*Schulich School of Medicine & Dentistry, Western University, London, ON N6A 3K6, Canada
The opinions expressed in this piece are solely those of the author and do not represent those of HMSR. We welcome counterpoint submissions to be published in future issues.
Complementary and alternative medicines permeate health care today, yet undergraduate medical education fails to appropriately inform students of such therapies. Critical evaluation of CAM is necessary to produce well-informed physicians who are capable of providing evidence-based care.
During orientation week of first year medical school, the class visited small communities to experience how rural medicine was practiced. Here, we toured through the services these community health centers offered: physiotherapy among them. The first physiotherapist demonstrated how he treats patients with ankle injuries by mobilizing the affected joints. The second physiotherapist explained how he uses acupuncture to treat his patients’ pain by unblocking the flow of qi through their meridians. The third proudly displayed her magnet therapy machine, which she claims can cure anything from chronic arthritis to cancer. I knew immediately that one of these things was not like the others; one of these things didn’t belong.
Since I had completed my undergraduate degree in Life Sciences, I had developed a rather acute sense for questionable claims: those that don’t seem consistent with a scientifically informed view of the world. Nevertheless, I did my due diligence and looked into the evidence for these therapies. Joint mobilization is a legitimate treatment for ankle injury, decreasing time to return to pain-free movement, increasing function, and increasing range of motion (Green et al., 2001; van der Wees et al., 2006). Acupuncture, on the other hand, has failed to demonstrate efficacy in high-quality clinical trials using appropriate controls (i.e., sham acupuncture) for its major uses: low back pain, knee osteoarthritis, and migraine headaches (Ahn, 2013). Magnet therapy was more difficult to evaluate, due to the ambiguity of the claim and the general lack of evidence, but numerous studies found showed no benefit in the use of magnet therapy for patients with chronic low back pain, wrist pain (carpal tunnel), osteoarthritis, and motion sickness (Panush, 2013; Priesol, 2014; Kothari, 2013).
One of these things was not like the others; only one of these things was supported by evidence. I only knew this for certain because I went to the literature, but how many of my colleagues were less skeptical than I? How many future physicians trusted that their medical program would present to them only evidence-based therapies? How many are unable to identify a complementary or alternative medicine and distinguish it from an evidence-based medicine?
Later on in the year, I found myself at odds with some of my colleagues when the topic of complementary and alternative medicine (CAM) was raised. Having done extensive reviews of the existing literature around many CAM therapies, I knew that supporting evidence was scarce—to me this point was paramount; I took issue with the fact that most CAM therapies remain unproven and in some cases disproven. My colleagues, however, were more concerned with the effect that failing to support CAM would have on a physician’s relationship with their patient. They feared that if they were to criticize CAM in front of their patients who use it, the patients would feel alienated or distrustful toward the physician. My colleagues were so concerned with this that they seemed not to care whether or not the therapies they endorsed actually work. I believe that this reflects the structure of our undergraduate medical education (UME).
In medical school, we are taught that one of the most important skills to acquire is the ability to cultivate a trusting, honest, and non-judgmental relationship with your patient. This is undoubtedly an important characteristic, but it has been emphasized to the point that my colleagues were unable to approach the subject except in the context of the doctor-patient relationship; evidence, efficacy, and even safety had been put on the backburner. The result of this is the stagnation of academic discourse on the subject of CAM; it has become a topic people fear to criticize.
The purpose of medical school is not to produce physicians who forge strong relationships with their patients; the goal (according to the Royal College of Physicians and Surgeons of Canada) is to become a multi-faceted professional according to the CANMeds competencies, one of which is the role of health advocate (The Royal College of Physicians and Surgeons of Canada, 2005). To me, being a health advocate means not only favoring policies and practices that benefit health but also advocating against policies and practices that could have a detrimental effect. The American Medical Association Code of Ethics states, “It is unethical to engage in or to aid and abet in treatment which has no scientific basis and is dangerous, is calculated to deceive the patient by giving false hope, or which may cause the patient to delay in seeking proper care” (American Medical Association, 1996). I have not been able to find an analogous provision from the Canadian Medical Association. The closest recommendation in the CMA Code of Ethics is item 23: “Recommend only those diagnostic and therapeutic services that you consider to be beneficial to your patients or to others…” However, this is a provision based on the opinion of the physician, rather than the evidence (Canadian Medical Association, 2004).
Ultimately, I believe that this imbalance in the attitudes of medical students can be remedied by directly addressing CAM in UME. Several surveys have investigated medical students’ views on CAM, and all report that students have insufficient or no knowledge and understanding of the principles, efficacy, and safety of various CAM therapies (Chez et al., 2001; Hopper and Cohen, 1998). This is a problem since 70%–75% of Canadians report using CAM at least once, and 40% of Americans report using it in the past 12 months, and future physicians will need to make health care decisions involving CAM and have little or no formal instruction on it (Esmail, 2007; Barnes et al., 2008). Even physicians in current practice feel unprepared regarding CAM; according to a 2004 survey of California physicians, 61% do not feel sufficiently knowledgeable about CAM safety or efficacy, and 81% would like to receive more education on CAM (Milden and Stokols, 2004).
Physicians should be required to know, at least, basic information on the more popular CAM therapies (e.g., chiropractic, homeopathy, naturopathy, acupuncture, etc.), including the following: (1) the core beliefs and principles of the therapy; (2) a strict definition of the therapy*; (3) the evidence surrounding its efficacy; (4) the evidence surrounding its safety, including special populations who may be at increased risk compared to the general population (e.g., patients on warfarin can have life threatening interactions with Ginseng, a naturopathic remedy marketed as COLD-FX (Vázquez and L. Agüera-Ortiz, 2002); and (5) who typically uses it and for what purpose. A well-planned course during medical school could easily make a generation of physicians more aware and informed about exactly what other medical advice their patients might be receiving.
Medical students need to be more adequately prepared to critically evaluate therapies and draw conclusions accordingly. I consider evidence to be the pillar upon which conventional medicine is built, and the only thing that raises it to a higher standard of quality and reliability than every other healing practice that has arisen throughout human history. I believe that with the appropriate emphasis on evidence built into their education, future generations of physicians can be more shrewd and critical, not just of CAM, but of all therapies and questionable practices. This next generation can be true physician advocates that oppose unscientific medical practices on a policy level and enable patients to make informed decisions regarding treatment, whether in favor of the evidence or not. If the priority is placed, however, on maintenance of the doctor-patient relationship, at the cost of ignoring the evidence, we no longer have the right to call what we do evidence-based medicine.
*Strict definitions are important because CAM is so easily misrepresented. Acupuncture, for example, specifically refers to targeting meridians with needles to alter the flow of Qi; however, many use the term to refer to any type of needling (not on meridians), which is what well controlled studies call “sham acupuncture.”
Ahn, A.C. (2013) Acupuncture. In: UpToDate, Aronson MD (Ed), UpToDate, Waltham, MA. Accessed on August 26, 2014.
American Medical Association (1996) AMA’s Code of Medical Ethics. Accessed August 26, 2014.
Barnes, P.M., Bloom, B., and Nahin, R.L. (2008). Complementary and alternative medicine use among adults and children: United States, 2007. Natl. Health Stat. Report 12, 1–23.
The Royal College of Physicians and Surgeons of Canada (2005) CanMEDS 2005 Framework. Accessed August 26, 2014.
Chez, R.A., Jonas, W.B., and Crawford, C. (2001). A survey of medical students’ opinions about complementary and alternative medicine. Am. J. Obstet. Gynecol. 185, 754–757.
Canadian Medical Association (2004) CMA Code of Ethics. Accessed August 26, 2014.
Esmail, N. (2007) Complementary and alternative medicine in Canada: Trends in use and public attitudes, 1997-2006. Accessed August 26, 2014.
Green, T., Refshauge, K., Crosbie, J., and Adams, R. (2001). A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Phys. Ther. 81, 984–994.
Hopper, I., and Cohen, M. (1998). Complementary therapies and the medical profession: a study of medical students’ attitudes. Altern. Ther. Health Med. 4, 68–73.
Kothari, M.J. (2013) Treatment of carpal tunnel syndrome. In: UpToDate, Shefner JM (Ed), UpToDate, Waltham, MA. (Accessed on August 26, 2014).
Milden, S.P., and Stokols, D. (2004). Physicians’ attitudes and practices regarding complementary and alternative medicine. Behav. Med. 30, 73–82.
Panush, R.S. (2013) Complementary and alternative remedies for rheumatic disorders. In: UpToDate, Furst DE (Ed), UpToDate, Waltham, MA. (Accessed on August 26, 2014).
Priesol, A.J. (2014) Motion sickness. In: UpToDate, Deschler DG (Ed), UpToDate, Waltham, MA. (Accessed on August 26, 2014).
van der Wees, P.J., Lenssen, A.F., Hendriks, E.J.M., Stomp, D.J., Dekker, J., and de Bie, R.A. (2006). Effectiveness of exercise therapy and manual mobilisation in ankle sprain and functional instability: a systematic review. Aust. J. Physiother. 52, 27–37.
Vázquez, I., and Agüera-Ortiz, L.F. (2002). Herbal products and serious side effects: a case of ginseng-induced manic episode. Acta Psychiatr. Scand. 105, 76–77; discussion 77–78.