Should Medical Schools Teach "Integrative Medicine"?

Robert W. Donnell, MD; Nicholas Genes, MD, PhD; Roy M. Poses, MD

Disclosures

December 06, 2007

In This Article

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.

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