Re: Should medical students be taught alternative medicine?
Alternative medicine - calls for clarity
The volume of responses to our contribution to the alternative medicine debate1, revealed an evident split among BMJ readers. Of 1363 votes cast in the online poll, ‘Should medical students be taught alternative medicine?’2, 47% voted yes and a marginally victorious 53% voted no.
The correspondence raised several points to which we would like to respond.
What is alternative medicine?
Alternative medicine encompasses such a diverse range of practices that it becomes near impossible to define precisely. Pragmatically, it could be regarded as anything that falls outside the Cochrane Collaboration’s definition of evidence-based medicine: ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’3.
Herbal, or ‘natural’, remedies are therefore considered alternative. Some may contain pharmacologically active ingredients, but will only make the transition to mainstream medicine when these have been isolated, characterised, made available in standardised formulations and their effects and side-effects fully understood from properly designed clinical trials. Crucially, they will have to have demonstrated efficacy and an acceptable risk:benefit profile under those conditions.
Similarly, diet, exercise and other lifestyle interventions which demonstrate benefits that are supported by a robust evidence base should be part of mainstream medical practice. Practices that do not satisfy these criteria, or which claim an implausible mechanism of action at odds with basic science, can be considered ‘alternative’. We have no quarrel with measures that might work, only with those who fail to put them to the test, or who refuse to accept evidence that they have no effect beyond an unethical placebo.
Should UK medical students be taught alternative medicine?
We agree that, as long as patients in the UK continue to explore alternative therapies, their doctors must be equipped to discuss the benefits - or lack thereof - and risks of these. This does not mean that medical students should be taught how to practise alternative medicine. Crucially, the pseudoscience and fudged statistics of alternative medicine must not figure in a 21st-century medical curriculum. It is wholly inappropriate to teach the intricacies of palm healing, homeopathic succussion or the balance of qi flow, in an age where drugs with proven efficacy are rejected because they are not quite good enough.
Undergraduate education needs to be unbiased, highlighting the strength, or absence, of supporting evidence. It is enriching for students to develop an awareness of other cultures and traditional practices, but this must be through the prism of safety and effectiveness. We may reflect on the historic traditions of the four humours, or bloodletting, but it would be harmful to advocate these at the expense of modern medicine that can actually help.
There is evidence that alternative therapies are currently being uncritically taught to students in their early years through self-selected modules4. We maintain that to cover such material before students have had the opportunity to acquire a firm grounding in pharmacology and evidence-based medicine carries a risk of indoctrination. Our intention is not to censor or stifle debate. Senior students, if competent in critical appraisal, are suitably placed to make informed decisions regarding the safety and effectiveness of alternative therapies and should be offered this opportunity.
There is a clear parallel with the universally-accepted principle of informed consent. We accept that patients cannot make informed decisions regarding their treatment options until equipped and supported to interpret such new information. Medical students, in their transition between lay and specialist insight, are no different.
Should teaching about alternative medicine be regulated?
Undergraduate education must prepare doctors to have sensible discussions with their patients, through a curriculum that prioritises, as one commenter advocated, evidence-based medicine, critical appraisal and the management of risk and uncertainty.
The current teaching of alternative medicine in some UK medical schools therefore raises fundamental concerns about quality assurance. The General Medical Council’s direction, in Tomorrow’s Doctors, that medical graduates should ‘demonstrate awareness…of the existence and range of [complementary and alternative therapies]’, provides flexibility to be applied variably across the country, according to course coordinators’ personal interpretations. Feeding false information about alternative medicine to medical students, especially those unprepared for critical analysis of evidence, undermines the standard of education provided to undergraduates as a whole and weakens the teaching of evidence–based medicine elsewhere.
We have identified an opportunity here to improve the curricula of medical schools for the benefit of our patients. We repeat our call to the GMC1 to review the quality of teaching related to alternative medicine in the UK, and await their response with interest.
1. Catto G, Cork N, Williams G. Should medical students be taught alternative medicine? BMJ 2014;348:g2417.
2. BMJ. Poll Archive. 2014. http://www.bmj.com/about-bmj/poll-archive.
3. The Cochrane Collaboration. Evidence-based health care and systematic reviews. 2013. http://www.cochrane.org/about-us/evidence-based-health-care.
4. Smith KR. Factors influencing the inclusion of complementary and alternative medicine (CAM) in undergraduate medical education. BMJ Open 2011;1:e000074.
Competing interests: No competing interests