The Corpus Callosum

First there was Alternative Medicine, then there was Complimentary and
Alternative Medicine, and now there is Integrative, Complimentary and
Alternative Medicine.  

I guess the natural cynic in me becomes suspicious when I see acronyms
undergoing hypertrophy.  

So is this growing collection of concepts worthwhile?  Do we
really need to create a terminology?  Or does the acronym
creep indicate that the concepts are to vague, too ill-defined, to
merit the creation of a term?


href="http://scienceblogs.com/insolence/2006/11/the_future_of_american_medicine_woo_1.php">Orac,
href="http://scienceblogs.com/terrasig/2006/11/alternative_medicine_education.php">Abel
and href="http://doctorrw.blogspot.com/2006/11/woo-pitching-med-students-say-theyre.html">RW
have expressed concern that AMSA is vociferously href="http://www.amsa.org/ICAM/resources.cfm">advocating the
inclusion and expansion of ICAM in traditional medical
training. (Disambiguation note: AMSA is the href="http://www.amsa.org/">American Medical Student
Association, not the href="http://www.accessmylibrary.com/comsite5/bin/pdinventory.pl?pdlanding=1&referid=2930&purchase_type=ITM&item_id=0286-6052457">Association
of Metropolitan Sewerage Agencies.)

They raise some valid points, although I would not be quick to be
entirely dismissive of ASMA’s efforts.  There are several
reasons for that.

For one, kids will be kids.  While medical students are not
exactly kids, probably most of them did not get to
be very rebellious during their teenage years.  Maybe they
need to get it out of their system.  

My concern is not that they will end up as
physicians who promote ICAM to the exclusion of things that really
work.  I have to assume that the intent is to integrate
complimentary and alternative medicine with traditional medicine.
 That is why they expanded the acronym.

If there is a reason to be concerned, it is that there is already too
much to learn in a traditional curriculum.  In order to make
room for ICAM, you have to leave something else out.  So it
boils down to a question of balance: how much time do you spend on
ICAM, knowing that there is so much more to learn?

To look at a specific example, the href="http://www.med.umich.edu/umim/education/curriculum.htm">program
at the University of Michigan involves courses in the first
three years, with some electives available in the fourth year.
 It seems like a lot.  For what it is worth, I have
heard some of them complain that it seems that too much time is devoted
to ICAM.

So is it worth the time and effort?  In order to answer that,
you would need to know what is gained, and what is lost.  That
can be difficult to quantify.  To the skeptics, though, it may
seem easy.  If what is gained is zero, and what is lost is
something greater than zero, no additional quantification is needed.
 

However, looking at it from a biopsychosocial perspective, I am not
confident that there is zero benefit.  In fact, I think there
is a benefit.  What I am not clear about is how big the
benefit is.  I suspect that it helps some doctors, but not
others.

Traditional medicine tends to focus or preventing or curing disease.
 It is hard to find fault with that.  When the
disease cannot be prevented cured, the focus shifts to stopping or
slowing the progression.  When that cannot be done, the focus
shifts to minimizing the impact of the disease, by assisting with
adaptation.  

Patients, of course, want to be cured.  Sometimes that is not
possible, so the best thing for the physician to do is to help the
patient accept the shift in focus.  ICAM probably has a lot to
offer in that area.  

The other area of potential benefit is a bit more obscure, more
difficult to understand.  Patients come to the clinic with a
conception of what is wrong.  To them, their conception of the
disease is what defines the problem.  usually, their concept
of the disease is quite different from that of the physician.  

In order to have the best chance of helping, it is necessary for the
physician to make recommendations that are consistent with the
patient’s concept of the disease.  Education in ICAM can, at
least potentially, help broaden the physician’s ability to understand
the patients concept of the disease.  This could facilitate
communication, and the development of a therapeutic alliance.  

Now, I am aware that the idea of a therapeutic alliance is pretty much
restricted to psychiatry and allied disciplines.  But the idea
is an old one: every doctor knows about the concept of bedside
manner
, which is probably the single most important skill to
have.  

In fact, over the entire history of medicine, various concepts have
come and gone.  Probably the one concept that has endured over
the entire history of medicine, is that of the centrality of the
physician-patient relationship.  

Part of the skill of bedside manner is the ability to understand the
disease from the perspective of the patient.  Increasingly,
patients are coming in, having conceptualized their illness in terms
borrowed from a variety of sources.  Sometimes these are
concepts from ICAM, sometimes they are from drug company ads, or Oprah,
or Reader’s Digest; sometimes they are idiosyncratic.  But
whatever the origin, the doctor has to listen and understand.  

From the href="http://www.eurekalert.org/pub_releases/2002-01/uomh-ums012802.php">Eureka
Alert synopsis of the UMich program:

ANN ARBOR, Mich. – Recent reports indicate that
although 42 percent of the U.S. population uses some form of
complementary and alternative medicine (CAM), most individuals withhold
this information from their physicians because they fear lack of
understanding, disapproval, or both. Because of this, health
professionals increasingly acknowledge the need for a deeper awareness
and understanding of the alternative treatment modalities used by their
patients…

Like it or not, the ability to form a working relationship between the
doctor and the patient is always going to be a critical part of medical
practice.  And the relationship is always going to be unique.
 

For the evidence-based practitioner, this presents a quandary.
 The strength of evidence-based medicine comes from the
replicability of observations, and the study of populations.
 Yet each instance of a doctor-patient relationship is not
only unique, but evanescent.  The relationship that exists
today, will be different tomorrow.

While it is possible to study some aspects of bedside manner using
controlled experiments, there always will be aspects that are not
controllable, and thus not amenable to the scientific method.  

So, as it happens, the single most important part of medicine is
something that never will be based entirely upon evidence.
 And that is a problem.  

Having said that, I hasten to add that the problem is not intractable.
 On the contrary, it is a problem that can be addressed.
 It can be addressed, but not entirely systematized.
 One way to address it is to become familiar with a wide
variety of mental models of disease.  There is little point in
getting hung up on the question of which models are correct, since all
of them are wrong anyway.  What is important, is to keep in
mind that the models that are empirically validated are the ones that
are most likely to be useful in the treatment planning process.
 

When the doctor and the patient have widely divergent models for
understanding the disease, it sometimes is helpful to acknowledge that
openly. Sometimes, that opens the door for the patient to consider
treatments that might seem contrary to their own conceptualization of
the disease.  Sometimes I will tell people that when there are
two conflicting views of the proper course of treatment, it makes sense
to pursue both courses simultaneously.  

Another potential benefit to inclusion of ICAM is that it provides
opportunities to teach critical thinking skills.  It is
important for physicians to be able to critically evaluate the evidence
supporting each treatment modality, regardless of whether it originated
in href="http://www.pfizer.com/pfizer/subsites/philanthropy/caring/community.programs.local.groton.jsp">New
London or in Tibet.  

What this all means to me is that the inclusion of ICAM in medical
training could serve some practical purposes, and should not be
rejected out of hand.  However, it does come at a cost.
 Part of the cost is the time involved, considering that the
medical curriculum already is jammed with other, possibly more
important topics.  Another risk comes from the potential to
give certain treatment modalities more credibility than they deserve.
 

Comments

  1. #1 logtar
    November 15, 2006

    Why not, old medicine and new medicine? LOL

  2. #2 drb
    November 15, 2006

    “In order to have the best chance of helping, it is necessary for the physician to make recommendations that are consistent with the patients concept of the disease.”

    Not in my experience. A major reason people are drawn to ICAM has little to do with esoteric reasoning about their “concept” of disease, and much more about the fear of death and disability. Even if this was true, how does one effectively deal with a patient whose “concept” of disease is, frankly, nuts? Clinical truths will always seem cold and heartless, no matter how good one’s bedside manner is, and if people can turn to unproven feel-good substitutes in order to avoid hearing details of the hard reality of illness, they will. It is in the nature of evidence-based medical practice to provide information about risks, complications and mortality, much of which is discouraging and frightening. Appealing to the gods of ICAM is, in many ways, a surrogate for praying, and likely to be just as useful. Painful as it may be, patients (including even myself) must be encouraged to face the reality of their situation – we do them no favor by making them feel good about their “therapeutic” herbal teas and coffee enemas while condemning them to the potential for untrammeled progression of disease.

  3. #3 bob koepp
    November 16, 2006

    That _medical_ students are pushing for “inclusion” (i.e., integration) of bogus interventions is very worrisome to me. I want my physician to be able to think critically, to understand the relation between evidence and conclusion. Do these students need remedial education in scientific reasoning?

  4. #4 Orac
    November 16, 2006

    Yes.

  5. #5 Joseph j7uy5
    November 17, 2006

    As it happens, I have spoken to some of the students who have endured the curriculum, and they are still bright, capable, and reasonable people. They are not going to be bad doctors because of he experience.

    Do they need remedial education? Not at all. They use the experience to exercise their critical thinking skills.

    My impression is that they think of the experience as a bit of a break from more rigorous topics.

    Also, it is important to remember that a lot of what is contained in the traditional biomedical curriculum is wrong. We just don’t know yet which part is wrong.

    The program at the University of Michigan is funded by a federal grant. The idea is to see if it is useful. I have some faith that the faculty will critically appraise the program, and probably pare it down quite a bit when the grant runs out.

    If they seem that some elements have value, presumably they will keep them. I suspect that much will be taken out.

    Another thing to consider is that patients differ, sometimes in systematic ways, depending on the community. Also, individuals physicians tend to have a selected clientèle. Many of the people I’ve seen, who have inquired about ICAM, are bright people who’ve done a lot of background research already.

    Sometimes they are plainly off on the wrong track, and I tell them so. But because I listen to them, they listen to me. Funny how that works. Plus, by showing them how I apply critical thinking skills, it provides an opportunity to model rational thinking,which is therapeutic.

    Of course, I see people for 30 minute appointments, so there is time to do that. It is a reasonable thing to do, because it is actually part of their treatment. That may not be the case for those in other specialties.

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