending the SBM conference on July 9! I hope to meet many of you there.