Should medical students be taught about CAM?
Focus Altern Complement Ther 2005; 10: 101–3
Should medical students be taught about CAM?
Medical students should be taught about CAM to enable them to distinguish between truth and fiction
David Colquhoun
CAM is big business, and many patients are interested in it, so medical students must know something about it. They should be taught about CAM in exactly the same way as they are taught about all the other subjects they must master: the aim in all of them must be to enable the student to distinguish between truth and fiction. That is not as easy as it sounds because medicine as a whole has a long and distinguished record of the propagation of fictions. Within my lifetime ‘tonics’ (often with nux vomica, i.e. strychnine) and ‘demulcents’ were widely prescribed. Now the very categories have vanished.
It is unimaginable that, 400 years after Galileo, we should find it necessary to have departments of evidence-based physics. The idea is quite laughable. Yet it has been necessary to found departments, and journals, of evidence-based medicine, as opposed, presumably, to myth-based medicine. This, I take to be a residual sign of the recent time when medical people were commonly as authoritarian as Cardinal Bellarmino about what was true. Let us assume, though, that this age is passing. The generous view is that the backwardness of medicine in distinguishing truth from fiction is because it is surprisingly difficult to do so (and can sometimes be hindered by the suppression of relevant data for financial reasons). Vigorous arguments still rage about whether or not serotonin reuptake inhibitors are really much good as antidepressants, despite considerable efforts to find out. Much of the lore of physiotherapy is as untested as homoeopathy. And if it is hard to find out whether or not conventional medicines work, where real efforts are made, it is much harder to know whether or not CAM treatments work, where rather fewer efforts are made to find out. It is not as though we did not know what to do. A House of Lords report said clearly what should be done, the government gave some money to do it, but sadly the Department of Health allowed the money to be hijacked for other purposes.1
Thus, the first thing that medical students need to be taught is that it is very hard to assess whether or not any sort of treatment is really effective. They must also be told that the efforts made by CAM practitioners to tackle this difficult problem have been wholly inadequate. For this reason, teaching about CAM cannot be done by those who make a living from it; their vested interest is too great, and their knowledge of statistics almost always too small.
The second thing that medical students need to be aware of is the dilemma that is posed by placebo effects. It seems very likely that patients with terminal cancer do indeed feel better after reflexology treatment. From the point of view of the patient, it does not matter a damn whether it is a placebo effect or not. Of course it is very likely that any old foot massage, or just a good chat, would be as effective. But, guess what? Nobody knows. The placebo effect may not be a problem for the patient, but medical students must realise that is a big problem for them, and for universities. In susceptible patients it would not be surprising if the size of the placebo effect were maximised by incorporating as much mumbo jumbo into the treatment as possible. But mumbo jumbo means lies, and that is contrary to all the admirable efforts that have been made recently to make the medical profession more open, more honest and less authoritarian with their patients. Yet, the more lies, the better the placebo effect. That is a dilemma that has not yet been resolved. Indeed it is now considered unethical for a medical practitioner to knowingly prescribe a placebo since patients must give informed consent to treatment. Informing the patient that a prescription is a placebo would tend to destroy the placebo effect (a blinded clinical trial is different because the patient does consent to the chance of receiving a placebo). Of course there would be no dilemma if proper experiments had been done, but by and large they have not. If, as one might guess, foot massage or chat is as good as reflexology, then we should provide foot massage or chat. Without knowing what is true, we risk telling lies to patients, and we risk universities being pressurised into teaching degrees in the mediaeval mumbo jumbo of reflexology. That is why I think it is quite wrong for Peter Fisher2 to say (in a report on the ineffectiveness of a homoeopathic treatment for rheumatoid arthritis) ‘It seems more important to define if homeopathists can genuinely control patients’ symptoms and less relevant to have concerns about whether this is due to a “genuine” effect or to influencing the placebo response.’ Truth does matter.
CAM advocates are fond of portraying themselves as being persecuted by an intolerant establishment. While it is perfectly true that a few great ideas have been denounced as crackpot when first suggested (before the evidence became compelling), it is also true that the vast majority of crackpot ideas are simply crackpot. ‘Alas, to wear the mantle of Galileo it is not enough that you be persecuted by an unkind establishment; you must also be right.’ (Robert Park, of the American Physical Society).
References
* Garrow J, Glenn S, Wilson P et al. UK government funds CAM research. Focus Altern Complement Ther 2003; 8: 397–401.
* Fisher P, Scott DL. A randomized controlled trial of homeopathy in rheumatoid arthritis. Rheumatology 2001; 40: 1052–5. [Abstract]
David Colquhoun, FRS is a Professor at the Department of Pharmacology, University College London, Gower St, London WC1E 6BT. E-mail: d.colquhoun@ucl.ac.uk
Should medical students be taught about CAM?
Medical students should be taught about CAM to enable them to distinguish between truth and fiction
David Colquhoun
CAM is big business, and many patients are interested in it, so medical students must know something about it. They should be taught about CAM in exactly the same way as they are taught about all the other subjects they must master: the aim in all of them must be to enable the student to distinguish between truth and fiction. That is not as easy as it sounds because medicine as a whole has a long and distinguished record of the propagation of fictions. Within my lifetime ‘tonics’ (often with nux vomica, i.e. strychnine) and ‘demulcents’ were widely prescribed. Now the very categories have vanished.
It is unimaginable that, 400 years after Galileo, we should find it necessary to have departments of evidence-based physics. The idea is quite laughable. Yet it has been necessary to found departments, and journals, of evidence-based medicine, as opposed, presumably, to myth-based medicine. This, I take to be a residual sign of the recent time when medical people were commonly as authoritarian as Cardinal Bellarmino about what was true. Let us assume, though, that this age is passing. The generous view is that the backwardness of medicine in distinguishing truth from fiction is because it is surprisingly difficult to do so (and can sometimes be hindered by the suppression of relevant data for financial reasons). Vigorous arguments still rage about whether or not serotonin reuptake inhibitors are really much good as antidepressants, despite considerable efforts to find out. Much of the lore of physiotherapy is as untested as homoeopathy. And if it is hard to find out whether or not conventional medicines work, where real efforts are made, it is much harder to know whether or not CAM treatments work, where rather fewer efforts are made to find out. It is not as though we did not know what to do. A House of Lords report said clearly what should be done, the government gave some money to do it, but sadly the Department of Health allowed the money to be hijacked for other purposes.1
Thus, the first thing that medical students need to be taught is that it is very hard to assess whether or not any sort of treatment is really effective. They must also be told that the efforts made by CAM practitioners to tackle this difficult problem have been wholly inadequate. For this reason, teaching about CAM cannot be done by those who make a living from it; their vested interest is too great, and their knowledge of statistics almost always too small.
The second thing that medical students need to be aware of is the dilemma that is posed by placebo effects. It seems very likely that patients with terminal cancer do indeed feel better after reflexology treatment. From the point of view of the patient, it does not matter a damn whether it is a placebo effect or not. Of course it is very likely that any old foot massage, or just a good chat, would be as effective. But, guess what? Nobody knows. The placebo effect may not be a problem for the patient, but medical students must realise that is a big problem for them, and for universities. In susceptible patients it would not be surprising if the size of the placebo effect were maximised by incorporating as much mumbo jumbo into the treatment as possible. But mumbo jumbo means lies, and that is contrary to all the admirable efforts that have been made recently to make the medical profession more open, more honest and less authoritarian with their patients. Yet, the more lies, the better the placebo effect. That is a dilemma that has not yet been resolved. Indeed it is now considered unethical for a medical practitioner to knowingly prescribe a placebo since patients must give informed consent to treatment. Informing the patient that a prescription is a placebo would tend to destroy the placebo effect (a blinded clinical trial is different because the patient does consent to the chance of receiving a placebo). Of course there would be no dilemma if proper experiments had been done, but by and large they have not. If, as one might guess, foot massage or chat is as good as reflexology, then we should provide foot massage or chat. Without knowing what is true, we risk telling lies to patients, and we risk universities being pressurised into teaching degrees in the mediaeval mumbo jumbo of reflexology. That is why I think it is quite wrong for Peter Fisher2 to say (in a report on the ineffectiveness of a homoeopathic treatment for rheumatoid arthritis) ‘It seems more important to define if homeopathists can genuinely control patients’ symptoms and less relevant to have concerns about whether this is due to a “genuine” effect or to influencing the placebo response.’ Truth does matter.
CAM advocates are fond of portraying themselves as being persecuted by an intolerant establishment. While it is perfectly true that a few great ideas have been denounced as crackpot when first suggested (before the evidence became compelling), it is also true that the vast majority of crackpot ideas are simply crackpot. ‘Alas, to wear the mantle of Galileo it is not enough that you be persecuted by an unkind establishment; you must also be right.’ (Robert Park, of the American Physical Society).
References
* Garrow J, Glenn S, Wilson P et al. UK government funds CAM research. Focus Altern Complement Ther 2003; 8: 397–401.
* Fisher P, Scott DL. A randomized controlled trial of homeopathy in rheumatoid arthritis. Rheumatology 2001; 40: 1052–5. [Abstract]
David Colquhoun, FRS is a Professor at the Department of Pharmacology, University College London, Gower St, London WC1E 6BT. E-mail: d.colquhoun@ucl.ac.uk
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