Tuesday, November 13, 2007

CAM and Medical Education: Close, But This is a No-smoking Section

Orac of Respectful Insolence and Panda Bear, MD have had some great things to say about so-called "complimentary and alternative medicine" lately, notably some discussion about the infiltration of woo at major universities, including Ohio State.

I have a cousin that graduated from their medical school. I cringe at the idea that he might've been infected with woo, or, perhaps just as bad, the idea that we should be absolutely tolerant of woo. On the other hand, the last time he and I talked shop, there was no indication that he was abandoning his promising career in anaesthesiology to become a swami or move out to Andrew Weil's place in Arizona, so I can let loose a sigh of relief for now.

Woo hasn't infiltrated my university, as far as I can tell--not yet, anyway. But if a recent lecture is any indication, the university isn't taking a hard stance against it. I can see why not. Such a maneuver would arguably be politically loaded, and my university advertises itself as a school for the liberal arts. Oh well. But as a current student receiving a medical education, I think I have a unique insight into what's going on in academics today. Call it "insider information," if you will.

At first, I was kind of worried. The professor started by explaining the regulatory process for homeopathic products in the U.S. Standard stuff, really. But then she got into talking about the Law of Similars and the Law of Infinitesmial Dose. Granted, she was prefacing her statements with "homeopaths believe" and "according to homeopathy," but the way she was talking left me wondering where she might be going with this lecture. Was she going to conclude that homeopathy was an equally valid way of looking at medicine, even if, as she admitted to us, she had trouble understanding how it was supposed to work? I scanned the audience for reactions from my peers. Inscrutible. How many of them knew anything about homeopathy and sCAM before this class? Considering that I found QuackWatch as an indirect result of an assignment about a year or so ago, I found it hard to believe that they could all be totally ignorant of the subject.

It was at this point that the professor noted that she wasn't entirely sure how she should give this lecture, and that was why she had prepared a video clip for us to watch instead. "Homeopathy," concluded the program clip, "is impossible." The clip got quite a few laughs, and when we took a short break afterward, the room was abuzz with student chatter. "I never knew homeopathy was infinitely diluted!" "Oh, so that's what homeopathy is?" "I knew a woman who..."

Honestly, it was a breath of fresh air.

The professor noted that she "had trouble" buying into homeopathy because she was a scientist. As a fan of evidence-based medicine, she couldn't recommend it to other people, nor did she think it was terribly useful. But she did note that a lot of people swear by it, and she joked that it was very popular with new parents--at that point, you're basically treating mom and dad instead of the kid. She made it very clear, in a roundabout, placating manner, that she didn't think homeopathy was useful medicine, but she didn't come down hard on it as a scourge.

I can see why this might be the approach taken by major universities. As I mentioned earlier, it's all about politics. I think it's fair to call it "appeasement," hearkening back to the days of the Communism and the Cold War, although that's potentially an overdramatic analogy. Some professors are afraid to step on the toes of their students, at least a few of whom might favor alternative medicine, or at least bear it no ill will. But I'm not sure that's the only motivation; I think that by strongly denouncing homeopathy, professors of medicine and science will look like rabid zealots, and students will slam their ears shut like Creationists do when their profs start discussing evolution. By presenting the case against sCAM too vociferously, we may alienate supporters by looking like fanatics. Instead, the strategy employed (at least, by this professor at my university) seems to be more along the lines of "here's some information, here's a video clip, make up your own minds." Which is good. The idea that ritualistic indoctrination against sCAM would be counter to the ideals of the critical thinking process.

It would also appear to validate the conspiracy theories of altmedders, but they aren't letting go of those anytime soon anyway.

So I understand the approach. But I still don't like the "appeasement." Medical professionals giving lip-service to sCAM as "having some potential value--making people feel better" when it "isn't likely to cause harm" is inconsistent, because I've also been told (although by another professor) that you should never reinforce patient delusions. And isn't it unethical--a lie by omission--to tell a patient, "it's okay, go ahead and try it, it might help and isn't likely to hurt?"

According to an article I dug up, 50% of medical interns learned about the use of placebos from other physicians. They are influenced by mentors and by writings by mentors, not necessarily taught to use placebos in an academic setting. It is obviously necessary to use placebos to conduct drug trials. But placebo usage in clinical settings is not ethical. Even the "evil" and "fascist" AMA says so. Imagine that, the AMA standing up for patients! How would you like your crow, CAM devotees?

It can't be all about money, at least, not from the end of academic institutions. I think some of them are legitimately afraid of alienating people by coming down hard on sCAM. And others fear that being too enthusiastically anti-sCAM will make them look like fascists, fanatics, or both. Herein lies the dilemma. If education is the primary weapon against sCAM, what are we going to do?


Anonymous said...

It appears that you are condemning Complimentary Alternative Medicine, CAM based on your knowledge of a singular modality, homeopathy. CAM is a broad term that incorporates traditional Chinese Herbal Medicine, Naturopathy, Chiropractic, Acupuncture, Ayurvedic, Osteopathic Cranial Manipulation (last time I looked Osteopaths had full prescribing authority in all 50 states and could be boarded in all medical subspecialties) and homeopathy (not an exhaustive list).

In your second to your last paragraph you imply that all CAM therapies are placebo or sham therapies. I do not disagree that one would be very hard pressed to find an MOA for homeopathic therapies that involved a biological target/receptor. However, that is not the case for herbal preparations. A vast majority of herbal agents have MAOs identified. The real question then becomes what level of evidence do we have to support the use of these agents? Have there been any head to head clinical trials? Do we have outcomes data? In response to these kinds of questions and the fact that the sale of CAM products grew from about 6 billion to 18 billion annually in 6 short years the NIH formed NCAM (http://nccam.nih.gov/) to formally look at the scientific merit of CAM therapies. CAM therapies may be most useful in the setting of wellness programs and not in the treatment of active disease, the allopathic model, but the jury is still out.

So do you totally dismiss CAM? If you do you are doing a large disservice to your patients. Pharmacists should take a very proactive role in learning about CAM and gaining as much knowledge as possible. Are you scratching your head at this point and asking yourself why? Pharmacists are best positioned to be the integrators of all this information. As you are aware often times it is the community pharmacist who has the whole medication profile available to them. We have all heard of the primary care provider that was unaware of what the specialist were prescribing. With CAM the vast majority of purchases are not made at pharmacies but at grocery stores. Take an active role become involved with your patients to help them make rational health care choices and recognize that many patients will try herbal products no matter what your recommendation and it is far better to know what they are using than not. Since they are not all placebos they can interact with prescription drugs.

So have you ever dispensed a prescription drug that has not been vetted by clinical trials? Look at the GRAS list for your answer; medicine/pharmacy is an imperfect science.

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