http://www.bmj.com/content/348/bmj.g2417
BMJ
2014;
348
doi: http://dx.doi.org/10.1136/bmj.g2417
(Published 28 March 2014)
Cite this as:
BMJ
2014;348:g2417
- Graeme Catto, president1,
- Nick Cork, medical student2,
- Gareth Williams, emeritus professor of medicine and senior research fellow in philosophy3
- Correspondence to: Graeme Catto president@collegeofmedicine.org.uk, Nick Cork nicholascork@gmail.com
Yes—Graeme Catto
“Demonstrate
awareness that many patients use complementary and alternative
therapies, and awareness of the existence and range of these therapies,
why patients use them, and how this might affect other types of
treatment that patients are receiving.”1
This guidance, from the UK General Medical Council’s Tomorrow’s Doctors
encapsulates lucidly and concisely why medical students are taught
about alternative medicine. I find it difficult to conceive of a
counterargument.
The choices patients make
To
provide quality care doctors must be aware of choices patients make and
be able to discuss them in an informed and non-judgmental way. Any
other approach puts the doctor-patient relationship at risk. Patients
are reluctant to raise issues that they believe meet with disapproval.
These principles apply to complementary and alternative medicine the
same way as to other lifestyle choices.
And this is a
choice made by many people in the United Kingdom. The annual spend on
alternative health treatments has been estimated to be as much as £5.4bn
(€6.5bn; $8.9bn).2
All aspects of medical care are involved and not only in general
practice. As a nephrologist I learnt that patients wanted complementary
therapies to relieve some of the intractable and distressing symptoms,
such as skin itch and restless legs, associated with chronic renal
failure. Patients discussed among themselves the therapies they found
useful. For my part I checked that there were no known interactions with
their current conventional treatment and was pleased if symptoms were
relieved.
With the development of the internet and social
media, such suggestions for self care and for complementary therapy are
much more readily available and circulate more rapidly. Serious drug
interactions are fortunately not common; St John’s wort, however,
increases the effect of conventional antidepressants, and evening
primrose oil increases the effect of warfarin with potentially serious
consequences.3
Where efficacy has been accepted
In
2000, the House of Lords Select Committee on Science and Technology
produced a far sighted report on complementary and alternative medicine.4
It recognised the weakness of the evidence base and the difficulty of
identifying funding for necessary but expensive clinical trials. So what
has changed since then? Perhaps not a great deal. The National
Institute for Health and Care Excellence recommends complementary and
alternative therapies only in a limited number of conditions where
efficacy has been accepted. The Alexander technique is suggested as part
of the treatment for Parkinson’s disease,5 ginger and acupressure for reducing morning sickness in pregnancy,6 and acupuncture and massage for persistent low back pain.7
Complementary
therapies are, however, widely used in cancer and palliative care, and
the National Cancer Institute at the National Institutes of Health
provides information on research activity and clinical practice in the
US.8
Many of these treatments relate to relaxation and meditation techniques
thought to be of value for patients with life threatening illnesses.
That hypothesis gained support from an unexpected source. Elizabeth
Blackburn, awarded the Nobel prize in 2009 for her work on telomerase,
and her colleagues showed that increased telomere length protected not
only the chromosome but the cell against the ageing process and cell
death. They have further shown that meditation and relaxation increase
telomerase activity and telomere length thus providing objective
information on the effect of complementary medicine at the cellular
level.9
These
are not isolated examples. Dean Ornish and his colleagues have shown in
patients with prostatic cancer that changes in lifestyle and diet have
been associated with lengthening of telomeres.10
We await to see if these cellular changes are associated with an
improved prognosis. Similar dietary and lifestyle changes have produced
lasting improvements in patients with coronary artery disease. These
interventions are now accepted as good practice in cardiovascular
disease and in preventing both obesity and type 2 diabetes. In these
situations, concepts that may originally have been considered as
complementary to conventional medicine are now widely adopted.
One
of the joys of medicine is dealing with uncertainty. The evidence base
for much of our current practice is weak. I believe, as once did the
GMC, that doctors “must work with colleagues and patients . . . to help
resolve uncertainties about the effects of treatments.”11
That means following the scientific evidence and questioning
established practice. Iain Chalmers has spoken movingly of the many
infant deaths caused by the inadequately researched advice to place
young children in the prone position for sleep.12
Volumes of learned articles seeking to cure peptic ulcers by reducing
gastric acid secretion were shown to be irrelevant, even if
scientifically valid, by the discovery of Helicobacter pylori.
Good doctors have always had the flexibility to change their practice in
the light of new evidence and patients have benefitted.
Partnership and support
In
many clinical situations, however, modern medicine is able only to
modify, not cure, the underlying condition. Optimum management of long
term conditions requires partnership among the patient, the doctor, and
the other members of the healthcare team. It is not surprising that many
patients turn to complementary and alternative therapies when their
symptoms persist. The good doctor will provide support while advising
against any treatments that may be dangerous or conflict with their
current drugs.
We may not require a randomised
controlled trial to know that aromatherapy makes some patients feel
better or that yoga has benefits. Learning to work well in partnership
with patients is an essential skill for all of us and not only medical
students. If you accept that premise, understanding something about
complementary and alternative therapies is an essential component, like
it or not.
No—Nick Cork and Gareth Williams
In 1910, the Flexner Report13
brought much needed scientific rigour to medical education in the
United States and led directly to the closure of many schools that
taught chiropractic, naturopathy, and homoeopathy. Now, over a century
later, alternative medicine has insinuated itself into medical education
in the UK.
In 2010, 18 of the UK’s then 31 medical
schools responded to a survey about the teaching of so called
“complementary and alternative medicine” (CAM) within the undergraduate
programme.14
All 18 stated that CAM was an integral part of the curriculum,
including student selected research projects in eight, and formal
teaching (ranging from a single lecture to a theme running throughout
the programme) in six.
Mainstream, science based
medicine is far from perfect. Many shelves in the therapeutic cupboard
remain depressingly bare, and the evidence base for many drugs is patchy
or skewed by fashion, industrial lobbying, and publication bias. Not
surprisingly, as many as 52% of UK patients have tried an alternative
medicine at some point, most commonly herbal medicine, homoeopathy,
aromatherapy, massage, or reflexology.15 These options undoubtedly provide comfort for some, even if only through a placebo effect.
What’s the evidence?
However,
alternative therapies must be tested as rigorously as conventional
drugs, and like them must be rejected if they prove to be useless or
dangerous. A recent review carried the provocative title, “How much of
CAM is based on research evidence?” The answer: very little. Of 685
alternative therapies investigated through adequate clinical trials and
meta-analyses, only 7% showed any evidence of efficacy, and this figure
may be an overestimate.16
There is certainly no scientific basis for homoeopathy, as illustrated
by the world’s most popular homoeopathic remedy, Oscillococcinum,
recommended for colds and flu. The allegedly active ingredient, the
viscera of the Muscovy duck, is supposedly a rich source of a bacterium
that has never been shown to exist.17
One duck would provide enough material to treat every person on the
planet, but unfortunately there is not enough water in the solar system
to produce the “therapeutic” dilution of one part in 10200.
Contrary
to propaganda, these therapies are not risk free. Various systematic
reviews have attributed 121 fatalities to acupuncture, chelation
therapy, and chiropractic, and 1159 adverse events, including four
deaths, to the use of homoeopathy.18 19
Herbal therapies—particularly ginkgo, ginseng, kava, and St John’s
wort—may interact with common conventional medicines, potentially with
mild to severe consequences.20
What are we teaching our students?
These
shortcomings of alternative therapies are not adequately discussed in
undergraduate curricula. In a recent survey of 25 medical schools,21
one third of the 95 students who responded reported that those teaching
alternative medicine failed to provide evidence of efficacy. Twenty
students in the same survey indicated that their self selected research
project lacked scientific rigour because the supervisor was reluctant to
confront evidence against alternative therapies. Moreover, students in
at least one medical school are taught about alternative therapies
during their first year, before fully covering pharmacology or the
principles of evidence based medicine.
In this era of
evidence based medicine, it seems strange that alternative therapies
should have found their way into medical curricula—especially when the
undergraduate teaching programme is already overcrowded. Who has driven
this change? In the UK, alternative medicine has the stamp of approval
of the royal family and various celebrities. It enjoys the support of
some senior doctors and the grandly named College of Medicine, which
collaborates to run courses entitled “Integrating complementary medicine
in everyday practice”22 in line with its objective of “promoting, fostering and advancing an integrated approach to healthcare.”23
Seductive yet utterly devoid of scientific merit
The
defences against the invasion of unscientific material should centre on
the UK regulator, the General Medical Council, which dictates the
content and emphasis of the nation’s medical education programmes and
has the power to close down medical schools that fall short of the mark.
In Tomorrow’s Doctors (2009)24
the GMC’s guidance is that qualified doctors should “demonstrate
awareness that many patients use complementary and alternative
therapies, and awareness of the existence and range of these therapies,
why patients use them, and how this might affect other types of
treatment that patients are receiving.” This seems entirely reasonable,
but incompatible with the GMC’s guidance, in Good Medical Practice (2013), that “in providing care you must provide effective treatments based on the best available evidence.”
In
medicine, there are few concepts as seductive yet utterly devoid of
scientific merit as alternative therapies. Doctors must be aware that
these exist, and that they have limitations and contraindications, to
help patients to make informed decisions about using them or not. Beyond
this, we argue that teaching alternative medicine to medical students
is illogical and a waste of time. It is unethical to indoctrinate
students when they might not yet have acquired the critical skills to
decide for themselves whether a particular therapy is effective, safe,
and affordable. Moreover, it takes a great deal of courage for medical
students—especially in their junior years—to challenge or contradict
their teachers.
There is no place in the undergraduate
curriculum for promoting any treatments that are not underpinned by hard
evidence that they work and are acceptably safe. The GMC has appointed
itself the guardian of quality and scientific rigour in medical training
in the UK. It should now follow the example of Abraham Flexner and
ensure that teaching about alternative medicine in UK medical schools is
strictly reviewed—and removed if it does not meet the basic criteria of
efficacy and safety.
Artículo completo con referencias y bibliografía aquí.
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