Respectful Insolence

I don’t know about you, but I was getting a little tired of writing so often about the same topic last week, namely the insinuation of unscientific and unproven “alternative medicine” into the medical school curriculum and its promotion by the American Medical Student Association (AMSA). I had planned on giving the topic a rest for a while, but then on a mailing list to which I subscribe, an example came up of something so outrageously egregious that I had to post just one more time. (Dr. R. W., as usual, has beaten me to it, but I plan on going into it in a little more detail.) It’s a terrifying example of what can happen if you let a little pseudoscience in; pretty soon it’s taking over medical schools. Worse, it’s showing up at a prestigious medical school where, I would have hoped, the faculty should know better.

Apparently my assessment was overly optimistic.

Just look at this brochure published by the Georgetown University School of Medicine. If you’re scientifically inclined with me, it ought to make you shudder. I thought I was being facetious (or at least half-facetious) when I entitled an article: Woo: The Future of American Medicine? Maybe the joke’s on me, and woo really is the future of American medicine. Certainly, if other medical schools start following Georgetown’s lead, it will be. Not content to offer complementary and alternative medicine (CAM) modalities as part of electives that interested students can take if they are so inclined, Georgetown is taking the next logical step that I feared: It’s dedicating significant educational resources and time to teaching CAM in its mandatory general medical curriculum, where every student has to learn it:

Figures on how medical schools are introducing CAM education are less definitive. Another study published in JAMA in 1998 reports that 75 of the 117 participating U.S. medical schools offer CAM elective courses or include CAM topics in required courses.

“One of the reasons CAM is usually offered as an elective is that there’s just no time or room in U.S. medical schools to fit in one more massive subject,” says Michael Lumpkin, Ph.D., professor and chair of the department of physiology and biophysics at Georgetown. “When the course is an elective, a self-selected group – maybe 10 or 20 students in a class of 180 medical students – will take it,” Lumpkin says. “What we’ve tried at Georgetown is rather than create all new courses, we take relevant CAM issues and modalities and weave them seamlessly into existing courses.

The “seamless” weaving of CAM into existing classes includes, for instance, a presentation by an acupuncturist on the “anatomy of acupuncture” in the gross anatomy course for first-year students. The same lecturer explores acupuncture’s application in pain relief in the neuroscience course…

Haramati and Lumpkin say Georgetown’s program is distinct from CAM initiatives in other medical schools in two ways: The school is integrating CAM education into existing course work across all four years of each student’s medical education, and the initiative includes a mind-body class to help students use techniques to manage their own health and improve self-care.

Teaching the “anatomy of acupuncture” in formal anatomy classes that every medical student has to take and pass? Great. Heck, why not teach “intelligent design” creationism in basic biology classes while they’re at it? Next they’ll be teaching Samuel Hahnemann’s “principle of similars” and concept of homeopathic dilution in biochemistry and pharmacy classes! Or maybe they’ll teach about qi in physiology or neurology. In fact, Georgetown’s program is actually coming close, as it is teaching a veritable cornucopia of altie favorites, including: the anatomy of acupuncture; stress hormone modulation in physiology; “mechanisms” of acupuncture action in neuroscience; and psychoneuroimmunology in immunology courses. In fact, it’s worse than that. Woo is apparently being integrated into every aspect of every year of the four year curriculum:

The first year will include an introduction to CAM practices in ambulatory care. In the program’s second year, Georgetown aims to double the number of mind-body session groups and introduce CAM-related issues in lectures in the pharmacology, microbiology, and pathology courses in the students’ second year of medical school.

A CAM elective will also be offered to fourth-year students. Between year two and three of the program, a biomedical research component for students will be introduced; in the remaining years, CAM will be further integrated into the rest of the preclinical courses and most of the clinical clerkships.

“We welcome the medical students to participate with us in conducting those research projects,” Lumpkin explains. “If students get involved in these research projects, it will allow them to go to the cutting edge of CAM. They will become the thought leaders in this field.”

In other words, they will become advocates for woo–exactly what medicine doesn’t need. Geez, as I pointed out before, this sort of woo is actually losing favor in China, where many of the concepts of traditional Chinese medicine that underlie large swaths of alternative medicine originated. Here the same concepts are taking over the medical school curriculum. And Georgetown’s reasoning for integrating woo so deeply into the curriculum strikes me as disingenuous:

Haramati realizes that some mainstream medical practitioners remain skeptical of CAM due to the perception that such therapies lack the rigorous scientific testing that traditional therapies undergo. That’s why exposing medical students to CAM practices and principles is so important, he says.

“Perception”? It’s not just a “perception.” The vast majority of CAM therapies do lack rigorous scientific testing that mainstream medical therapies must undergo. That’s a fact, not a “perception.” So what is Georgetown’s solution? Integrate it into the curriculum because it’s not scientifically validated? That’s putting the cart before the horse! It needs to be validated first. They do, however, give one reason that’s semi-reasonable:

“Rather than to say ‘there’s no data here, why teach it?’ we need to inform our students as much as possible about the therapies that are out there … ‘what does the research tell us, which are useful, which are dangerous’,” Haramati explains. He is also quick to note the initiative is not a program of advocacy. “We’re not teaching a belief system or teaching students to practice CAM, but rather we’re informing students about CAM.”

My retort would be that it’s not necessary to integrate this woo deeply into the curriculum in order to accomplish this. For the vast majority of CAM therapies, a brief overview would be all that is needed. It is not necessary to teach “acupuncture points” in regular anatomy class, particularly when there is no evidence that these points mean anything on a strictly anatomic and physiological basis. The organizers of this curriculum also point out that many people take herbal remedies and dietary supplements, many of which can interact with standard drugs, and cite this as a justification for teaching CAM. That is perhaps their best argument, but my retort would be that it’s not necessary to integrate various non-herbal aspects of CAM into the curriculum to accomplish this. In pharmacology class, all that would have to be done would be, when teaching drug interactions, to include herbal remedies and supplements among the compounds and drugs that can interact with each new medication that is discussed and perhaps include a module on such remedies. Drug interactions are a very important topic, and It is not necessary at all to integrate woo into the medical school curriculum to warn future physicians of what herbal medicines might interfere with various drugs.

As for not being a program of advocacy, if that’s the case, then why is Georgetown not only teaching but also actively encouraging the use of “mind-body” skills that may or may not have any scientific basis by its own medical students? This is what I’m talking about:

Year one of the five-year grant began in fall 2001, with CAM lectures integrated into basic science classes. In winter 2002, educators are introducing a new workshop, “Mind-Body Medicine: An Experiential and Didactic Introduction,” which includes topics on a wide range of mind-body approaches, including meditation, nutrition, physical exercise, relaxation, and self-awareness. Students meet in three or four groups of eight to ten people each.

“Over the next five years we’ll be training additional faculty facilitators,” Haramati says. “Then they’ll form their own groups until the entire medical school class is exposed to the utilization of mind-body skills.” “The idea is to help students with the stress of the intense course of study and expectations that come with medical school,” Lumpkin adds. “By learning their own techniques of self-care, students will naturally internalize that and then be able to use it with their patients in the future. This is a skill physicians generally lack because it’s something they were never taught. In some cases it was debunked as being nonsense. Now there’s a new view of its usefulness.”

Let’s see. Georgetown is teaching “mind-body” medicine to its medical students and actively encouraging them to use it, all in the context of teaching other areas of woo. Sure, the faculty claim that they will be teaching students to “critically assess” the various CAM modalities, but you’ll excuse me if I remain skeptical. As I’ve pointed out before, such programs may start out with the best of intentions with regards to a critical assessment of the evidence (or, in the cases of most CAM, the lack of evidence for its efficacy). However, over time, these things tend to develop a momentum of their own. They also tend to get taken over by true believers. This is probably because most doctors committed to EBM just aren’t that interested in CAM because there’s not much good evidence for the vast majority of modalities that fall under its label and because so many CAM modalities are associated with spiritual/religious concepts underlying them that have no business in science. Moreover, advocates of CAM tend to be much more passionate about promoting it than skeptics are about expressing their skepticism about it. Indeed, if they do, they often are labeled as “close-minded” or “intolerant.”

Like the program at the University of Michigan that I mentioned the other day, the CAM program at Georgetown is funded by a grant from the National Center for Complementary and Alternative Medicine (NCCAM). And here’s where we come to the most pernicious effect of all of NCCAM. The problem is that NCCAM doesn’t just fund grants to study CAM, which, although it often leads to studies of dubious scientific merit about therapies lacking even scientific plausibility, much less data, at least is an intellectually and scientifically defensible endeavor. Unfortunately, NCCAM goes beyond this and funds grants to promote the teaching–indeed, the integration–of CAM in medical schools before these modalities are scientifically proven. Once again, this putting the cart before the horse. The usual order of things in medical education is that modalities to be included in the medical curriculum must first have considerable evidence of efficacy such that they are considered standard of care. Medical school is where students learn the basics. During the first two years they learn the well-established basic science, and during the second two years they learn how to take care of patients according to the standard of care. Then they go on to residency, where they expand on the basics and progress to more advanced education in their therapy. The topics and therapies that Georgetown is integrating into its curriculum are neither well-established science nor the standard of care. Teaching unproven CAM modalities so extensively in the core medical school curriculum rather than as electives is neither scientifically nor educationally appropriate, as it puts the imprimatur of scientific medicine as represented by medical schools on therapies that are anything but scientific.

The virus is spreading.

Comments

  1. #1 Andrew Dodds
    November 20, 2006

    At this rate, in 20 year patients will be going across the border to Mexico for strange, novel treatments like ‘Chemotherapy’ and ‘Surgery’..

    On the other hand it will help with the whole US social security problem, what with people not living as long..

  2. #2 bob koepp
    November 20, 2006

    I think I’m pretty “open-minded” about alternative treatment modalities, and I think there probably are a few things that we still need to learn about human health and disease. What concerns me most about the warm embrace of woo in medical schools is that medical professionals and their students, people who are supposed to have been trained to think scientifically, can’t manage even simple inferences linking (or not) evidence and hypotheses. It’s scary to think that people who can’t distinguish good from bad reasoning are treating real flesh and blood patients.

  3. #3 Joshua
    November 20, 2006

    This makes me want to vomit. Quick, someone call an M.D. in Reiki therapy!

  4. #4 Catherina
    November 20, 2006

    oi woo – just as my daughter tells me she wants to go to medical school and become a doctor. She’ll graduate high school in 6 years, by that time she’ll only need knowledge in woo. Do you think I should make her do her work placement in a chiropodist practise to boost her CV for the application?

  5. #5 anonimouse
    November 20, 2006

    Oh. My. God.

    Thankfully, if one of the folks on the curriculum committee here tried to force CAM into first-year classes as a required part of their education, I think they’d be shot. Hopefully.

  6. #6 Joe
    November 20, 2006

    Here is the link for a course that, I think, gets it right:

    http://biochemistry.louisville.edu/education/altmed.htm

    The author reviews each claim made in major areas of AM, and then explains what is wrong. Anyone interested in up-to-date references on AM should download this material while it is still available.

  7. #7 Abel Pharmboy
    November 20, 2006

    Just when I thought we basic scientists were being left out in the cold, I learned that Georgetown also offers a 11-month MS in Physiology focusing on Complementary and Alternative Medicine.

    But why not a Ph.D.?

    (In their defense, they at least seem to have a pretty modest urban medicinal herb garden; I just don’t know anything about the faculty members who teach that part of the curriculum.).

  8. #8 Hyperion
    November 20, 2006

    There is a flip side to this as well, however:

    If it becomes widely known that a Georgetown Medical degree means substandard education in unproven pseudomedical techniques, how long will it be before the perceived value of that degree declines precipitously?

  9. #9 Infophile
    November 20, 2006

    Is there no one on that campus willing to speak out against this? I mean, if the woos tried to invade my university, I know I’d be fighting them tooth and nail. Maybe they’re taking a stealthy approach, and on the first day of class students will find posters explaining the flaws of woo mystery taped to the classroom doors.

    Unfortunately, that’s probably not going to happen. Skeptic activists are far too rare.

  10. #10 JoE
    November 20, 2006

    Infophile,

    “Skeptic activists are far too rare.”

    Do you mean sophomores like you?
    http://www.blogger.com/comment.g?blogID=30970875&postID=115758448927257674

  11. #11 Cain
    November 20, 2006

    I’m a Georgetown alum, and this sickens me. I started a thread over on one of the off-topic message boards at the basketball fan site, if anyone is interested. Link: http://hoyatalk2.proboards48.com/index.cgi?action=display&board=bluegray&thread=1164041915&page=1” rel=”nofollow”

  12. #12 Sastra
    November 20, 2006

    The “woo” you cite seems to sound more or less reasonable — meditation, nutrition, physical exercise, relaxation, and self-awareness. I would think they were already integrated into mainstream medicine, or should be. And my understanding is that some forms of acupuncture, which use electric needles and ignore all the nonsense on ‘chi,’ do seem to show some benefit for pain relief. If so, then the danger is that, now that they have a foot in the door, full blown woo will be able to enter on the strength of the not-so-unreasonable forms.

    The possible up side would be if “alternative medicine” is retranslated and redefined as limited only to “meditation, nutrition, physical exercise, relaxation, and self-awareness,” with other forms dropped.

    Ok, yeah, but I said it was only “possible.”

  13. #13 Amy Alkon
    November 20, 2006

    If you believe Reiki works, then hire me as your Reiki car mechanic. Here’s how it works: You pay me $300, give me a glass of Pouilly-Fuissé, raise the hood of your car, and I’ll wave my hands over your engine. Sound fair?

  14. #14 Valhar2000
    November 21, 2006

    Hyperion: [...]how long will it be before the perceived value of that degree declines precipitously?

    Centuries.

    Terry Prattchett got it right when he wrote this: “You have to be human to be this stupid; an animal couldn’t do it.”

    Truer words were neevr spoken.

  15. #15 Infophile
    November 21, 2006

    The “woo” you cite seems to sound more or less reasonable — meditation, nutrition, physical exercise, relaxation, and self-awareness.

    With the exception of meditation and self-awareness, those aren’t CAM practices at all. Seems to me like they’re stealing legitimate subjects and claiming they’re CAM in order to make CAM look good. Meditation and self-awareness seem innocuous, but they tend to simply be woo-filled ways to just relax.

    That’s not all that’s in the brochure, either. The first page mentions “…acupuncture, biofeedback, chiropractic,
    herbal treatments, meditation, and other care practices.” All of these subjects, interestingly enough, are mostly woo but have a small portion of legitimacy. They’re not jumping in the deep end quite yet, but they’re slowly wading out.

    JoE: Random insult aside, linking to a post where you make a claim isn’t evidence of the claim’s truth.

  16. #16 Darrin Cardani
    November 27, 2006

    So what happens when some first year student, upon being taught acupuncture during anatomy, starts asking questions like, “what do these meridian structures in the body look like?” Or, “What device do we use to measure the energy running along the meridians to make sure we aren’t giving too much or too little?” I mean honestly, how are they going to answer such questions? Aren’t they worried that the other students will see through their BS at that point and question the validity of the rest of their course of study?

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