Teaching Alternative Treatments in Medical School

Two prominent physicians squared off at the University of Arizona last month to debate this question: “Is Integrative Medicine the Medicine of the Future?” The event occurred at the Arizona Health Sciences Center, the academic base of Andrew Weil, director of the university’s Program in Integrative Medicine.

A proponent of expanding medical education to encompass techniques and treatments often referred to as alternative medicine, Weil is an author whose works include “Spontaneous Healing” and “Eight Weeks to Optimum Health.”

Arguing against the incorporation of Weil’s agenda into the country’s medical schools was Arnold S. Relman, editor in chief emeritus of the New England Journal of Medicine and a professor emeritus at Harvard Medical School. In December, Relman published an article in the New Republic in which he criticized “alternative practitioners” such as Weil for promoting methods that “are often based on notions totally at odds with science, common sense and modern conceptions of the structure and function of the human body.”

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Below are excerpts from that debate.

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Relman: Integrating alternative medicine with mainstream medicine, as things stand now, would not be an advance but a return to the past--an interruption of the remarkable progress achieved by science-based medicine over the past century. I can’t see how such integration, even if it were possible, would improve medical care or further the cause of human health.

Future advances in clinical practice will depend on the application of new developments in science. Indeed, it is hard to imagine any progress at all in the prevention, diagnosis or treatment of disease without continued, even closer cooperation between modern science and evidence-based medical practice.

With the promise of so many new breakthroughs in the offing, why on Earth should we now want to drive a wedge between medicine and science? Alternative medicine stands apart from modern science, challenging many of its assumptions and methods and depending for its verification largely on personal belief and subjective experience. This allows the practitioners of alternative medicine to believe in the power of mind and thought to change physical matter and heal organic diseases--a concept that basically contradicts the laws of physics and the modern scientific view of nature.

Furthermore, considering all the dubious and disparate theories and practices gathered under the banner of alternative medicine, I don’t see how our medical schools could make sense of such a hodgepodge, much less unify it with conventional medicine, which is so fundamentally different. It simply can’t be done.

Most alternative systems of treatment are based on irrational or fanciful thinking and false or unproven factual claims. Their theories often violate basic scientific principles and are at odds not only with each other but with modern knowledge of the structure and function of the human body as now taught in our medical schools. They could not be woven into the fabric of the medical curriculum without confusion, contradiction and an undermining of the scientific foundation upon which modern medicine rests.

Here is just a very small but representative sample of the many unproven and often highly unlikely claims made by practitioners of alternative medicine led, most notably, by Dr. Weil.

1. Improper breathing is a common cause of ill health, and breathing exercises will cure disease and promote good health.

2. Massive doses of intravenous vitamin C speed the healing of surgical wounds.

3. Guided imagery, meditation or hypnotherapy will reduce the frequency of recurring attacks of herpes simplex.

4. Topical application of human urine is effective treatment for athlete’s foot.

5. Two tablespoons of ground flax seed daily reduces the risk of breast cancer.

6. Cutting down on sugar intake decreases the frequency of urinary tract infections in nondiabetic women.

7. Therapeutic touch and other forms of so-called energy medicine can heal disease through the manual transmission or adjustment of types of “energy” that are simply too subtle to be detectable by instruments.

8. Belief alone without any physical intervention can cure organic disease as proven by visits to miracle shrines, faith healers and Christian Science practitioners.

As for herbal therapy, it apparently would be an important feature of any proposed new curriculum. In one sense, herbal therapy should not be in fundamental conflict with the conventional medical curriculum because many plant-derived materials have been proven to have important biological effects. Unfortunately, however, herbal products are not regulated by the [Food and Drug Administration] and so commercially marketed herbal preparations are highly variable in content purity and potency. What is more, they pass no tests for therapeutic effectiveness or safety. Despite these facts, drugstore and supermarket shelves are filled with all kinds of herbal products and dietary supplements and consumers are being bombarded by a confusing and misleading advertising blitz.

We need to see many more control studies comparing standardized herbal preparations with conventional pharmaceuticals before concluding that herbs have any special advantage over conventional drugs and that herbal therapy should be taught in medical schools.

If any alternative methods prove to be effective in treating disease, they should be integrated into the medical curriculum, and they will be. All clinical biases and preconceptions, whether in alternative medicine or conventional medical practice, must fall before the objective evidence. And we should all be assiduous in seeking such evidence to improve our practices.

However, in the absence of evidence, it makes no sense to remodel our clinical training programs to include alternative medicines simply because many “customers,” to use Dr. Weil’s term, seem to want it.

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Weil: In this country and throughout the world, patients in unprecedented numbers are going outside of conventional medicine to look for help. This is a movement that has been building since the late 1960s and it’s now reached the point that visits to alternative practitioners exceed visits to primary-care providers, and the amount of money spent on these visits exceeds that spent on visits to primary-care providers. This is a very powerful social and cultural force that we’re witnessing.

Now why are people doing this? Clearly, there is dissatisfaction with conventional medicine. I don’t think it is simply with the recent impersonality and time constraints that have come with managed care, because this movement began long before that. In my experience--and I know this is a phrase that Dr. Relman doesn’t like, but I consider experience to be one valuable source of data--in my experience many patients use alternative methods because they work. They find that they work. And if a patient has tried a method and found that it works, that patient needs no further proof, does not need to read the reports of a randomized double-blind control trial in a medical journal to be convinced of the efficacy of treatment. So I think large numbers of patients have found that there are treatments out there that their conventional physicians do not know about, did not advise them about, that have worked for them and in some cases after conventional medicine has failed.

The vast majority of patients who now come to our integrative medicine clinic in this institution are patients who have been through conventional medicine, often many times over, have been tested to death, have tried many conventional therapies and have found that they haven’t worked or have caused harm or both. We have to take seriously this consumer movement.

There is a large and growing gulf in this country between what patients expect of doctors and what medical schools are training them to do. Patients want physicians who can take the time to sit down with them and listen and explain to them in language they can understand the nature of their problem. Who are aware of nutritional influences on health. Who will not just push drugs and surgery as the only approach to treating illness. Who can answer intelligently questions about dietary supplements. Who are sensitive to mind-body interaction. Who will not laugh in your face if you ask questions about Chinese medicine. . . . I think those are very reasonable requests and that’s not what we’re training physicians to do. And it is that gulf widening between patient expectations and physician realities that is leading so many patients to go elsewhere for treatment.

Our integrative medicine clinic has seen an enormous number of cancer patients over the past year and a half. And I must say I feel very sorry for many of these patients. I think they’re left out in the cold. Their conventional oncologists have given them standard treatments and tell them that there’s nothing else to be done--and they know that there are other things to be done. That there are things that can mitigate the toxicity of the standard therapies, can protect their immune systems from those therapies, can enhance general health--and they go to alternative practitioners who tell them that if they use the conventional therapies they may as well not bother with the alternative treatments. And so it’s the patient that suffers in this.

How much better it would be if there were physicians trained to advise patients about the intelligent combination of the different kinds of therapies that are out there. Again, this is what patients want.

I am all for refining our medical practice and making it more consistent with scientific evidence. But as Dr. Relman himself has pointed out in an editorial in the New England Journal, medicine constantly operates in areas of uncertainty where the evidence has not yet come in. And I think there is a great difference here between being a researcher and being a practitioner.

Now, as a researcher you have the luxury of insisting on rigorous scientific testing and you have the leisure to wait for results to come in. As a practitioner you are in the trenches working with patients who have medical needs and you often have to guess and you have to make use of your best medical judgment in the absence of definitive evidence. And as a practitioner, what do you do then? It seems to me you do the best you can. And the first principle from which you operate, or should operate, is that you do no harm. Now that was Hippocrates’ first teaching and it’s something that is not much stressed in medical education today.

As an example of that, I would cite a lead article that was published in the Journal of the American Medical Assn. exactly a year ago, titled “The Incidence of Adverse Drug Reactions in Hospitalized Patients” . . . that estimated that there are now 100,000 deaths a year in U.S. hospitals directly caused by pharmaceutical drugs. In contrast to the few disasters that happen with herbal medication, these are the correct drugs, correctly prescribed for the correct condition. These drugs have come through that process of rigorous testing. They have come through the FDA’s regulatory mechanisms. And nonetheless they are producing this degree of harm.

If integrative medicine did nothing other than reduce the incidence of this direct kind of . . . harm, I think it would be very worth incorporating into our medical schools and teaching.

I’d also like to comment on the kinds of bias that exist in conventional science. A very interesting article was published in the proceedings of the National Academy of Sciences on the use of MRI scans of the brain to show that stimulation of acupuncture points on the lateral aspect of the foot, which in traditional Chinese medicine are associated with vision, caused activation of the visual cortex.

That paper was rejected by the New England Journal of Medicine and the Journal of the American Medical Assn. Despite what Dr. Relman says, there is very strong prejudice against accepting ideas that run counter to preconceptions. I don’t think you can have it both ways. You can’t demand evidence and then when evidence is presented that contradicts your preconceptions say you aren’t going to look at it.

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Relman: I’d like to begin with one of the last points made by Dr. Weil, namely the suggestion that the medical establishment as represented by some of the leading medical journals, such as the New England Journal and JAMA, is suppressing heretical or unconventional data that ends up in an eminent journal like the Proceedings from the National Academy of Sciences.

It’s simply not true. The data submitted to the best medical journals are judged on their own basis. And if a paper that said what Dr. Weil says it said about acupuncture and changes in the brain was turned down by the New England Journal and JAMA, you can bet that the data was not convincing. . . . There is no bias. No bias at all. Every, every editor wants to publish good data on new and original ideas.

Now as far as his point about all the deaths from drugs and the problem there, I don’t know how reliable that number is, but there is no question that a lot of people die or are damaged from the side effects of prescription pharmaceuticals. No doubt about it. What’s the problem? The problem is largely not with the drug. It’s often due to the fact that the drug has a side effect that is not recognized promptly enough or the right drug was not given. The fact of the matter is that sometimes unexpected reactions occur that can’t be helped, but that’s part of the balance that you have to weigh of the drug’s benefit versus the risk and there are always . . . benefits and risks.

And finally, what do consumers want? They want, I believe, doctors whom they can trust, who are going to be honest with them and are going to tell them the truth. And if the truth is that alternative methods have not been adequately tested and we don’t know whether they can work or not, doctors should sympathetically and compassionately explain that to patients and not simply be indifferent to the fact that there is no evidence to support these methods.

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Weil: Dr. Relman asks how could you possibly, in a medical curriculum, evaluate this grab bag of so many different things and disparate methods and procedures. That’s exactly the mission of the program in integrated medicine here. That’s what we’re doing. We are trying to go through this and sort it all out and separate what is nonsensical and what is possibly harmful from what is potentially useful and to teach both doctors and patients to do that. I think both doctors and patients need to make those distinctions. I couldn’t agree more that the world of alternative medicine is a very rich mixture of ideas and practices that range from sensible and useful to ridiculous and potentially harmful and . . . the main priority of integrative medicine is to sort that all out.

Dr. Relman, considering the clear evidence that the public wants to use complementary and alternative medicine for both the prevention and treatment of diseases, how do you suggest that the medical establishment should respond? In particular, how should we educate medical students and physicians in training about these issues?

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Relman: Objective evidence should drive our practice of medicine. When there is no objective evidence, the fallback position is skepticism and reservation of judgment and . . . a whole lot of testing and a whole lot of data. Let Dr. Weil develop, let practitioners of alternative medicine develop the kind of experience that conventional medicine is based on before they want to change it, before they want to introduce new methods. I don’t object to evidence-proven medicine, but I object to medicine that hasn’t yet been tested.

Dr. Weil, you claim that many alternative healing methods work by a supposed mysterious power of mind over matter and you say quantum physics supports the existence of such a power. However, almost all physicists who have written about this subject say that quantum theory offers no support for the idea of the nonphysical causation of physical events. How do you reconcile the views of these scientists with your own and do you still advocate an integrated medical curriculum that would be based in significant part on what they say is a mistaken interpretation of modern physics?

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Weil: If I prescribe St. John’s wort for the treatment of depression or freeze-dried stinging nettles as a symptomatic treatment for hay fever, I find these to be clinically efficacious. There is research data to support this use.

There is a very strong emphasis in our program on mind-body interactions and this is an area that is very solidly researched and which we’ve been collecting data [on] for three decades now and I think there is abundant evidence for the reality of mind to affect the physical reality of the body.