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When “CAM” is mandatory: A science-based medical student’s dilemma

Early in the history of this blog, I wrote a rather long post expressing my dismay at the infiltration of unscientific “complementary and alternative medicine” (CAM) or “integrative medicine” (IM) modalities into American medical schools. In it, I listed the medical schools that had embraced pseudoscience through having started a CAM/IM program (a list desperately in need of an update). Moreover, we have also complained vociferously here about a clear effort on the part of advocates of faith-based medicine to infiltrate bastions of science-based medicine and to piggyback their agenda onto President Obama’s health care reform initiative in a clear political strategy to slip CAM/IM into any health care reform legislation as a form of “preventative medicine.” It’s all part of a multi-pronged strategy to claim popular and legal legitimacy in the absence of scientific legitimacy. At one point I even despaired because of the apparent success of half physician, half CAM huckster Dr. Andrew Weil at developing a CAM/IM curriculum that would be part of the mandatory training program in several family medicine residencies, while the rest of us watch Senator Tom Harkin try to promote pseudoscience in the halls of the Senate.

However, since one of our newest co-bloggers, medical student Tim Kreider, arrived, I’ve come to appreciate that medical schools and medical school curriculae are ground zero in the battle for science- and evidence-based medicine. Besides the infiltration of non-science-based modalities into the standard curriculum, another technique for making medical students believe that woo is equal to science is the student “campus CAM group” that invites, for example, homeopaths and naturopaths to give talks to medical students, too many of whom are too timid to challenge them on their pseudoscience. However, a reader of a “friend” of mine wrote me an e-mail that truly appalled me. In fact, it appalled not just me, but all of my co-bloggers who read it. It’s from a medical student in an American medical school. It’s not Harvard or a huge famous medical school. However, it is in medical schools like this one where the vast majority of medical students are trained in this country. If the infiltration of CAM/IM into medical schools continues in this way, we’ll have more than just “integrating” woo into the medical school curriculum from day one. We’ll have more tales like this; eventually, no one will find such tales unusual or even unacceptable anymore. The shruggies will no longer even shrug anymore. Such clinics will become simply the way medical students are educated. The following e-mail is de-identified, and I’ve edited it a bit to make as sure as I can that it is not traceable:

Dear Dr. Gorski,

I’m a third-year medical student going through my clinical rotations. The particular outpatient site I’m at promotes woo. A few of the attendings practice acupuncture, conduct OMM [osteopathic manipulative medicine] clinics, and just started to offer cupping.  Sadly, most of the attendings recommend CAM therapies to patients, the residents incredulously try them out, and I know they’ve recently Matched fourth-year students because this program promotes woo. Laughingly, an attending actually lectured us on how to use acupuncture to control post-partum bleeding!

Unfortunately, I’ve been assigned to participate in acupuncture clinic. I feel like a fraud to these patients and I despise being part of this sham.  I’ve already been asked “where I stand” on the issue of CAM.  As practicing physician I could choose to not hire someone who’d inflict CAM on patients, or as a professor I could fight to de-fund CAM departments, but as a student, I can’t speak up without the real risk of ruining my grade.  What do you think I should do?

If you choose to use this email as part of a post, then please de-identify it.

Thank you for your advice.

Student X

First off, Student X deserves kudos for his realization that being asked to participate in an acupuncture clinic is in essence being asked to subject patients to unscientific, religion-based, placebo medicine that has never been convincingly shown to be more efficacious than a placebo for any condition.

Next, I’m sure most readers of this blog will be as disturbed as I was to read this. At least I hope so. None of these therapies are science- or evidence-based. We’ve discussed why acupuncture is nothing more than placebo medicine on many occasions, although we haven’t discussed OMM at all. OMM is the aspect of osteopathic medicine that most resembles chiropractic, in that it postulates that realigning bones and muscles can somehow cure all manner of ills by physiologically dubious mechanisms. Although it’s still taught in most osteopathic medical schools, it’s more as a historical footnote, and few D.O.’s practice OMM anymore. That’s one reason why D.O.’s have over the years become virtually indistinguishable from M.D.’s, which to me is a very good thing indeed. In fact, the best surgical intensivist I’ve ever had the pleasure to work with is a D.O., and I’ve worked with excellent oncologists who are also D.O.’s. My overall impression is that science-based D.O.’s are somewhat embarrassed by these vestigial aspects of osteopathy, but clearly some osteopathic doctors still practice OMM. Some even practice a form of osteopathy called either “cranial osteopathy,” “craniosacral therapy,” “cranial therapy,” or similar names. Practitioners of these methods claim, as chiropracters claim for the spine, that the skull bones can be manipulated to relieve pain and remedy many other ailments. Worse, they claim that there is a “rhythm” in the flow of the cerebrospinal fluid and that diseases are characterized by changes in this rhythm, which can be used to diagnose many diseases, and that these abnormalities in this “rhythim” can be corrected by manipulating the skull. Student X didn’t mention whether any of these practitioners practiced craniosacral osteopathy.

Finally, before moving on to advice (such as it is) I have to point out that cupping is pure quackery. It is a method from traditional Chinese medicine that involves heating the air within a cup and then placing it on the skin so that it is drawn into the cup as the air within cools. There are two varieties: dry cupping, which involves just the cupping, and “wet” cupping, which involves puncturing the skin before applying the cup over it. “Wet” cupping is said to “draw the toxins out” while all forms of cupping are claimed, like acupuncture, to “unblock” or “realign” the flow of qi and thus restore health. It has no role in science-based medicine and should especially have no role in the education of medical students, which is why I was horrified that students anywhere in the U.S. are being taught about it as thought it were a legitimate therapy.

So what should Student X do? Before I answer, let me briefly summarize what else I learned in my e-mail exchange with him. He’s already midway through the rotation; so leaving or changing rotations is not really an option. Also, he was not aware until recently that he would be assigned to the acupuncture clinic. Finally, he has assured me that this is the only site affiliated with his medical school where students are assigned to an outpatient rotation where, as he put it, the “woo runs free.” Being the cancer surgeon that I am, I can’t help but use an analogy here. It sounds to me as though the cancer needs to be cut out of this school before the “woo runs free” to the point where it invades and metastasizes elsewhere and endangers what Student X assures me is an otherwise very supportive, science- and evidence-based medical school. Indeed, I extensively searched the medical school’s website and was unable to find anything about the clinic described. All I found was that one faculty member has an NCCAM grant to study natural products and that one faculty member had finished an “integrative medicine fellowship” before joining the faculty. In that, at least on the surface, there would appear to be less woo at Student X’s school than now exists at my alma mater. Finally, Student X, although not going into the specialty of the Woo Clinic (which is what I will call it from now on) where he is currently rotating, does not feel that he can risk burning bridges, as he needs favorable evaluations.

Back to what to do. Every fiber of my being wants to tell Student X to go to the dean and complain forthwith about the infiltration of quackademic medicine into his medical school. However, I appreciate his situation, and do not wish to give him advice that’s going to land him in a world of hurt, even though fiber of my being also wants to try to get Student X to give me permisison to name names, to call out his medical school right here on this very blog. Unfortunately, Student X informs me that the dean censors anything said by medical students on blogs or online forums that might bring the medical school into disrepute. Were I to name his medical school and it ever became known who had complained to me, the consequences are likely to be unpleasant. Given that it is known who’s rotating at the Woo Clinic right now, it wouldn’t be too hard for his dean to figure out who had complained to me, especially if he had answered honestly the question of “where do you stand on CAM?” So, I will not reveal the medical school.

That being said, regardless of the dean, the very first step Student X needs to take now is to gather as much information as he can. He needs to document everything: every dubious therapy recommended, every credulous statement, every bit of advocacy of unscientific therapy, and every instance of outright quackery. If the clinic has fliers on various CAM/IM modalities that it hands out to patients, he should collect them as evidence. If the clinic has published handouts, outlines, and notes that it uses to teach medical students about CAM/IM (particularly cupping), he should save those, because if he ultimately does complain he will need as much ammunition as he can get. This very blog and various other sites, such as QuackWatch, can provide material and scientific studies showing how discredited these therapies are. If this all blows up, more documentation is better to cover his behind. What critics of unscientific practices in medical often find out is that most of the faculty has essentially zero idea what is actually being done and taught. When they are informed of exactly what “cupping” is, for instance, they are often appalled that such woo is being taught in their medical school to medical students. Ditto reiki, homeopathy, and a lot of the other “woo-iest of the woo” that falls under the CAM/IM rubric. The best tool to educate shruggies, who refuse to believe that anyone would believe, much less teach, such mystical pseudoscientific nonsense is to show them exactly what is being taught to students in the very words of the CAM/IM practitioners. That is often more than damning enough evidence.

The second step is for Student X to find out if there are other students who agree with him and then to hook up with them. Indeed, he should go beyond that and find out if there are other faculty members in the department to which that outpatient clinic belongs who are concerned about the woo being taught to the medical students alongside scientific medicine. In fact, he should go beyond even that and find out whether there are any faculty in the medical school, period, who are proponents of science-based medicine and willing to take a look at the situation. In other words, he needs to find first those who are not shruggies first and network with them. That has to be done before there is any hope of changing the minds of the shruggies. The dean could easily ignore the voice of one lone medical student, but he could not so easily ignore the voices of several medical students if they are backed up by even a handful of faculty–or even just one senior influential faculty member. Ideally, he should seriously consider writing up a letter of complaint to the dean and getting as many signatures as he can on it. Having discussed this case with my cobloggers, I believe I can say with some confidence that all of us would also sign such a letter; indeed, we’d help Student X draft it.

As I’ve thought about this case over the weekend, I completely understand Student X’s reticience about speaking out. Quite frankly, I don’t know if I would have had the intestinal fortitude to have spoken out about an issue like this when I was in medical school. Fortunately for me, that was over 20 years ago, and the infiltration of CAM/IM had not yet become an issue. Indeed, I don’t remember its even being on the radar screen back then. In that, I and other physicians of my generation were fortunate; we weren’t put to the test. However, now, if we are not yet being tested, we soon will be. With NCCAM providing the cloak of undeserved legitimacy to these modalities, it is hard to speak out without being labeled as “close-minded” or even “bigoted,” given how many of these modalities are part of traditional Chinese medicine, Ayurvedic, or indigenous populations, usually mixed in with the usual appeal to ancient wisdom, a logical fallacy if ever there was one. These charges are a powerful blunt instrument to beat the critics of CAM/IM over the head with, which is why we must acquire thick skins to handle them. My counterargument is to ask why ancient Chinese or Indian medicines should be held to a lower standard as far as evidence goes than ancient Western medicine, like bloodletting and purging with toxic metals, which were ultimately abandoned based on science.

Finally, even as understanding as I am about Student X’s position, I’m going to point out that silence is acquiescence. If no one speaks out, the problem will only continue and likely get worse. The woo will spread and metastasize to other areas of Student X’s medical school. Unfortunately, speaking out can have consequences, but if there’s one thing I’ve learned it’s that CAM/IM infiltration thrives best when it’s under the radar. When the light is shined on CAM practitioners in academia and exactly what they do, they usually do not like it, and, unfortunately, their first reaction is often to try to attack the messenger. However, it is on the frontlines, such as the clinic where Student X is currently assigned, where the battle for science-based medicine in academia will be lost or won.

That is why we at SBM will help any medical student who asks us in whatever way we are able. If that includes writing letters, talking to program directors or deans, or even (if it can be pulled off), arranging for one or more of us to come to give talks at medical schools where students are being subjected to rotations teaching them pseudoscientific medicine along with scientific medicine, then we will do that when we can if asked. If it consists only of advising medical students who are science-based and object to the infiltration of pseudoscience into their medical schools on tactics to slow down or stop the CAM/IM train, we will do that as well. We also ask any faculty of medical schools who will support us in this effort to contact me or Steve. You can either do so by publicly leaving a comment below or e-mailing either of us at the e-mail addresses in the Contact tab above. If it’s feasible, you could even become more active by attending the Science-Based Medicine conference in July and networking with like-minded physicians and scientists. There’s nothing like a little face time to build relationships and alliances.

I now conclude with a request. First, of my fellow SBM co-bloggers, I request your input and that you chime in with your advice to Student X. Second, of our readers, I request the same thing. I also open the comments to any medical students or faculty who may have had a similar experience to that of Student X. It would be better if you used your real name, but I understand if you, like Student X, don’t feel comfortable doing that; you may register under a pseudonym if you like. We at SBM will never “out” you unless you give us permission to do so. Look at this post as a springboard to begin the process of organizing. We at SBM want this blog to be more than just a blog; we want it to be a clearinghouse, the beginning of a movement, a hub where like-minded supporters of science- and evidence-based medicine can gather. The CAM/IM revolution has gone frighteningly far; it’s long past time for the counterrevolution for science- and evidence-based medicine to begin.

Who’s with me?

(Sorry, I couldn’t resist using this scene again.)

Posted in: Acupuncture, Medical Academia, Medical Ethics

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