Mar 17 2008
The ultimate in “integrative medicine”: Integrating the unscientific into the medical school curriculum
For the second week in a row I find myself throwing out the original post that I had planned on doing in favor of a different topic. The reason this week is, quite simply, having read Dr. Atwood’s excellent two part post Misleading Language: The Common Currency of “CAM” Characterizations (Part I; Part II). I don’t at this time intend to expand on what Dr. Atwood said, although I may do so at one future time. What caught my attention in his lengthy deconstruction was his segment on the “woo-ification” of health care, which very much echoed my post a while back in which I lamented the creeping infiltration of non-science-based modalities into academic medical centers, as well as the credulous teaching of such modalities in medical schools. What I wanted to explore was just how far this might go and what the end result might be. It turns out that we are already witnessing an experiment in just such a thing.
About a year and a half ago, I first became aware of just how far this infiltration of unscientific “medicine” has infiltrated academia when I saw this brochure published by the Georgetown University School of Medicine. If you’re scientifically inclined, as I am, it ought to make you shudder. Reading this brochure, I truly have to worry whether woo really is the future of American medicine, as has been suggested in some quarters. Certainly, if other medical schools start following Georgetown’s lead, it will be. Not content to offer so-called complementary and alternative medicine (“CAM”) modalities as part of electives that interested students can take if they are so inclined, Georgetown is taking the next logical step that I feared: It’s dedicating significant educational resources and time to teaching “CAM” in its mandatory general medical curriculum, where every student has to learn it:
Figures on how medical schools are introducing CAM education are less definitive. Another study published in JAMA in 1998 reports that 75 of the 117 participating U.S. medical schools offer CAM elective courses or include CAM topics in required courses.
“One of the reasons CAM is usually offered as an elective is that there’s just no time or room in U.S. medical schools to fit in one more massive subject,” says Michael Lumpkin, Ph.D., professor and chair of the department of physiology and biophysics at Georgetown. “When the course is an elective, a self-selected group – maybe 10 or 20 students in a class of 180 medical students – will take it,” Lumpkin says. “What we’ve tried at Georgetown is rather than create all new courses, we take relevant CAM issues and modalities and weave them seamlessly into existing courses.
The “seamless” weaving of CAM into existing classes includes, for instance, a presentation by an acupuncturist on the “anatomy of acupuncture” in the gross anatomy course for first-year students. The same lecturer explores acupuncture’s application in pain relief in the neuroscience course…
Haramati and Lumpkin say Georgetown’s program is distinct from CAM initiatives in other medical schools in two ways: The school is integrating CAM education into existing course work across all four years of each student’s medical education, and the initiative includes a mind-body class to help students use techniques to manage their own health and improve self-care.
Teaching the “anatomy of acupuncture” in formal anatomy classes that every medical student has to take and pass? Great. Heck, why not teach “intelligent design” creationism in basic biology classes while they’re at it? It would be the same idea: Mixing nonscience with science. Next they’ll be teaching Samuel Hahnemann’s “principle of similars” and concept of homeopathic dilution in biochemistry and pharmacy classes! Or maybe they’ll teach about qi in physiology or neurology. In fact, Georgetown’s program is actually coming close, as it is teaching a veritable cornucopia of unscientific methods: the anatomy of acupuncture; stress hormone modulation in physiology; “mechanisms” of acupuncture action in neuroscience; and psychoneuroimmunology in immunology courses. In fact, it’s worse than that. Not only is this sort of material being taught in elective courses, but it is being “integrated” into every aspect of every year of the four year curriculum:
The first year will include an introduction to CAM practices in ambulatory care. In the program’s second year, Georgetown aims to double the number of mind-body session groups and introduce CAM-related issues in lectures in the pharmacology, microbiology, and pathology courses in the students’ second year of medical school.
A CAM elective will also be offered to fourth-year students. Between year two and three of the program, a biomedical research component for students will be introduced; in the remaining years, CAM will be further integrated into the rest of the preclinical courses and most of the clinical clerkships.
“We welcome the medical students to participate with us in conducting those research projects,” Lumpkin explains. “If students get involved in these research projects, it will allow them to go to the cutting edge of CAM. They will become the thought leaders in this field.”
In other words, they will become advocates for non-science-based medicine–exactly what medicine doesn’t need. This is ironic, given that it has been pointed out that “CAM” is actually losing favor in China, where many of the concepts of traditional Chinese medicine that underlie large swaths of alternative medicine originated. Here the same concepts are taking over the medical school curriculum. Here are the principles behind the project:
1. Aim CAM curriculum at all students through required courses.
2. Integrate material into basic science courses. For example:
Gross Anatomy: anatomy of acupuncture
Human Physiology: biofeedback, neuromuscular manipulation
Human Endocrinology: stress hormone modulation (relaxation response, meditation, imagery, breathing regulation)
Neuroscience: mechanisms of acupuncture action
3. Begin on the first day of school, if possible.
4. Address knowledge, skills and attitudes regarding CAM.
5. Change culture by evolution not revolution
And Georgetown’s rationale for integrating such practices so deeply into the curriculum strikes me as disingenuous:
Haramati realizes that some mainstream medical practitioners remain skeptical of CAM due to the perception that such therapies lack the rigorous scientific testing that traditional therapies undergo. That’s why exposing medical students to CAM practices and principles is so important, he says.
“Perception”? It’s not just a “perception.” The vast majority of CAM therapies do lack rigorous scientific testing that mainstream medical therapies must undergo. That’s a fact, not a “perception.” So what is Georgetown’s solution? Integrate them into the curriculum because they’re not scientifically validated? That’s putting the cart before the horse! “CAM” therapies needs to be validated through science first. In fact, the purpose of medical school is to teach medical students the basics. There’s little enough room in the curriculum to teach them that. No compelling case that I have yet seen has been made that CAM methodologies are so compelling in their efficacy that room must be made in the mandatory medical school curriculum for them.
Georgetown does, however, give one reason that’s semi-reasonable:
“Rather than to say ‘there’s no data here, why teach it?’ we need to inform our students as much as possible about the therapies that are out there … ‘what does the research tell us, which are useful, which are dangerous’,” Haramati explains. He is also quick to note the initiative is not a program of advocacy. “We’re not teaching a belief system or teaching students to practice CAM, but rather we’re informing students about CAM.”
My retort would be that it’s not necessary to integrate this sort of woo deeply into the curriculum in order to accomplish this. For the vast majority of CAM therapies, a brief overview would be all that is needed. It is not necessary to teach “acupuncture points” in regular anatomy class, particularly when there is no evidence that these points mean anything on a strictly anatomic and physiological basis. The organizers of this curriculum also point out that many people take herbal remedies and dietary supplements, many of which can interact with standard drugs, and cite this as a justification for teaching CAM. That is perhaps their best argument, but my retort would be that it’s not necessary to integrate various non-herbal aspects of CAM into the curriculum to accomplish this. In pharmacology class, all that would have to be done would be, when teaching drug interactions, to include herbal remedies and supplements among the compounds and drugs that can interact with each new medication that is discussed and perhaps include a module on such remedies. Drug interactions are a very important topic, and It is not necessary at all to integrate woo into the medical school curriculum to warn future physicians of what herbal medicines might interfere with various drugs.
As for not being a program of advocacy, if that’s the case, then why is Georgetown not only teaching but also actively encouraging the use of “mind-body” skills that may or may not have any scientific basis by its own medical students? Why does its program tout that it will be starting to teach CAM from the very first day of medical school, as described in on the Georgetown website and brochure. This is what I’m talking about:
Year one of the five-year grant began in fall 2001, with CAM lectures integrated into basic science classes. In winter 2002, educators are introducing a new workshop, “Mind-Body Medicine: An Experiential and Didactic Introduction,” which includes topics on a wide range of mind-body approaches, including meditation, nutrition, physical exercise, relaxation, and self-awareness. Students meet in three or four groups of eight to ten people each.
“Over the next five years we’ll be training additional faculty facilitators,” Haramati says. “Then they’ll form their own groups until the entire medical school class is exposed to the utilization of mind-body skills.” “The idea is to help students with the stress of the intense course of study and expectations that come with medical school,” Lumpkin adds. “By learning their own techniques of self-care, students will naturally internalize that and then be able to use it with their patients in the future. This is a skill physicians generally lack because it’s something they were never taught. In some cases it was debunked as being nonsense. Now there’s a new view of its usefulness.”
Let’s see. Georgetown is teaching “mind-body” medicine to its medical students and actively encouraging them to use it, all in the context of teaching other areas of woo. Sure, the faculty claim that they will be teaching students to “critically assess” the various CAM modalities, but you’ll excuse me if I remain skeptical. As I’ve pointed out before, such programs may start out with the best of intentions with regards to a critical assessment of the evidence (or, in the cases of most CAM, the lack of evidence for its efficacy). However, over time, these things tend to develop a momentum of their own. They also tend to get taken over by true believers. This is probably because most doctors committed to EBM just aren’t that interested in CAM because there’s not much good evidence for the vast majority of modalities that fall under its label and because so many CAM modalities are associated with spiritual/religious concepts underlying them that have no business in science. Moreover, advocates of CAM tend to be much more passionate about promoting it than skeptics are about expressing their skepticism about it. Indeed, if they do, they often are labeled as “close-minded” or “intolerant.”
Like the program at the University of Michigan, the CAM program at Georgetown is funded by a grant from the National Center for Complementary and Alternative Medicine (NCCAM). And here’s where we come to the most pernicious effect of all of NCCAM. The problem is that NCCAM doesn’t just fund grants to study CAM, which, although it often leads to studies of dubious scientific merit about therapies lacking even scientific plausibility, much less data, at least is an intellectually and scientifically defensible endeavor. Unfortunately, NCCAM goes beyond this and funds grants to promote the teaching–indeed, the integration–of CAM in medical schools before these modalities are scientifically proven. Once again, this putting the cart before the horse. The usual order of things in medical education is that modalities to be included in the medical curriculum must first have considerable evidence of efficacy such that they are considered standard of care. Medical school is where students learn the basics. During the first two years they learn the well-established basic science, and during the second two years they learn how to take care of patients according to the standard of care. Then they go on to residency, where they expand on the basics and progress to more advanced education in their therapy. The topics and therapies that Georgetown is integrating into its curriculum are neither well-established science nor the standard of care. Teaching unproven CAM modalities so extensively in the core medical school curriculum rather than as electives is neither scientifically nor educationally appropriate, as it puts the imprimatur of scientific medicine as represented by medical schools on therapies that are anything but scientific.
The virus is spreading.
Depending on what Dr. Atwood decides to write, next week I may take a look at the issue of Academic Medicine from October 2007 and examine some of what has been written there in more detail about the teaching of “CAM” in medical school.
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