Should Medical Schools Teach "Integrative Medicine"?


Robert W. Donnell
A century ago, medical education lacked standardization and scientific discipline. To address the problem, the American Medical Association formed the Council on Medical Education (CME), tasked with restructuring the curricula of American medical schools. At the CME's request, the Carnegie Foundation commissioned Abraham Flexner to survey and report on the quality of medical schools in the United States and Canada.[1] The Flexner Report that followed in 1910 was severely critical of medical education.[2] In its aftermath, many medical schools closed or merged. Those that survived instituted major reforms.[3]
The Flexner Report was revolutionary and even today is widely celebrated as a defining document for medical education. However, the last decade has seen a disturbing trend away from Flexner's warnings. Medical schools are reverting to pre-Flexnerian standards by adding pseudoscientific health claims to their course materials under the rubric of "integrative medicine."
Flexner condemned such claims, writing in Chapter X of the Report that they should have no place in medical education. Modern medicine, he said, "wants not dogma, but facts. It countenances no presupposition that is not common to it with all the natural sciences, with all logical thinking." Unfortunately, medical schools today not only countenance but teach and promote such presuppositions, many of which would require us to abandon basic science textbooks.
Let's make a distinction. Doctors need to know about the alternative treatments that patients are seeking so that they can recognize herb-drug interactions, engage patients in discussions about alternative treatments, and appreciate cultural differences that may lead patients to seek such treatments. Medical schools should equip students in these areas. However, they should teach an appropriately critical and scientific view of alternative theories.
For many medical schools today, that's the rub. Academic leaders, in fact, are suggesting that alternative modalities should be presented "in the context of their own philosophies and models of health and illness.[4]" Survey data from both MD- and DO-granting schools confirm this trend.[5-7] In other words, dubious claims are being promoted to students in an unscientific, uncritical manner. If you need more evidence, browse the Web sites of academic medical centers to see what's going on and note their promotions of therapeutic touch, homeopathy, Ayurvedic medicine, shamanism, chakras, and more.
So, you may say, what's wrong with combining other healing traditions with scientific methods? Plenty, because it results in an eclectic mix of diverse theories with no common basis. It leaves medicine without a consistent scientific framework upon which to evaluate treatments.
The Flexner Report came down strongly against integrative medicine. In Chapter X, Flexner posed this question about the compatibility of scientific medicine with pseudoscientific claims, which he termed dogma: "Is it essential that we should now conclude a treaty of peace, by which the reduced number of medical schools should be pro-rated as to recognize dissenters on an equitable basis?" His emphatic answer was "no." He later continued: "The ebbing vitality of homeopathic schools is a striking demonstration of the incompatibility of science and dogma."
Unfortunately, academic medicine is now turning its back on Flexner's mandate. Our medical schools are devolving into Hogwarts-like institutions of eclectic healing arts.[8] Reforms are urgently needed so that medical education will once again be rooted in science.
Nicholas Genes, MD, PhD: The Real Trend Is Evidence-Based Medicine, Not Complementary and Alternative Medicine
I have only been in medicine for a short time, but long enough to have encountered this well-worn debate. Both sides are entrenched, each accusing the other of being dogmatic and inflexible. On one side is scientific inquiry, with its breathtaking record of achievement and understanding. On the other side is complementary and alternative medicine (CAM), an umbrella term for remedies that are based on tradition and spiritualism, which receives heartfelt anecdotal support but little else to vouch for its efficacy.
The 1910 Flexner Report,[2] as the story goes, criticized CAM's widespread influence in medical school. The Report prompted a revolution, standardizing a medical education that is based on scientific principles and demonstrable facts.
So, if you subscribe to Dr. Donnell's narrative, you'd be inclined to believe that for nearly a century, physicians were consistently trained to critically evaluate scientific literature. You would think the tests that they employed, and the therapies that they prescribed, were based on a strong foundation of supporting evidence.
In fact, this was not the case. Medical education was dogmatic after Flexner. However, instead of calling upon the wisdom of the ancients, or their chakras, doctors relied on animal physiology experiments and the observations of a few brilliant, dead clinicians. The treatments that medicine espoused throughout the 20th century had a basis in science, to be sure, but whether these therapies were really helping patients was unknown -- and often not even properly studied.
In fact, as institutions of higher learning, today's medical schools are strangely steeped in tradition. From wearing white coats to "scutting out" third-years, medical students in the post-Flexner world still spend a large part of their day engaged in ritualized practices, solely because that's what their mentors learned.
The culture of reverence and obedience is enshrined in the opening of the Hippocratic oath[9] -- and extends to the classroom and patient bedside. In their preclinical years, students spend untold hours memorizing eponymously named anatomic features and physical exam findings of questionable clinical value. For instance, every doctor I know can recall learning Kernig's sign and Beck's triad, but few can vouch for their sensitivity or impact on decision making.
Of course, medical school also emphasizes scientifically determined biochemical pathways, with their opportunities for intelligent drug interventions. However, upon entering the wards, a significant student function is to push fluids and dole out cold remedies. Which ones? How much? Until recently, there was little scientific guidance for these decisions; students learned to simply do what their mentors and colleagues were doing.
No wonder CAM gained a foothold. If students were being made to learn arcane trivia and give time-honored but untested therapies, why not invoke energy fields and pressure points? Although CAM's infiltration into the halls of academia may be overstated by Dr. Donnell (the 2002 Brokaw survey he cites notes that the a "typical" CAM course is an elective with 20 hours or less of contact instruction[6]), it's understandable that a student, overwhelmed and unsatisfied with the traditions of modern medicine, would be seduced by other traditional therapies.
Make no mistake, though: There has been a sweeping change in medical education over the past decade. It's just not the teaching of CAM. Instead, it's a focus on evidence-based medicine (EBM) that is infiltrating school curricula.
What is it? In the words of an EBM pioneer, EBM is:
the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients... By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research... External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer.[10]
This seems reasonable and straightforward, but like Flexner's Report, EBM has prompted reflection and reform.
Students are now trained to critically appraise the literature. They can determine likelihood ratios for a diagnosis on the basis of a test result, and calculate how to properly judge a new therapy. They can point out the inherent biases and methodologic shortcomings in a study. Equipping future doctors with the tools of EBM has encouraged critical thinking about the way medicine is practiced, and has helped expose the inadequate underpinnings of 20th-century medicine's diagnostic and therapeutic modalities.
Clinicians have responded. New drugs and diagnostic tests are subject to more rigorous study. Old therapies, given routinely because they made sense physiologically or because they seemed to work in mice or in small observational studies, are finally getting proper scrutiny.
Prophylactic administration of class I antiarrhythmics after myocardial infarction -- which was once so indoctrinated that people feared it would be unethical to withhold the drugs from study control groups[11] -- is now a historical footnote. Hormone replacement therapy for postmenopausal women, which seemed so reasonable a decade ago, is much less common[12] thanks to large, randomized trials. Even the uncontroversial rudiments of medicine, such as which fluids to push in which patients[13] or what cold remedies actually work,[14] are being addressed.
The next generation of medical students will be able to critically evaluate claims made by scientists, pharmaceutical representatives, and even CAM practitioners. They'll be able to justify the medical decisions they make by referring to large, well-conducted trials. Also, they'll wonder how we, as clinicians supposedly grounded in science, ever functioned without these tools or this supply of evidence. Flexner would approve of this "new" direction in medical education.
Roy M. Poses, MD: Medical Schools Embrace CAM Uncritically
Unfortunately, Flexner may be rotating all too rapidly. I, too, am concerned that medical schools are teaching and promoting what is often called CAM, despite the lack of logic or evidence supporting many CAM practices. Meanwhile, the same schools seem to give only lip service to the application of logic and evidence to healthcare, as exemplified by the formal processes of EBM. What evidence I could find favors this gloomy assessment.
By 2002, most US medical schools (98 out of 126) were teaching about CAM practices in 1 or more required courses.[15] The material that was being taught was mostly uncritical: Less than one fifth of CAM courses included "critical evaluation of the scientific literature," and almost four fifths were taught by a "CAM practitioner" who was likely to be an enthusiast, not a critic. Many of the modalities being taught had little scientific justification. These included homeopathy (taught in 58% of courses); ethnomedicine, including Ayurveda and Native American medicine (48%); therapeutic touch (38%); naturopathy (36%); and energy medicine, including manipulation of electromagnetic fields and magnet therapy (12%).[6]
In fact, some medical schools have demonstrated major institutional commitments to CAM. For example, the University of Pennsylvania, Philadelphia, Pennsylvania, signed an agreement with the Tai Sophia Institute of the Healing Arts, whose faculty taught, among other things, that people feel better after dislodging "a blockage of qi, or life energy." In the wake of faculty protests and some unfavorable publicity, the university announced that the agreement was "more loosely...a partnership.[16]"
Similarly, West Virginia University, Morgantown, West Virginia, founded the Sydney Banks Institute for Innate Health, which is based on the insights of Canadian welder Sydney Banks, who said he had found "the secret to life," describing his discovery as "what they call God -- the true meaning of God.[17]" The Institute described Banks as a "theosopher," a term best associated with Madame Blavatsky, the Victorian-era spiritualist who conducted seances. (The Institute later dropped "Sydney Banks" from its name, and now goes by the West Virginia Institute for Innate Health.) The Institute's education director, whose highest degree is a master's in English, has described the Institute's work as "profoundly scientific.[17]" However, in 7 years, the faculty apparently have published only 2 peer-reviewed articles, including a pilot study involving only 8 patients.[18]
Medical schools' often uncritical embracement of CAM sadly contrasts with their often lukewarm support of EBM. As Paul Glasziou put it, "evidence-based medicine (EBM) is like safe sex: talked about a lot, preached (taught) a little and practiced infrequently.[19]" In fact, even though more medical schools require instruction in EBM than require courses in CAM,[15] medical graduates continue to perform poorly when tested on EBM skills.[20,21]
In an era of increasingly commercialized healthcare, the managers and bureaucrats may be inclined to favor the popular and attractive CAM approaches over the rigorous and austere EBM approach. Patients, however, may not benefit from the ministrations of doctors better trained about "qi" than about selection bias and the "intention-to-treat" principle.

References
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O'Malley CM, Frumento RJ, Hardy MA, et al. A randomized, double-blind comparison of lactated Ringer's solution and 0.9% NaCl during renal transplantation. Anesth Analg. 2005;100:1518-1524. Abstract
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Mangan KS. Take 2 herbal remedies and call me in the morning: despite worries from some doctors, more medical schools are incorporating alternative treatments in their curricula. Chron Higher Ed. November 18, 2005.
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