BMJ 2014;348:g2417 doi: 10.1136/bmj.g2417 (Published 28 March 2014)
Page 1 of 3
Head to Head
HEAD TO HEAD Should medical students be taught alternative medicine? Doctors should be able to discuss the non-evidence based therapies that patients want to try, says Graeme Catto. But Nick Cork and Gareth Williams say that students risk being indoctrinated and should be taught only about interventions that have been shown to be safe and effective 1
2
Graeme Catto president , Nick Cork medical student , Gareth Williams emeritus professor of 3 medicine and senior research fellow in philosophy College of Medicine, Guy’s Hospital, Great Maze Pond, London SE1 9RT, UK; 2School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK; 3University of Bristol, City of Bristol BS8 1TH, UK 1
Yes—Graeme Catto “Demonstrate awareness that many patients use complementary and alternative therapies, and awareness of the existence and range of these therapies, why patients use them, and how this might affect other types of treatment that patients are receiving.”1 This guidance, from the UK General Medical Council’s Tomorrow’s Doctors encapsulates lucidly and concisely why medical students are taught about alternative medicine. I find it difficult to conceive of a counterargument.
The choices patients make To provide quality care doctors must be aware of choices patients make and be able to discuss them in an informed and non-judgmental way. Any other approach puts the doctor-patient relationship at risk. Patients are reluctant to raise issues that they believe meet with disapproval. These principles apply to complementary and alternative medicine the same way as to other lifestyle choices. And this is a choice made by many people in the United Kingdom. The annual spend on alternative health treatments has been estimated to be as much as £5.4bn (€6.5bn; $8.9bn).2 All aspects of medical care are involved and not only in general practice. As a nephrologist I learnt that patients wanted complementary therapies to relieve some of the intractable and distressing symptoms, such as skin itch and restless legs, associated with chronic renal failure. Patients discussed among themselves the therapies they found useful. For my part I checked that there were no known interactions with their current conventional treatment and was pleased if symptoms were relieved. With the development of the internet and social media, such suggestions for self care and for complementary therapy are much more readily available and circulate more rapidly. Serious
drug interactions are fortunately not common; St John’s wort, however, increases the effect of conventional antidepressants, and evening primrose oil increases the effect of warfarin with potentially serious consequences.3
Where efficacy has been accepted In 2000, the House of Lords Select Committee on Science and Technology produced a far sighted report on complementary and alternative medicine.4 It recognised the weakness of the evidence base and the difficulty of identifying funding for necessary but expensive clinical trials. So what has changed since then? Perhaps not a great deal. The National Institute for Health and Care Excellence recommends complementary and alternative therapies only in a limited number of conditions where efficacy has been accepted. The Alexander technique is suggested as part of the treatment for Parkinson’s disease,5 ginger and acupressure for reducing morning sickness in pregnancy,6 and acupuncture and massage for persistent low back pain.7
Complementary therapies are, however, widely used in cancer and palliative care, and the National Cancer Institute at the National Institutes of Health provides information on research activity and clinical practice in the US.8 Many of these treatments relate to relaxation and meditation techniques thought to be of value for patients with life threatening illnesses. That hypothesis gained support from an unexpected source. Elizabeth Blackburn, awarded the Nobel prize in 2009 for her work on telomerase, and her colleagues showed that increased telomere length protected not only the chromosome but the cell against the ageing process and cell death. They have further shown that meditation and relaxation increase telomerase activity and telomere length thus providing objective information on the effect of complementary medicine at the cellular level.9
Correspondence to: Graeme Catto [email protected], Nick Cork [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g2417 doi: 10.1136/bmj.g2417 (Published 28 March 2014)
Page 2 of 3
HEAD TO HEAD
These are not isolated examples. Dean Ornish and his colleagues have shown in patients with prostatic cancer that changes in lifestyle and diet have been associated with lengthening of telomeres.10 We await to see if these cellular changes are associated with an improved prognosis. Similar dietary and lifestyle changes have produced lasting improvements in patients with coronary artery disease. These interventions are now accepted as good practice in cardiovascular disease and in preventing both obesity and type 2 diabetes. In these situations, concepts that may originally have been considered as complementary to conventional medicine are now widely adopted. One of the joys of medicine is dealing with uncertainty. The evidence base for much of our current practice is weak. I believe, as once did the GMC, that doctors “must work with colleagues and patients . . . to help resolve uncertainties about the effects of treatments.”11 That means following the scientific evidence and questioning established practice. Iain Chalmers has spoken movingly of the many infant deaths caused by the inadequately researched advice to place young children in the prone position for sleep.12 Volumes of learned articles seeking to cure peptic ulcers by reducing gastric acid secretion were shown to be irrelevant, even if scientifically valid, by the discovery of Helicobacter pylori. Good doctors have always had the flexibility to change their practice in the light of new evidence and patients have benefitted.
Partnership and support In many clinical situations, however, modern medicine is able only to modify, not cure, the underlying condition. Optimum management of long term conditions requires partnership among the patient, the doctor, and the other members of the healthcare team. It is not surprising that many patients turn to complementary and alternative therapies when their symptoms persist. The good doctor will provide support while advising against any treatments that may be dangerous or conflict with their current drugs. We may not require a randomised controlled trial to know that aromatherapy makes some patients feel better or that yoga has benefits. Learning to work well in partnership with patients is an essential skill for all of us and not only medical students. If you accept that premise, understanding something about complementary and alternative therapies is an essential component, like it or not.
No—Nick Cork and Gareth Williams In 1910, the Flexner Report13 brought much needed scientific rigour to medical education in the United States and led directly to the closure of many schools that taught chiropractic, naturopathy, and homoeopathy. Now, over a century later, alternative medicine has insinuated itself into medical education in the UK. In 2010, 18 of the UK’s then 31 medical schools responded to a survey about the teaching of so called “complementary and alternative medicine” (CAM) within the undergraduate programme.14 All 18 stated that CAM was an integral part of the curriculum, including student selected research projects in eight, and formal teaching (ranging from a single lecture to a theme running throughout the programme) in six.
Mainstream, science based medicine is far from perfect. Many shelves in the therapeutic cupboard remain depressingly bare, and the evidence base for many drugs is patchy or skewed by fashion, industrial lobbying, and publication bias. Not For personal use only: See rights and reprints http://www.bmj.com/permissions
surprisingly, as many as 52% of UK patients have tried an alternative medicine at some point, most commonly herbal medicine, homoeopathy, aromatherapy, massage, or reflexology.15 These options undoubtedly provide comfort for some, even if only through a placebo effect.
What’s the evidence? However, alternative therapies must be tested as rigorously as conventional drugs, and like them must be rejected if they prove to be useless or dangerous. A recent review carried the provocative title, “How much of CAM is based on research evidence?” The answer: very little. Of 685 alternative therapies investigated through adequate clinical trials and meta-analyses, only 7% showed any evidence of efficacy, and this figure may be an overestimate.16 There is certainly no scientific basis for homoeopathy, as illustrated by the world’s most popular homoeopathic remedy, Oscillococcinum, recommended for colds and flu. The allegedly active ingredient, the viscera of the Muscovy duck, is supposedly a rich source of a bacterium that has never been shown to exist.17 One duck would provide enough material to treat every person on the planet, but unfortunately there is not enough water in the solar system to produce the “therapeutic” dilution of one part in 10200. Contrary to propaganda, these therapies are not risk free. Various systematic reviews have attributed 121 fatalities to acupuncture, chelation therapy, and chiropractic, and 1159 adverse events, including four deaths, to the use of homoeopathy.18 19 Herbal therapies—particularly ginkgo, ginseng, kava, and St John’s wort—may interact with common conventional medicines, potentially with mild to severe consequences.20
What are we teaching our students? These shortcomings of alternative therapies are not adequately discussed in undergraduate curricula. In a recent survey of 25 medical schools,21 one third of the 95 students who responded reported that those teaching alternative medicine failed to provide evidence of efficacy. Twenty students in the same survey indicated that their self selected research project lacked scientific rigour because the supervisor was reluctant to confront evidence against alternative therapies. Moreover, students in at least one medical school are taught about alternative therapies during their first year, before fully covering pharmacology or the principles of evidence based medicine.
In this era of evidence based medicine, it seems strange that alternative therapies should have found their way into medical curricula—especially when the undergraduate teaching programme is already overcrowded. Who has driven this change? In the UK, alternative medicine has the stamp of approval of the royal family and various celebrities. It enjoys the support of some senior doctors and the grandly named College of Medicine, which collaborates to run courses entitled “Integrating complementary medicine in everyday practice”22 in line with its objective of “promoting, fostering and advancing an integrated approach to healthcare.”23
Seductive yet utterly devoid of scientific merit The defences against the invasion of unscientific material should centre on the UK regulator, the General Medical Council, which dictates the content and emphasis of the nation’s medical education programmes and has the power to close down medical schools that fall short of the mark. In Tomorrow’s Doctors (2009)24 the GMC’s guidance is that qualified doctors should “demonstrate awareness that many patients use complementary and alternative therapies, and awareness of the existence and Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g2417 doi: 10.1136/bmj.g2417 (Published 28 March 2014)
Page 3 of 3
HEAD TO HEAD
range of these therapies, why patients use them, and how this might affect other types of treatment that patients are receiving.” This seems entirely reasonable, but incompatible with the GMC’s guidance, in Good Medical Practice (2013), that “in providing care you must provide effective treatments based on the best available evidence.” In medicine, there are few concepts as seductive yet utterly devoid of scientific merit as alternative therapies. Doctors must be aware that these exist, and that they have limitations and contraindications, to help patients to make informed decisions about using them or not. Beyond this, we argue that teaching alternative medicine to medical students is illogical and a waste of time. It is unethical to indoctrinate students when they might not yet have acquired the critical skills to decide for themselves whether a particular therapy is effective, safe, and affordable. Moreover, it takes a great deal of courage for medical students—especially in their junior years—to challenge or contradict their teachers.
There is no place in the undergraduate curriculum for promoting any treatments that are not underpinned by hard evidence that they work and are acceptably safe. The GMC has appointed itself the guardian of quality and scientific rigour in medical training in the UK. It should now follow the example of Abraham Flexner and ensure that teaching about alternative medicine in UK medical schools is strictly reviewed—and removed if it does not meet the basic criteria of efficacy and safety.
5 6
7 8 9 10
11 12 13 14 15 16 17 18 19 20
The authors have read and understood the BMJ Group policy on declaration of interests and declare the following interests: GC is president of the College of Medicine and a former president of the General Medical Council. NC and GW have no relevant interests to declare.
21
1
24
2 3 4
General Medical Council. Tomorrow’s Doctors. 2009.www.gmc-uk.org/education/ undergraduate/tomorrows_doctors.asp. Leggatt J. Complementary medicine: seeking out alternatives. Telegraph 11 Jun 2008.www. telegraph.co.uk/health/alternativemedicine/3355120/Complementary-medicine-seekingout-alternatives.html Moses GM, McGuire TM. Drug interactions with complementary medicines. Aust Prescr 2010;33:177-80. Select Committee on Science and Technology. Sixth Report. Complementary and alternative medicine. House of Lords, 2000. www.publications.parliament.uk/pa/ld199900/ ldselect/ldsctech/123/12301.htm.
For personal use only: See rights and reprints http://www.bmj.com/permissions
22
23
National Institute for Health and Care Excellence (NICE). Parkinson’s Disease: diagnosis and management in primary and secondary care. NICE clinical guideline 35. Jun 2006. http://publications.nice.org.uk/parkinsons-disease-cg35/guidance#other-key-interventions. National Institute for Health and Care Excellence (NICE). Antenatal care. NICE clinical guideline 62. 2008. http://pathways.nice.org.uk/pathways/antenatal-care#path=view%3A/ pathways/antenatal-care/routine-care-for-all-pregnant-women.xml&content=view-node% 3Anodes-managing-common-symptoms-of-pregnancy. National Institute for Health and Care Excellence (NICE). Low back pain: Early management of persistent non-specific low back pain. NICE clinical guideline 88. 2009. http://publications.nice.org.uk/low-back-pain-cg88/patient-centred-care. National Cancer Institute. Complementary and alternative medicine in cancer treatment. 2013. www.cancer.gov/cancertopics/pdq/cam/cam-cancer-treatment/patient/page2. Epel E, Daubenmier J, Moskowitz JT, Folkman S, Blackburn E. Can meditation slow rate of cellular aging? Cognitive stress, mindfulness, and telomeres. Ann N Y Acad Sci 2009;1172:34-53. Ornish D, Lin J, Chan JM, Epel E, Kemp C, Weidner G, et al. Effect of comprehensive lifestyle changes on telomerase activity and telomere length in men with biopsy-proven low-risk prostate cancer: 5-year follow-up of a descriptive pilot study. Lancet Oncology 2013;14:1112-20. Roberts I, Chaudhry B, Chalmers I. New GMC guidance takes a major, ethically flawed, backward step. BMJ 2013;346:f3879. Chalmers I. Trying to do more good than harm in policy and practice: the role of rigorous, transparent, up-to-date evaluations. Annals of the American Academy of Political and Social Science 2003;589:22-40. Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the advancement of teaching. 1910. www.carnegiefoundation.org/sites/ default/files/elibrary/Carnegie_Flexner_Report.pdf. Smith KR. Factors influencing the inclusion of complementary and alternative medicine (CAM) in undergraduate medical education. BMJ Open 2011;1:e000074. Posadzki P, Watson LK, Alotaibi A, Ernst E. Prevalence of use of complementary and alternative medicine (CAM) by patients/consumers in the UK: systematic review of surveys. Clin Med 2013;13:126-31. Ernst E. How much of CAM is based on research evidence? Evid Based Complement Alternat Med 2011;2011:676490. Anas barbariae, hepatis et cordis extractum. The Homeopathic Pharmacopoeia of the United States, monograph #0137, June 1989. Ernst E. Fatalities after CAM: an overview. Br J Gen Pract 2011;61:404-5. Posadzki P, Alotaibi, A, Ernst E. Adverse effects of homeopathy: a systematic review of published case reports and case series. Int J Clin Pract 2012;66:1178-88. Posadzki P, Watson L, Ernst E. Herb-drug interactions: an overview of systematic reviews. Br J Clin Pharmacol 2013;75:603-18. Ho D, Chan K, Bewley S, Bender DA. Evidence-based medicine and complementary and alternative medicine teaching in UK medical courses: a national survey of the student experience. Focus Alternat Complement Ther 2013;18:176-81. The Royal London Hospital for Integrated Medicine. Integrating complementary medicine in everyday practice. 2013. www.uclh.nhs.uk/OurServices/ServiceA-Z/INTMED/IMED/ Documents/Integrating%20Complementary%20Medicine%20in%20Everyday%20Practice. pdf. College of Medicine. Constitution of College of Medicine. 2013. www.collegeofmedicine. org.uk/sites/default/files/doc_com_constitution_summary_10629727_1.doc. General Medical Council. Tomorrow’s doctors: outcomes and standards for undergraduate medical education: outcomes 2—the doctor as a practitioner. 2009. www.gmc-uk.org/ education/undergraduate/tomorrows_doctors_2009_outcomes2.asp.
Cite this as: BMJ 2014;348:g2417 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
Page 1 of 3
Head to Head
HEAD TO HEAD Should medical students be taught alternative medicine? Doctors should be able to discuss the non-evidence based therapies that patients want to try, says Graeme Catto. But Nick Cork and Gareth Williams say that students risk being indoctrinated and should be taught only about interventions that have been shown to be safe and effective 1
2
Graeme Catto president , Nick Cork medical student , Gareth Williams emeritus professor of 3 medicine and senior research fellow in philosophy College of Medicine, Guy’s Hospital, Great Maze Pond, London SE1 9RT, UK; 2School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK; 3University of Bristol, City of Bristol BS8 1TH, UK 1
Yes—Graeme Catto “Demonstrate awareness that many patients use complementary and alternative therapies, and awareness of the existence and range of these therapies, why patients use them, and how this might affect other types of treatment that patients are receiving.”1 This guidance, from the UK General Medical Council’s Tomorrow’s Doctors encapsulates lucidly and concisely why medical students are taught about alternative medicine. I find it difficult to conceive of a counterargument.
The choices patients make To provide quality care doctors must be aware of choices patients make and be able to discuss them in an informed and non-judgmental way. Any other approach puts the doctor-patient relationship at risk. Patients are reluctant to raise issues that they believe meet with disapproval. These principles apply to complementary and alternative medicine the same way as to other lifestyle choices. And this is a choice made by many people in the United Kingdom. The annual spend on alternative health treatments has been estimated to be as much as £5.4bn (€6.5bn; $8.9bn).2 All aspects of medical care are involved and not only in general practice. As a nephrologist I learnt that patients wanted complementary therapies to relieve some of the intractable and distressing symptoms, such as skin itch and restless legs, associated with chronic renal failure. Patients discussed among themselves the therapies they found useful. For my part I checked that there were no known interactions with their current conventional treatment and was pleased if symptoms were relieved. With the development of the internet and social media, such suggestions for self care and for complementary therapy are much more readily available and circulate more rapidly. Serious
drug interactions are fortunately not common; St John’s wort, however, increases the effect of conventional antidepressants, and evening primrose oil increases the effect of warfarin with potentially serious consequences.3
Where efficacy has been accepted In 2000, the House of Lords Select Committee on Science and Technology produced a far sighted report on complementary and alternative medicine.4 It recognised the weakness of the evidence base and the difficulty of identifying funding for necessary but expensive clinical trials. So what has changed since then? Perhaps not a great deal. The National Institute for Health and Care Excellence recommends complementary and alternative therapies only in a limited number of conditions where efficacy has been accepted. The Alexander technique is suggested as part of the treatment for Parkinson’s disease,5 ginger and acupressure for reducing morning sickness in pregnancy,6 and acupuncture and massage for persistent low back pain.7
Complementary therapies are, however, widely used in cancer and palliative care, and the National Cancer Institute at the National Institutes of Health provides information on research activity and clinical practice in the US.8 Many of these treatments relate to relaxation and meditation techniques thought to be of value for patients with life threatening illnesses. That hypothesis gained support from an unexpected source. Elizabeth Blackburn, awarded the Nobel prize in 2009 for her work on telomerase, and her colleagues showed that increased telomere length protected not only the chromosome but the cell against the ageing process and cell death. They have further shown that meditation and relaxation increase telomerase activity and telomere length thus providing objective information on the effect of complementary medicine at the cellular level.9
Correspondence to: Graeme Catto [email protected], Nick Cork [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g2417 doi: 10.1136/bmj.g2417 (Published 28 March 2014)
Page 2 of 3
HEAD TO HEAD
These are not isolated examples. Dean Ornish and his colleagues have shown in patients with prostatic cancer that changes in lifestyle and diet have been associated with lengthening of telomeres.10 We await to see if these cellular changes are associated with an improved prognosis. Similar dietary and lifestyle changes have produced lasting improvements in patients with coronary artery disease. These interventions are now accepted as good practice in cardiovascular disease and in preventing both obesity and type 2 diabetes. In these situations, concepts that may originally have been considered as complementary to conventional medicine are now widely adopted. One of the joys of medicine is dealing with uncertainty. The evidence base for much of our current practice is weak. I believe, as once did the GMC, that doctors “must work with colleagues and patients . . . to help resolve uncertainties about the effects of treatments.”11 That means following the scientific evidence and questioning established practice. Iain Chalmers has spoken movingly of the many infant deaths caused by the inadequately researched advice to place young children in the prone position for sleep.12 Volumes of learned articles seeking to cure peptic ulcers by reducing gastric acid secretion were shown to be irrelevant, even if scientifically valid, by the discovery of Helicobacter pylori. Good doctors have always had the flexibility to change their practice in the light of new evidence and patients have benefitted.
Partnership and support In many clinical situations, however, modern medicine is able only to modify, not cure, the underlying condition. Optimum management of long term conditions requires partnership among the patient, the doctor, and the other members of the healthcare team. It is not surprising that many patients turn to complementary and alternative therapies when their symptoms persist. The good doctor will provide support while advising against any treatments that may be dangerous or conflict with their current drugs. We may not require a randomised controlled trial to know that aromatherapy makes some patients feel better or that yoga has benefits. Learning to work well in partnership with patients is an essential skill for all of us and not only medical students. If you accept that premise, understanding something about complementary and alternative therapies is an essential component, like it or not.
No—Nick Cork and Gareth Williams In 1910, the Flexner Report13 brought much needed scientific rigour to medical education in the United States and led directly to the closure of many schools that taught chiropractic, naturopathy, and homoeopathy. Now, over a century later, alternative medicine has insinuated itself into medical education in the UK. In 2010, 18 of the UK’s then 31 medical schools responded to a survey about the teaching of so called “complementary and alternative medicine” (CAM) within the undergraduate programme.14 All 18 stated that CAM was an integral part of the curriculum, including student selected research projects in eight, and formal teaching (ranging from a single lecture to a theme running throughout the programme) in six.
Mainstream, science based medicine is far from perfect. Many shelves in the therapeutic cupboard remain depressingly bare, and the evidence base for many drugs is patchy or skewed by fashion, industrial lobbying, and publication bias. Not For personal use only: See rights and reprints http://www.bmj.com/permissions
surprisingly, as many as 52% of UK patients have tried an alternative medicine at some point, most commonly herbal medicine, homoeopathy, aromatherapy, massage, or reflexology.15 These options undoubtedly provide comfort for some, even if only through a placebo effect.
What’s the evidence? However, alternative therapies must be tested as rigorously as conventional drugs, and like them must be rejected if they prove to be useless or dangerous. A recent review carried the provocative title, “How much of CAM is based on research evidence?” The answer: very little. Of 685 alternative therapies investigated through adequate clinical trials and meta-analyses, only 7% showed any evidence of efficacy, and this figure may be an overestimate.16 There is certainly no scientific basis for homoeopathy, as illustrated by the world’s most popular homoeopathic remedy, Oscillococcinum, recommended for colds and flu. The allegedly active ingredient, the viscera of the Muscovy duck, is supposedly a rich source of a bacterium that has never been shown to exist.17 One duck would provide enough material to treat every person on the planet, but unfortunately there is not enough water in the solar system to produce the “therapeutic” dilution of one part in 10200. Contrary to propaganda, these therapies are not risk free. Various systematic reviews have attributed 121 fatalities to acupuncture, chelation therapy, and chiropractic, and 1159 adverse events, including four deaths, to the use of homoeopathy.18 19 Herbal therapies—particularly ginkgo, ginseng, kava, and St John’s wort—may interact with common conventional medicines, potentially with mild to severe consequences.20
What are we teaching our students? These shortcomings of alternative therapies are not adequately discussed in undergraduate curricula. In a recent survey of 25 medical schools,21 one third of the 95 students who responded reported that those teaching alternative medicine failed to provide evidence of efficacy. Twenty students in the same survey indicated that their self selected research project lacked scientific rigour because the supervisor was reluctant to confront evidence against alternative therapies. Moreover, students in at least one medical school are taught about alternative therapies during their first year, before fully covering pharmacology or the principles of evidence based medicine.
In this era of evidence based medicine, it seems strange that alternative therapies should have found their way into medical curricula—especially when the undergraduate teaching programme is already overcrowded. Who has driven this change? In the UK, alternative medicine has the stamp of approval of the royal family and various celebrities. It enjoys the support of some senior doctors and the grandly named College of Medicine, which collaborates to run courses entitled “Integrating complementary medicine in everyday practice”22 in line with its objective of “promoting, fostering and advancing an integrated approach to healthcare.”23
Seductive yet utterly devoid of scientific merit The defences against the invasion of unscientific material should centre on the UK regulator, the General Medical Council, which dictates the content and emphasis of the nation’s medical education programmes and has the power to close down medical schools that fall short of the mark. In Tomorrow’s Doctors (2009)24 the GMC’s guidance is that qualified doctors should “demonstrate awareness that many patients use complementary and alternative therapies, and awareness of the existence and Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g2417 doi: 10.1136/bmj.g2417 (Published 28 March 2014)
Page 3 of 3
HEAD TO HEAD
range of these therapies, why patients use them, and how this might affect other types of treatment that patients are receiving.” This seems entirely reasonable, but incompatible with the GMC’s guidance, in Good Medical Practice (2013), that “in providing care you must provide effective treatments based on the best available evidence.” In medicine, there are few concepts as seductive yet utterly devoid of scientific merit as alternative therapies. Doctors must be aware that these exist, and that they have limitations and contraindications, to help patients to make informed decisions about using them or not. Beyond this, we argue that teaching alternative medicine to medical students is illogical and a waste of time. It is unethical to indoctrinate students when they might not yet have acquired the critical skills to decide for themselves whether a particular therapy is effective, safe, and affordable. Moreover, it takes a great deal of courage for medical students—especially in their junior years—to challenge or contradict their teachers.
There is no place in the undergraduate curriculum for promoting any treatments that are not underpinned by hard evidence that they work and are acceptably safe. The GMC has appointed itself the guardian of quality and scientific rigour in medical training in the UK. It should now follow the example of Abraham Flexner and ensure that teaching about alternative medicine in UK medical schools is strictly reviewed—and removed if it does not meet the basic criteria of efficacy and safety.
5 6
7 8 9 10
11 12 13 14 15 16 17 18 19 20
The authors have read and understood the BMJ Group policy on declaration of interests and declare the following interests: GC is president of the College of Medicine and a former president of the General Medical Council. NC and GW have no relevant interests to declare.
21
1
24
2 3 4
General Medical Council. Tomorrow’s Doctors. 2009.www.gmc-uk.org/education/ undergraduate/tomorrows_doctors.asp. Leggatt J. Complementary medicine: seeking out alternatives. Telegraph 11 Jun 2008.www. telegraph.co.uk/health/alternativemedicine/3355120/Complementary-medicine-seekingout-alternatives.html Moses GM, McGuire TM. Drug interactions with complementary medicines. Aust Prescr 2010;33:177-80. Select Committee on Science and Technology. Sixth Report. Complementary and alternative medicine. House of Lords, 2000. www.publications.parliament.uk/pa/ld199900/ ldselect/ldsctech/123/12301.htm.
For personal use only: See rights and reprints http://www.bmj.com/permissions
22
23
National Institute for Health and Care Excellence (NICE). Parkinson’s Disease: diagnosis and management in primary and secondary care. NICE clinical guideline 35. Jun 2006. http://publications.nice.org.uk/parkinsons-disease-cg35/guidance#other-key-interventions. National Institute for Health and Care Excellence (NICE). Antenatal care. NICE clinical guideline 62. 2008. http://pathways.nice.org.uk/pathways/antenatal-care#path=view%3A/ pathways/antenatal-care/routine-care-for-all-pregnant-women.xml&content=view-node% 3Anodes-managing-common-symptoms-of-pregnancy. National Institute for Health and Care Excellence (NICE). Low back pain: Early management of persistent non-specific low back pain. NICE clinical guideline 88. 2009. http://publications.nice.org.uk/low-back-pain-cg88/patient-centred-care. National Cancer Institute. Complementary and alternative medicine in cancer treatment. 2013. www.cancer.gov/cancertopics/pdq/cam/cam-cancer-treatment/patient/page2. Epel E, Daubenmier J, Moskowitz JT, Folkman S, Blackburn E. Can meditation slow rate of cellular aging? Cognitive stress, mindfulness, and telomeres. Ann N Y Acad Sci 2009;1172:34-53. Ornish D, Lin J, Chan JM, Epel E, Kemp C, Weidner G, et al. Effect of comprehensive lifestyle changes on telomerase activity and telomere length in men with biopsy-proven low-risk prostate cancer: 5-year follow-up of a descriptive pilot study. Lancet Oncology 2013;14:1112-20. Roberts I, Chaudhry B, Chalmers I. New GMC guidance takes a major, ethically flawed, backward step. BMJ 2013;346:f3879. Chalmers I. Trying to do more good than harm in policy and practice: the role of rigorous, transparent, up-to-date evaluations. Annals of the American Academy of Political and Social Science 2003;589:22-40. Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the advancement of teaching. 1910. www.carnegiefoundation.org/sites/ default/files/elibrary/Carnegie_Flexner_Report.pdf. Smith KR. Factors influencing the inclusion of complementary and alternative medicine (CAM) in undergraduate medical education. BMJ Open 2011;1:e000074. Posadzki P, Watson LK, Alotaibi A, Ernst E. Prevalence of use of complementary and alternative medicine (CAM) by patients/consumers in the UK: systematic review of surveys. Clin Med 2013;13:126-31. Ernst E. How much of CAM is based on research evidence? Evid Based Complement Alternat Med 2011;2011:676490. Anas barbariae, hepatis et cordis extractum. The Homeopathic Pharmacopoeia of the United States, monograph #0137, June 1989. Ernst E. Fatalities after CAM: an overview. Br J Gen Pract 2011;61:404-5. Posadzki P, Alotaibi, A, Ernst E. Adverse effects of homeopathy: a systematic review of published case reports and case series. Int J Clin Pract 2012;66:1178-88. Posadzki P, Watson L, Ernst E. Herb-drug interactions: an overview of systematic reviews. Br J Clin Pharmacol 2013;75:603-18. Ho D, Chan K, Bewley S, Bender DA. Evidence-based medicine and complementary and alternative medicine teaching in UK medical courses: a national survey of the student experience. Focus Alternat Complement Ther 2013;18:176-81. The Royal London Hospital for Integrated Medicine. Integrating complementary medicine in everyday practice. 2013. www.uclh.nhs.uk/OurServices/ServiceA-Z/INTMED/IMED/ Documents/Integrating%20Complementary%20Medicine%20in%20Everyday%20Practice. pdf. College of Medicine. Constitution of College of Medicine. 2013. www.collegeofmedicine. org.uk/sites/default/files/doc_com_constitution_summary_10629727_1.doc. General Medical Council. Tomorrow’s doctors: outcomes and standards for undergraduate medical education: outcomes 2—the doctor as a practitioner. 2009. www.gmc-uk.org/ education/undergraduate/tomorrows_doctors_2009_outcomes2.asp.
Cite this as: BMJ 2014;348:g2417 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
