Need for Scholarly, Objective Inquiry into Alternative Therapies

In the March 2001 issue, we were heartened to see your journal addressing the issue of alternative medicine in medical school education, but were disappointed by some of the articles that the editors selected for that issue. Unfortunately, those articles failed to address the topic in an open and unbiased fashion. It is clear that wide public use of complementary and alternative therapies requires a considered approach to this subject in medical education to create graduates who are “informed intermediaries” between the patient and the marketplace. This marketplace, it is true, may offer unproven or dangerous practices, products, and services. Unfortunately, the overall tone of several of the articles goes beyond skepticism to unconstructive pessimism; they are replete with unsupportable generalities that show a lack of familiarity with the authors cited and the field as a whole. From the beginning, statements such as “An evidence-based medicine movement has emerged in academic medicine at the same time that the use of unproven therapies has increased” (made by Grollman in his foreword) implying that contamination has crept into the ranks of academic medicine. Regarding alternative therapies, however, the author fails to adopt the responsible attitude of scholarly, openminded inquiry that underlies the scientific studies on which contemporary medicine is based. How many times in the history of science and medicine has premature foreclosure of inquiry led to unwarranted prejudice against life-enhancing and life-saving alternative or novel therapies and resulted in unnecessary delays in their adoption into the mainstream of medicine? I believe that a journal with the stature and high standards of Academic Medicine would better serve its readers by adopting a more open-minded, evidence-based approach to this controversial field, not just using EBM terminology to cloak bias. The Beyerstein article adopts the mode of an “attack” piece that not only diminishes the public and professional contributions of Drs. Herbert Benson and Andrew Weil, but seems to distrust the ability of the public to make any kind of rational separation of truth from fallacy in this field. This paternalistic view of patient autonomy, self-care, and desire for personal responsibility for care is inconsistent with the current evolution of medicine to a patient-centered model. Whatever the validity of alternative therapies, patients are increasingly using them on their own. Thus their physicians need to be well informed about the physiologic effects of these treatments as well as their potential interactions with conventional medical therapies in order to optimize the care they provide those patients. Marcus's dismissal as unscientific of Dr. Larry Dossey's thoughtful essay on the methodologic challenges of complementary and alternative medicine (CAM) shows limited understanding both of scientific methods other than the method demonstrated in the randomized controlled trial (RCT) and also of the considerable scholarly work of Dr. Dossey in the CAM area. In fact, the field of alternative medicine is currently in a healthy, ongoing process of investigation and critical appraisal. Dr. Sampson's objectivity is belied by his well-publicized bias toward a negative, “quack-buster” view of alternative therapies. He makes the a priori assumption that these therapies are predominantly fraudulent and highly suspect, despite evidence to the contrary, some of which is published in the most respected medical journals. Grollman's foreword seems to imply that if alternative therapies are effective, they are so predominantly through the placebo effect; this view underestimates the value of the placebo as well as the proven validity of many CAM therapies, beyond the placebo effect. On the other hand, the Talalays' article realistically addresses legislative and regulatory problems with herbs and supplements; these authors seem to appreciate that the notable successes of many modern therapies trace their origins to plants. Over time, the efficacy and mechanisms of action of these agents were demonstrated by empirical methods. Dispassionate, critical, systematic, evidence-based investigation is what is suggested in these pieces. The Frenkel and Ben Arye article on curriculum is likewise helpful and neutral in tone. In short, these authors model true scholarship in their approach, adopting skepticism without bias. Our institution and others are currently addressing the needs of learners in the domain of CAM with grants from the National Institutes of Health (NIH) and the National Center for Complementary and Alternative Medicine. At the University of Texas Medical Branch, we have initiated an NIH-funded project on curriculum development and educational research project called “Evidence-based Curriculum in Alternative Therapies.” The curriculum has goals in three axes: (1) Creating improved communication skills about CAM therapies between patients and providers, (2) teaching critical thinking skills to students and applying clinical decision making and evidence-based principles to evaluating CAM therapies, and (3) developing new skills and knowledge for students in well-evidenced CAM therapies that can be safely incorporated into their practices when they become physicians. Rather than proposing the “transmission of unproven practices,” as Dr. Marcus suggests, we as well as other educators are devising methods to show to students the hierarchy of evidence for alternative therapies. We also acknowledge the need to be familiar with culturally and historically defined practices that have not been and probably never can be fully evaluated by the scientific method or tested by randomized, controlled trials. Anthropologic, sociologic, and medical humanities approaches to practices such as traditional Chinese medicine, spiritual and religious practices, curanderismo, and Ayurveda will allow students to become competent in the cultural domains that fostered these practices. One value of studying the history of medicine and the influences of different cultures on medicine is that the student comes to see the world through a lens different from the purely biomedical view of reality. Such studies help caregivers to understand medicine as many patients see it, so they can provide more effective care. In the future, educational organizations such as the Association of American Medical Colleges need to support a healthy and reasoned discussion of alternative therapies in academic medicine. We would argue that a more balanced presentation of viewpoints, including those of authors who do not have “an axe to grind” on the topic (either pro or con), will shed the most light on controversies in this field. It is the least we as scholars in the field can do.