Mar 11 2010
My previous posts have described guest lecturers at my medical school campus, invited by a student interest group in CAM. Those events continue; currently ongoing is an 8-weekend certification course in Ayurveda for the subsidized cost of $1500 (includes “tuition, syllabus, and personal guru”). I could pick on this student group, but what’s the point? There will always be medical students who organize to promote ideas that you or I disagree with, whether it be political, religious, or personal. The fact that Tim Kreider disagrees with a particular student group is not terribly interesting.
The more important issue is how CAM is treated by faculty in the curriculum. Particularly during the preclinical years, medical students are in the habit of transcribing and commiting to memory everything uttered by the professors who grade them. A lack of rigorous skepticism is frankly necessary given how much information we are required to master. Where would CAM fit in among the lectures on anatomy, physiology, and pathology?
This post describes a lecture to the first-year medical students given by a respected faculty member and high-ranking administrator at my university, whom I will call Dr. P. This lecture was a mandatory part of the core curriculum. Dr. P comes across as an intelligent, reasonable, sincere, caring, and competent physician. It just so happens that he reaches some very different conclusions on questions of CAM than do I and my role models on this blog, and these conclusions have led him to become director of CAM programs at my university and a major player in the integrative medicine movement nationally. This post and my next will attempt to summarize how Dr. P presents his message when he has an entire medical school class for an audience.
[A note on my anonymization of Dr. P: my goal in writing for SBM has never been to bring bad publicity to my medical school, which is a terrific institution in most ways that matter to me. Identifying Dr. P would make my university affiliation obvious. I write not to call out a particular professor or program or university but rather to illustrate from a student's perspective a situation that may be increasingly common at US medical schools. Feel free to criticize my decision to keep him anonymous for now, but please honor it by not naming him in the comments, if you know his identity.]
Dr. P stressed throughout his lecture that he is not trying to advocate specifically for CAM use. In fact, he dislikes the label “alternative” because it implies abandoning “conventional” medicine. Instead he is promoting “integrative medicine” (IM), which he described as “the practice of medicine that reaffirms the importance of relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health.” (quoted by him from a consortium of IM programs) This definition by itself sounds eminently reasonable and completely consistent with everything we are taught about compassionate, professional, evidence-based practice. Indeed, after presenting this definition Dr. P said, “it isn’t different from what we do in conventional medicine.” So why do we need IM at all? Do we need a new label and concept for something we agree is already our goal? Dr. P insisted that IM is not simply a re-branding of CAM, as he knows we skeptics suspect, but rather a more open-minded and inclusive approach to care that may or may not involve particular aspects of CAM. My concern with IM, as I will describe, is that Dr. P and I seem to have different thresholds for what kind of evidence is compelling in determining an appropriate therapeutic approach. All the changes in labeling seem to me, in my most cynical moments, to be little more than a savvy marketing strategy.
Part of IM is attention to spirituality, by which Dr. P means not religion but rather values and sources of meaning. Dr. P shared with his audience that he derives personal meaning, for example, from his family and children, and he described how he engages his patients in discussions about what is important to them. Such talks, he told us, can be particularly helpful in establishing a therapeutic relationship and plan in the face of chronic or life-threatening disease. Dr. P spoke eloquently and compellingly here, and these segments of his presentation could easily fit into separate sessions on these topics that we have throughout med school. But what, I wonder, does this have to do with CAM, and why do we need IM in order to promote such discussions? This common conflation of CAM with humanism contributes to my suspicion that physicians who embrace CAM do so not because they reject science—Dr. P is a smart guy who understands statistics and methodology—but rather out of objection to the business aspect of medicine or to problems with its delivery in our current system.
Another confounder, in my opinion, is preventive care. Dr. P is a practicing internist, but both his graduate training and his academic appointments also involve preventive medicine. Part of the appeal of his message about IM is how it is wrapped up in a concern for improving disease prevention and health maintenance in primary care. I agree that this concern is a laudable goal and hopefully an uncontroversial one. What frustrated me was how Dr. P explicitly condemned “conventional medicine” for ignoring preventive care, even to the point of saying that most docs “just talk” about prevention rather than really do it! (I was stunned by this casual dismissal, particularly given that our school has faculty who actively combat lead poisoning, vitamin D deficiency, and low vaccination rates in our community, just to name a few initiatives.) Although it may be that such sentiments on crank websites reflect theoretical disputes over “true cause” of disease, I suspect that the issue for most IM-sympathetic physicians is rather the practical constraints and financial incentives that restrict physician-patient interactions. I am happy to discuss ways that physicians could more effectively promote good nutrition, exercise, and stress management. Can’t these system problems be addressed without using language about “alternative” approaches that opens the door to implausible therapies?
Dr. P introduced CAM using the NCCAM categories: alternative whole medical systems (naturopathy, Ayurveda, TCM); biologically based practices (herbs, supplements); energy therapies (Reiki, Qi Gong, TT); manipulative and body-based practices (chiropractic, massage therapy); and mind-body medicine (Yoga, meditation). His language while describing these categories was most instructive, as he refrained from making specific claims that I might offer for evaluation. He described energy therapies and alternative systems as the categories most “foreign” to our “Western” approach, whereas I would say they represent pre-modern, magical thinking that limits their value. He made the important distinction between modern DO physicians (like MDs) and osteopathic manipulation (like chiropractic), and I noticed at that point that he almost said “allopathic” before correcting himself with “conventional.” (Another deliberate marketing strategy, perhaps?) He warned us about the challenges of quality assurance and unsupported claims that plague the unregulated supplement market, though he seemed more optimistic than I about finding diamonds in that rough. He said that mind-body techniques are the “most integrated” of the CAM modalities, meaning most supported by evidence, and he seemed more impressed by their effects on psychological stress and wellbeing than purported physiological effects. The impression he gave while discussing these general types of CAM was not of an ideological booster but rather of an open-minded investigator, whose only fault might be too much hesitance to conclude that a CAM modality is worthless. He comfortably points out weaknesses and challenges while remaining enthusiastic overall.
Following the categories, Dr. P showed a few photographs of examples of CAM. He reminded us that his goal was not to teach or encourage CAM but rather to make us aware so that we can respond appropriately to patients. Photo and description of acupuncture, of course. At a photo of a child’s back covered in horrible bruises he told us that if we didn’t know about the alternative practices of “cupping” (e.g.) and “coining” (e.g.) we might mistake such marks for child abuse… Again, my interpretation differs: although I agree that knowledge about culturally-specific practices is helpful for interventions, I might argue that injuries without benefit are indeed a form of abuse, no matter how well-intentioned.
Dr. P made one of several valiant attempts at audience participation by soliciting any family or folk remedies that we had encountered at home. Crickets chirped as students kept quiet in front of 180 peers. One brave soul volunteered that his mother swears by Airborne, which got no reaction from Dr. P. (I suspect he was hoping for a remedy not quite so laughable.) Dr. P suggested as an example the common use of prunes for constipation and pointed out that we are unlikely to see anyone fund a randomized, controlled trial (RCT) for that indication. Fair enough. Failing RCT evidence, continued Dr. P, we need to look for other supporting evidence. As an example of such non-RCT evidence, he showed the abstract from a 2000 Chest publication describing an inhibitory effect of chicken soup extract on neutrophil chemotaxis in vitro, as support for grandma’s home flu remedy. While this “chicken soup for the cell” (my snarky phrase, not his) is amusing and perhaps intriguing, I cannot fathom how this level of evidence meaningfully influences clinical decision making, beyond being an excuse to give advice that we might give anyway. While the goal of this presentation was explicitly not to detail the evidential support for any particular CAM, I was disappointed that such a lame example was given. Even if I buy it, though, how does the efficacy of chicken soup for a cold have any relevance to homeopathy? Here is a danger of accepting a garbage pail category like CAM as a coherent discipline, in my opinion.
What followed next was an extended appeal to popularity, not necessarily to claim that CAM is useful per se or that we should embrace it in our practice, but at least to convince us to take it seriously as something our patients may use or want. Dr. P cited the 1993 NEJM survey that reported CAM use by 34% of Americans (see Dr. Crislip on this oft-cited report). Discussing the results of this and later surveys, Dr. P suggested that changes in relative rankings of modalities reflected rational responses to evolving evidence, specifically a fall in the popularity of Echinacea and spinal manipulation for head colds following negative RCT evidence. He showed a New York Times article describing how alternative medicine is popping up in US hospitals, though to my reading the article paints hospitals more as selling out and cashing in than as thoughtfully adopting newly proven practices. For the second time, Dr. P mentioned the consortium of 40+ medical schools with IM programs (including Harvard, you know). He noted 2006 Resolution #306 of the American Medical Association, which recommended promotion of physician awareness of the “benefits, risks, and evidence for efficacy or lack thereof” of CAM (see the students’ initial proposal and then search for the watered down amended version here), as well as practice guidelines for addressing CAM use in lung cancer patients prepared by American College of Chest Physicians.
Dr. P seemed to be familiar with common objections to his support for CAM, and he tried to deflect them by telling us how difficult it is to rely only on solid RCT evidence in practice. He readily admitted that much CAM research has methodological flaws, and he explained that many CAM therapies are too individualized for conventional study methods. Dr. P pointed out that only 20-30% of conventional medicine is based on RCTs, anyway. Although we are “focused on evidence” at this stage in our training, he said, later on we’ll see that physicians have to do the best they can with limited available evidence. I commented in my notes at this point that some of his reflections on the limitations of EBM seemed similar to what I read on SBM… though given the different verdicts reached on CAM, it seems that IM and SBM fall back on different sources of evidence when the RCTs are inconclusive!
Dr. P’s message to us was to be open and non-judgmental to patients who use CAM, which of course is appropriate. He did not counsel us to practice any CAM that we do not first specifically obtain training in, but rather to consider referring patients to qualified CAM providers when necessary. He described doing literature searches to answer patient questions, such as whether acupuncture might help with in vitro fertilization. I am sure that Dr. P is a great physician to have if you are a patient who wants CAM; so long as your desired CAM is not harmful and does not replace proven, needed care, he is willing to work with you. While that attitude may be valuable in a particular context (keep the patient happy in order to ensure she gets “conventional” care along with the CAM), I find myself wishing that Dr. P would admit that some of CAM is frankly nonsense and that not every proposed CAM indication deserves research. At least to us, if not to the patient in his office.
This talked was billed as a general introduction to CAM and IM, given in order to help us be more receptive to patients’ beliefs and practices. The details of or evidence for specific CAM modalities were not discussed, rather the field was painted with a broad brush as probably harmless and sometimes effective and increasingly evidence-based and, by the way, very popular. The presentation also conflated CAM use with compassionate and preventive care; if this is a deliberate tactic to win acceptance, it is a savvy one. The talk seemed like it would be quite attractive, or at least not at all objectionable, to a shruggie. I could not help but notice, however, that although Dr. P did not dwell on the more outlandish CAM modalities (homeopathy, Reiki), he also refrained from saying anything critical of them. He was very careful and seemed quite reasonable, making it difficult for me to offer specific criticisms despite leaving the lecture with a sense that he and I would disagree on much.
My next post will cover Dr. P’s lecture to second-year medical students on CAM, ethics, and the law. That lecture offered a little more insight than this one in how Dr. P thinks differently than some of us do on questions of CAM usefulness.
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