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How I would run the CAM club

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.

Posted in: Science and Medicine

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17 thoughts on “How I would run the CAM club

  1. daedalus2u says:

    I would start with the standard med school classes. If you are going to practice holistic medicine, you have to know how to do everything including all that easy, boring materialistic and evidence based science. The SBM stuff is easy, it can be taught, it can be measured, it follows logically from facts. It is the same all around the world. Teach them the easy stuff first.

    Once they have the easy stuff down pat, then you can start teaching the stuff that can’t be measured. Stuff like homeopathy that is so difficult that no one understands how it could possibly work. Stuff like reiki, where the first person to figure out how it really works and reliably teach others to use it at will, will get a ticket to Stockholm. The first one to reliably cure cancer with colon flushes will too.

    With any luck, once you teach them the easy basics of SBM, they will know exactly what to do with all the CAM ;)

  2. Basiorana says:

    I agree with daedalus2u. Start by teaching SBM, then branch out. Or maybe say only second-years and beyond can join/attend, so they hopefully know what SBM is coming into it.

  3. @daedalus2u and Basiorana

    At least at my institution (and I would bet, at Tim’s) The problem is that SBM isn’t really an organized part of the curriculum in the first two years. Oh we talk about randomized controlled trials for a few diseases. We get the odd statistics lecture. Once in a while we have presentations where we need to cite a few studies.

    But we don’t get organized lectures on how to find and evaluate research pertaining to our studies. We don’t get lectures on how to reject bad practices. We don’t get lectures on the process of science. I think that’s key. If you don’t understand the process of science, you won’t understand why your clinical experience doesn’t prove that you’re a magnificient healer.

    Incidentally Tim, I’m really impressed with your writing, and your gutsyness. I personally don’t have the stones to blog out in the open at the moment.

  4. SGNeill says:

    At my institution (from which I am graduating in 3 days, hurray!) we were given an EBM course that stretched through the M1 year. It was reasonably comprehensive, but it included little in the way of statistics beyond the very basics. During the 3rd and 4th years students attended several Journal Clubs on the various rotations, but there was no integrated effort on the part of the school to build on the M1 course.

    On the CAM side, we were given some guest lectures on one or two days from local chiropractors, acupuncturists, and the like. The invited speakers ranged from non-scientific shamanistic practitioners to MDs who do acupuncture on the side. There was no institutional effort to either integrate CAM into the curriculum or specifically denigrate it.

    The curriculum changed two years after I was admitted, and I am unsure as to how the situation has been addressed since that time. I’ll have to inquire a bit, as I’ve only recently reacquainted myself with my inner skeptic (I read the HuffPo long enough to realize that CAM is a bigger deal than I thought). Fortunately I’m sticking at the same institution for residency so I’ll have a chance to follow along.

    Tim, I think what you’ve written is pretty good, and not a bad way to approach teaching CAM from the perspective of a medical school. We (medical students) will have to know some of these things as we move into practice, not least because our patients will want us to know about them.

  5. Versus says:

    A thoughtful, well-written post. I like your categories — they are certainly more descriptive and accurate than the ones NCCAM uses.
    I wish someone would come up with other names for “CAM” and “integrative medicine” that we could all use and which would catch on with the public–preferably names without the word “medicine” in them because it lends an unwarranted air of legitimacy, as has been discussed on SBM. Perhaps SBM could sponsor a contest.

  6. Joe says:

    @Versus, I second what you wrote. I confidently offer the winning substitute for CAM- quackery. What do I win?

  7. Newcoaster says:

    A good post. I certainly wish I had learned more about sCAM during medical school, but at the same time, I’m glad my institution never drank the KoolAid. We did learn about some cultural practices…such as “cupping” in TCM…just so we wouldn’t think the kids had been abused if we saw welts over them in the pediatric clinics.

    I first heard about Therapeutic Touch my first day as an intern on the medical ward when the head nurse that was with us on rounds mentioned that she had performed TT on a patient. When she explained what TT was, a couple of us burst out laughing…needless to say, she made my life miserable the next 8 weeks.

    I like your categorization idea. One of the main ways sCAM has been insidiously creeping into the mainstream, is by the use of non-threatening terminology. The latest being “integrative”.
    The all inclusive umbrella of CAM does seem to give equal weight to complete nonsense like homeopathy, as to plausible things like various herbal treatments. Singh and Ernst break things down similarly in their book “Trick or Treatment: Alternative Medicine on Trial”

    I still prefer the (slightly) insulting sCAM (so called alternative medicine) because I think it is the most factually accurate, as well as being a handy acronym, but I realize the use of that term doesn’t really help win friends and influence people who have health beliefs that are not science or evidence based.

    My approach with colleagues who are into sCAM is much more confrontational than with patients. I have had a few loud arguments at staff meeting with a local GP who is into crystals, auricular accupuncture AND Healing Touch (a woo trifecta, if you will) Doctors should know better, so I have less patience when they drink the KoolAid. Of course, Michael Shermer in “Why People Believe Weird Things” did explain why smart people believe weird things…its because they are smart, they assume they can’t be fooled.

    I’m not sure what is being taught to med students at our local institution, but when the students rotate through our hospital for their “rural experience”, I do try and engage them on the topic, as our little sleepy resort town is a hotbed of alternative healers.

  8. Esattezza says:

    Here’s my question: why teach CAM at all? By definition, CAM isn’t accepted by the scientific community. Now, with that statement I’m not saying that the scientific community is biased against CAM, rather, once CAM is accepted by the scientific community it – by definition – stops being CAM.

    When someone says that such-and-such herb cures whatever illness, it’s CAM, nothing more than a folk remedy. As soon as randomized, controlled trials are done and science determines that that herb really does help that illness, it goes on to determine what chemical in the herb does what and makes it into pill form. Guess what, now it’s not CAM anymore!

    CAM is always one of two things: 1) hypotheses that want to be “real” medicine when they grow up )no matter how much their proponents disparage SBM) or 2) pure quackery (a nod to Joe) that should be called as such.

    If you want to teach about those CAM remedies that might have some benefit, it should be treated in the same way as off-label drug use or experimental procedures – to be used only as a last resort, as it is unproven.

  9. overshoot says:

    Here’s my question: why teach CAM at all? By definition, CAM isn’t accepted by the scientific community. Now, with that statement I’m not saying that the scientific community is biased against CAM, rather, once CAM is accepted by the scientific community it – by definition – stops being CAM.

    Because the pay is good, both for the University and for the practitioners. No insurance companies to argue with, no Medicare-set reimbursement rates, patients willing to plonk down cold hard cash, and wealthy donors willing to write honking checks to the med school. Double that last if they can get their names on something.

    And, no, this isn’t cynical disillusionment. You do what you have to to keep the doors open until you can’t stand to look yourself in the mirror. I’ve spent years worrying about whether my kids would be able to afford college and more than once where their next meal was coming from.

  10. karenejames says:

    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.

    In my observation of well-meaning buyers-in of woo, too.

  11. @Esattezza

    I second whoever said money. My institution is a member of whatever that CAMWOO coalition of medical schools is called. They get a significant amount of “research” dollars, of which the school exacts a pretty hefty cut.
    The CAM’ers who are getting that money want in on the medical education. It’s not be a strict quid pro quo for them – grant money for teaching time. But at the same time, once you’ve accepted them as professors and researchers, it’s hard to keep them out of the classorom.

  12. Esattezza says:

    *hangs head* It’s so unfortunate that false hope and fake medicine are sold as a package deal. You know… I love capitalism, really, I do, but it doesn’t work so well here for some reason.

    People listen to consumer reports when they but computers, which they don’t understand the inner-workings of, why isn’t it the same as medicine? Although, I suppose not all people listen to consumer reports… half of my friends have apples because they’re “sexy”. Of course, they’re lucky because macs are also pretty nice pieces of machinery. However, if it turned out that their sexy computer was junk, it’s not the end of the world. They’re out a couple hundred dollars, never buy one of those computers again, word spreads, and the company goes out of business. Not the same in medicine. If you use medicine based on junk science and it goes badly, you don’t often get a second chance to make an informed decision.

  13. Basiorana says:

    [quote]“Here’s my question: why teach CAM at all? By definition, CAM isn’t accepted by the scientific community…”[/quote]

    Every school needs to prepare doctors to face alternative medicine. They shouldn’t TEACH nonscientific healthcare, but doctors need to know the philosophies behind homeopathy, naturopathy, and Ayurveda; they need to know the studies. I’ve had many friends who were lured in by various alternative treatments. One notable case– I knew a girl who took homeopathic cold treatments. I asked her about it. She said it seemed to work. I asked how it could work, and she said she didn’t know, it was a medicine. So, I sat her down, explained to her the law of similars and water memory and told her exactly how they make homeopathic treatments. By the time I was done she was kind of looking at me in horror and said something along the lines of good lord, people actually believe that works?

    The truth is, most people who take these medicines, if you explain to them exactly how they are SUPPOSED to work under the philosophy, they will realize they aren’t based in reason. Tell the average American how Ayurveda is basically similar to the principles of the four humors and they’ll never touch the stuff. A doctor, nurse, whatever has a powerful ability to teach patients how to care for themselves. If you teach the doctor the full truth, they will never believe it, and if they then teach the full truth to their patients, their patients will only believe it if they are truly deluded, completely uneducated or have been 100% brainwashed into believing it. My fiance has never taken a hard science course, even in high school, and he understands that Ayurveda, Unani, and homeopathy could never work with only the most cursory explanation of the principles behind them. It takes more work to explain why things like acupuncture are ineffective but for the big ones, all you have to do is tell them all of what the practitioners believe.

    Considering that the physician’s job is to guide the patient to better health, being able to teach them why alternative medicine is bad is a powerful thing.

  14. Mandos says:

    When someone says that such-and-such herb cures whatever illness, it’s CAM, nothing more than a folk remedy. As soon as randomized, controlled trials are done and science determines that that herb really does help that illness, it goes on to determine what chemical in the herb does what and makes it into pill form. Guess what, now it’s not CAM anymore!

    This is exactly what CAMists complain about. As the Barad-Dur of CAM blogs quoth:

    Then there is the potentially ugly mis-step of the name change proposal from NCCAM to National Center for Integrative Medicine (NCIM). This would be a step backwards. We would thus centralize this version of healthcare alternatives in a single medical guild which has a crappy history of sharing. That this isn’t empty talk. Case in point: Take a listen to the hearing. Check whether any of the MD speakers even note the licensed complementary and alternative healthcare practitioners on whose backs this movement was based. (And I challenge any of them to a debate on whether or not what i have asserted is so.) All favor including conventional allied health practitioners who were in their club prior to the advent of this entire dialogue. And c’mon, the focus we need is on health. Let’s put it in the name. Credit the voice from the crowd who suggested National Center for Integrative Health Care.

    I see two clear goal emerging for organizing. One is to make sure that, if there is a name change at NCCAM, it is a name that underscores the paradigm shift to health and the diversity of professions involved in leading the effort toward health. The second is the push to create on Office of Wellness to gain some foothold for this concept and not have it drift off as an dried up artifact of the early days of the Obama heaklth reform. Those with long memories will known that the Clinton reform effort, 15 years gone, included many very sublime and fetching, paradigm-shifting ideas, that went nowhere. I remember. I fell for them.

    And, more importantly, this bit:

    Particularly nasty is the intellectual slight of hand by which an “alternative” therapy is first derided for having no support then, once if it gains support, this practice becomes “scientific medicine” which allows them to continue to deride all the rest of “alternative medicine” as having no support. Say what?

    The intended implication being that if one treatment from an alternative system works, you should accept the entire system, because it is part of an Integrated Whole. To do otherwise is a form of imperialism, selon lui.

  15. Dacks says:

    @ Basiorana,
    I agree. Doctors need to be familiar with what their patients are taking or doing in terms of alternative treatments. Most people take information from a doctor quite seriously; if a patient mentions a dubious treatment it is an excellent opportunity to talk about the reasoning behind medical recommendations. And it reinforces the doctor-patient relationship if the doc has some real knowledge about the more common supplements: why people take them and whether there is any basis for their beliefs.

  16. Jules says:

    Excellent article, Tim.

    I have to agree that there’s a lot of good stuff lumped in under CAM to wholly dismiss it from the field of medicine, but at the same time, I despair of it ever getting its dues. Nutrition and exercise certainly aren’t emphasized in coursework, but it is hard to make definitive recommendations because the studies that are done are so limited–and contradictory. The only “safe” thing to say about these two is “everything in moderation and nothing to excess”, but of course “moderation” for an overweight smoker of 45 is quite different from the moderation a world-class Ironman athlete subscribes to.

    I am hopeful that the careful study of some herbal medications will grant the field more respect than it currently gets, and I think that the advent of personalized medicine will reveal that some herbs currently considered under “quackery” will actually be shown to be useful for people with Biomarker X.

    I cannot tell you how much it irritates me when the parts of CAM that can be scientifically validated get lumped under the same umbrella as homeopathy or reiki (though, I must confess, a foot massage does feel something wonderful). It’s almost as maddening as when people write about yoga as some mystical belief system without taking into consideration that it can be a very effective exercise, even without talk about prana.

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