Should medical students be taught alternative medicine?
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2417 (Published 28 March 2014) Cite this as: BMJ 2014;348:g2417
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The authors of both sides of this debate are clearly passionate about their subject with each raising valid points. Moreover, it is laudable to see medical students engaging in debate over what they are taught. I do, however, think that there is likely to be a large amount of agreement from both sides on points that have seemingly been glossed in the pursuit of hammering home either ‘for’ or ‘against’ the question of whether there is any evidence for CAM.
Catto seems to be arguing, amongst his more dubious claims about the efficacy of some CAMs, that doctors ought to collaborate with patients in order to decide on the best treatments. Indeed, Cork and Williams are also agreeable to helping patients ‘make informed decisions’. Nevertheless they rightly point out that there is little evidence for CAM. It does not follow directly from this, however, that CAM should therefore not be taught in medical schools. This requires a premise ‘x should be taught in medical schools if and if x can be shown to be evidence based’. With this undeclared premise Cork and Williams argument would run as follows:
(1) CAM should be taught in medical schools if and only if it can be shown to be evidence based
(2) CAM cannot be shown to be evidence based
(C) Therefore CAM should not be taught in medical schools.
We could take issue with either of the premises or the conclusion. There may be some other reason why CAM should not be taught in medical schools. We could question the standards of ‘evidence based’ required or attempt to show that there is an evidence base for CAM. A further issue one may take with (1) would be that there may be valuable activities in medical schools that are not evidence based but nevertheless would be desirable and therefore ought to remain on the curriculum.
The above argument aside, what I believe all thee authors would agree on is that doctors have a duty to help their patients make good decisions. Yet neither case from ‘yes’ nor from ‘no’ shows how they would help patients make decisions. Omitting or including CAM in the medical school curriculum will not necessarily lead to patients making better decisions, which both authors have recognised as an important ethical imperative. What the authors collectively ought to argue is that medical students should be taught to address premise (2). That is, that medical schools should focus on teaching on critical appraisal, managing risk and dealing with uncertainty. In this way, tomorrows doctors can be better equipped to address any patient’s needs and contribute meaningfully to that individual’s decision. Doctors can be more adaptive to a changing evidence landscape and avoid the dogmatic non sequitor ‘it is complementary medicine therefore it’s snake oil’. Rather than banning CAM from the medical school curriculum or giving it pride of place, medical students should be taught to assess it on its merits — as they should be for any therapy complementary or not — and integrate this into a package of care of maximal benefit to the individual patient.
I think the all three authors have missed the important point here, that medical school is about equipping our future doctors to deal with the complexity of individuals and their needs. Quibbling over the merits of CAM does not necessarily make a case for it being on the medical school curriculum. Catto, Cork and Williams all single out aiding patients’ decision-making as important, yet leave it unclear how placing CAM on the curriculum or not enhances this. Evidence based medicine, critical appraisal and understanding risk are far more likely to equip doctors to help patients and this should be first amongst any curriculum modifications.
Competing interests: No competing interests
Should ALL healthcare professionals have some awareness of alternative medicine, yes. Should publicly funded medical training devote time in packed curricula to teaching this - no. Degrees in alternative and complementary therapies can be studied at a cost of £9k per year as an alternative to medicine. Medics and other HCP can learn more about alternative medicines post-registration if they wish to do so and pay for this.
Competing interests: No competing interests
I’d like to respond to the comment from David Colquhoun, but rather than get into a personal debate here, let’s focus on the issue, and yes there is credible evidence to support that many complementary therapies are effective, see the original argument and references provided by Graeme Catto.
But my point is not to focus on the evidence we currently have, it’s also about whether or not we are supporting young researchers or allowing the funding for such high quality research on CAM? Also to get back to the main point of this debate, should we teach alternative medicine to medical students?
I still argue an unequivocal yes, and there is no wishful thinking involved, I argue this from the perspective of a qualified CAM practitioner who has a background in conducting published health research
Competing interests: No competing interests
Prof David Colquhoun in his response to the discussion ‘Should medical students should be taught alternative medicine?’ (1) claims that alternative medicine ‘IS mostly snake oil, hoaxes and deceit’.
‘Snake oil’, as an expression that refers to fraudulent health products or unproven medicine could equally be applied to many commonly practiced conventional medical interventions which lack rigorous evidence of efficacy, such as influenza vaccines in the elderly (2) or arthroscopic surgery for degenerative medial meniscal tears (3).
However, it seems that snake oil salesmen were actually onto something, as snake oil is actually a concentrated source of omega-3 fatty acids and a credible therapeutic agent. Omega-3 fatty acids not only reduce inflammation, such as arthritis pain, but may also improve cognitive function, protect against coronary heart disease and strokes, relieve depression and even reduce the risk of some cancers.
Chinese water-snake oil contains 20 percent eicosapentaenoic acid (EPA), rattlesnake oil 8.5 percent (4); salmon, one of the most popular food sources of omega-3's, contains a maximum of 18 percent EPA.
Erabu sea snake oil has a lowering-effect on plasma and liver lipids and plasma glucose in mice and is more effective than a fish oil mixture (5); it also exerts an equivalent influence on the learning ability [in mice] to that of fish oil (6).
Medical students should certainly be taught that snake oil is not ‘snake oil’ but that some conventional treatments are!
1. Should medical students be taught alternative medicine? Graeme Catto et al. BMJ 2014;348:g2417
2. Vaccines for preventing influenza in the elderly (Review). Tom Jefferson el al. Cochrane Database of Systematic Reviews 2010, Issue 2. Art. No.:CD004876. DOI:10.1002/14651858.CD004876.pub3.
3. Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. Raine Sihvonen et al. N Engl J Med 2013; 369:2515-2524
4. Snake oil. Richard Kunin. WJM 1989; 151(2): 208
5. The effects of Erabu sea snake oil on the plasma lipids and glucose, and liver lipids in mice. Nobuya Shirai et al. Nutrition Research 2002; 22(10):1197-1207.
6. Effect of Erabu sea snake Laticauda semifasciata oil intake on maze-learning ability in mice. Nobuya Shirai et al. Fisheries Science 2004;70(2):314-318
Competing interests: No competing interests
Tracey O'Neill says
"we know that certain complementary therapies have proven to be effective"
Perhaps she should tell us which? It rather worries me that London Met students get exposed to such wishful thinking.
Competing interests: No competing interests
I think that members of the medical profession who continue to advise that students should remain oblivious to and ignorant of the alternative medicines that their future patients are using do not realize the reputational damage that they are causing to the practice of medicine. Suppose that a newborn infant was taken to the hospital with the symptoms of seizures, kidney damage and transient fetal tachycardia. Or the same baby is born in hospital with meconium staining of the amniotic fluid. Should the doctor be clueless about the cause or should s/he be able to guess that the mother or midwife used blue and black cohosh to induce labour? Raspberry leaf is commonly used to shorten labour, shouldn’t doctors know that?
World leaders have made a commitment to reduce cases of dementia by 2025. Should doctors know that the use of certain plants such as Annona muricata and Datura stramonium may produce symptoms similar to Parkinsonism or should they know nothing about it? There are many plants that are used to treat Type 2 diabetes. In the last two decades the trials conducted on these plants have improved in quality but the results remain the same – they appear to work, but do they work because they help weight loss or are there active compounds – more and more reviews and trials are seeking to establish this. It is extremely unlikely that doctors could treat a diabetic patient from the Caribbean or India who is not already using medicinal plants. What about multi-drug resistant bacteria in hospitals – is there no role for plant derived essential oils in resource poor medical facilities? Medicinal plants were discussed in the early issues of the Lancet, the British Medical Journal and other medical journals. There is no reason to remove alternative medicines from official medicine in order to increase the profits of pharmaceutical companies.
Anon, 1863. Descriptions of new remedies introduced into the practice of medicine, with their therapeutical effects. The Lancet 81 (2059): 190.
British Medical Journal. 1900. Indian and Colonial Addendum to the British Pharmacopoeia, 1898. British Medical Journal 2(2084): 1676-1678.
Campbell WM. 1886. Notes on Viburnum prunifolium in abortion. British Medical Journal 1(1313): 391-392.
Efird J, T Choi YM, Davies SW, Mehra S, Anderson EJ, Katunga LA. Potential for improved glycemic control with dietary Momordica charantia in patients with insulin resistance and pre-diabetes. Int J Environ Res Public Health. 2014 Feb 21;11(2):2328-45. doi: 10.3390/ijerph110202328.
Gunn TA, Wright IMR. “The use of black and blue cohosh in labour.” New Zealand Medical Journal 1996;109:410-411.
Sienkiewicz M(1), Łysakowska M, Pastuszka M, Bienias W, Kowalczyk E. The potential of use basil and rosemary essential oils as effective antibacterial agents. Molecules. 2013 Aug 5;18(8):9334-51. doi: 10.3390/molecules18089334.
Simpson M(1), Parsons M, Greenwood J, Wade K. Raspberry leaf in pregnancy: its safety and efficacy in labor. J Midwifery Womens Health. 2001 Mar-Apr;46(2):51-9.
Competing interests: No competing interests
Yes, Medical students should be taught ‘about’ alternative medicines.
I would agree in principle that medical students should be taught ‘about’ alternative medicines [1]. But the teaching should not be done by advocates of alternative medicine but by open minded clinicians who are able to point out the thin evidence base which underpins most alternative medicines.
Medical students need to be educated about all the commonly used alternative medicines so that when patients ask questions, the budding doctors are in a position to explain to patients that it is mostly not advisable to use the myriad of alternative medicines.
Tomorrow’s doctors should be taught to be non-judgemental of patients who use the alternative medicines. They should also learn to avoid being dogmatic and, keep an open mind and be scientifically curious about unexplained effects of some alternative therapies [2].
More importantly, medical students should be made aware of the clever marketing techniques and sophisticated sales tactics used by many web based, alternative medicine practitioners to lure the gullible patients. And John Diamond’s book ‘Snake Oil and Other Preoccupations’ should be on their reading list [3].
References
1 Catto G, Cork N, Williams G. Should medical students be taught alternative medicine? BMJ 2014;348:g2417–g2417. doi:10.1136/bmj.g2417
2 Sundar S. Effect of Mistletoe on Cervical cancer (n =1) | BMJ. http://www.bmj.com/rapid-response/2011/11/01/effect-mistletoe-cervical-c... (accessed 1 Apr2014).
3 Ferriman A. Snake Oil and Other Preoccupations. BMJ 2001;323:288. doi:10.1136/bmj.323.7307.288
Competing interests: No competing interests
It’s not just medical students who should be taught about alternative medicine, but physiotherapist too, especially as the latter practice a great deal of it on the NHS at the tax-payer’s expense.
However I believe education on alternative therapy should be taught within the context of; (i) the philosophy of medicine (including the teaching of animism and it’s place in ancient medicine), (ii) placebo medicine and the ethics related to this, and (iii) the potential harms of alternative medicine.
Competing interests: No competing interests
David Colquhoun states "Perhaps she should tell us which? It rather worries me that London Met students get exposed to such wishful thinking." and "I find it quite alarming that a place like Johns Hopkins teaches otherwise. Remind me to keep away from that place."
Clarification needs to be made in regard to what should and should not be considered alternative medicines. My initial response was meant to convey that if a treatment works for a specific indication it should be considered as medicine. Recent literature has shown benefit for changing one's diet (Estruch et al., N Engl J Med 2013; 368:1279-1290), participating in exercise (Naci et al., BMJ 2013;347:f5577), and even using some dietary supplements (Chowdhury et al., BMJ 2014;348:g1903) decreases mortality among our patients. Authors like Li et al. (N Engl J Med 2012; 366:511-519) have shown benefits from tai chi for postural stability in patients with Parkinson's disease, while Tang et al. (Proc Natl Acad Sci USA. 2007 Oct 23;104(43):17152-6) have shown benefits in attention and self-regulation with short-term meditation training. While issues such as confounding and placebo effects do complicate any observed benefits, it would be a disservice to not teach future physicians about these results, their implications for patient care, and provide an understanding for therapies and their efficacies for patients who may ask about or even specifically request said therapies.
However, if the treatment does not work it should not even be considered as the misnomer alternative medicine.
Competing interests: No competing interests
Re: Should medical students be taught alternative medicine?
Catto states that doctors should be able to discuss alternative medicine "in a non-judgmental way", and that "These principles apply to complementary and alternative medicine the same way as to other lifestyle choices."
Well, being non-judgmental is a fine aim of course, but it would be a mistake to confuse a non-judgmental attitude (a good thing) with a failure to give patients proper advice (a bad thing).
I suspect most good physicians, when discussing a patient's 60-a-day smoking habit, might try to explain to the patient that it probably isn't good for their health. I assume Catto would wish to see such patients given appropriate lifestyle advice?
I don't see why the situation should be different for alternative medicine. While there are a small number of alternative medicines that do have some evidence of efficacy, that number really is very small indeed, and the majority of alternative medicines are of benefit only to the people making money from selling them.
A good physician has a duty to advise patients that by using alternative medicine they will, with very few exceptions, at best be wasting their money, and at worst be putting their health at risk.
Patients undoubtedly have a right to use alternative treatments if they wish. But they deserve to have good information on why that will generally be at best a futile exercise, and it is the job of the physician to provide that information.
Competing interests: My company provides consultancy services to a variety of clinical researchers, many of whom are pharmaceutical companies. We would be equally happy to offer our services to companies selling complementary medicine, but oddly enough, those companies don't seem to be very interested in doing research.