The popularity of alternative medicine1,2 has encouraged its advocates to criticize traditional medicine, and to propose revisions in medical education, including the incorporation of alternative therapies into medical education and practice (integrative medicine).3, pp 277-283,4,5,6 In his recent testimony,7 Dr. Andrew Weil proposed that Congress designate funds for the introduction of integrative medicine into health care education. These calls for change are in part a result of the fact that medical educators have been slow to recognize the need for development of curricula in alternative medicine, and have not responded to the various criticisms of traditional medicine and medical education made by proponents of alternative medicine and others. In this article, I examine the most important of these criticisms, all of which misrepresent medicine and the medical curriculum and obscure the basic differences between traditional and alternative medicine. I also make proposals for educating physicians and patients about alternative treatments.
CRITICISMS OF TRADITIONAL MEDICINE AND MEDICAL EDUCATION
Physicians Ignore Mind—Body Interactions
A recurrent allegation is that traditional medicine is based on Cartesian dualism—i.e., that it ignores mind—body interactions—and that physicians are not trained to assess the whole person. A typical example of this rhetoric is this comment about biomedicine (allopathic medicine) by Micozzi8: “The study of dead tissues, cells, components and chemicals to understand life processes are based upon a reductionistic, materialist view of health and healing.” Another example is the description of the “Old Paradigm” of traditional medicine by naturopathic doctors9: “The body is a machine; the body and mind are separate; the physician should be emotionally neutral and detached.”
Awareness of the profound influence of temperament and emotions on body functions has always been prominent in Western medicine. Prior to the 20th century most treatments had no value, and some, such as purging and bleeding, were harmful. The primary benefits resulting from the interactions between patients and healers were reassurance and relief of anxiety. As stated by Houston,10 “the history of medicine is a history of the dynamic power of the relationship between doctor and patient.”
Training physicians to consider the whole person and to identify and address emotional and social problems (the biopsychosocial model) is a central tenet of medical education. This aspect of the art of medicine was traditionally taught by the apprenticeship model during bedside teaching rounds. In recent decades, the apprenticeship method of teaching the biopsychosocial model has been supplemented by the incorporation of appropriate learning objectives into medical school curricula, and by development of techniques to teach and assess communication and interviewing skills of students. For example, a recent report of the Association of American Medical Colleges that presents guidelines for medical schools with respect to learning objectives for medical students' education11 includes the following objective: “The medical school must ensure that… a student will have demonstrated, to the satisfaction of the faculty, knowledge of the important non-biological determinants of poor health and of the economic, psychological, and cultural factors that contribute to the development and/or continuation of maladies.” In addition, the humanistic attributes of students and resident physicians are a prominent part of their evaluations, and are required by accrediting agencies and boards. Finally, the role of emotions in the pathogenesis and outcome of disease has received intensive study during the last 50 years,12,13,14,15,16 and recent progress in neuroscience is providing insight into the molecular basis of communication between the nervous system and the immune and cardiovascular systems.17,18
Medical Treatment Does Not Address the Cause of Disease
A second criticism is that traditional medicine does not seek to understand the cause of illness, that it attempts to suppress symptoms by means of pharmacologic agents, and it ignores the potential of the body to heal itself. For example, Dr. Weil has written that “most of the treatments I had learned in four years of Harvard Medical School and one of internship did not get to the root of disease processes and promote healing but rather suppressed those processes or merely counteracted the visible symptoms of disease.”19, pp 13-14
There are two allegations being made in this surprising statement. In regard to the first—that physicians are not trained to analyze the pathophysiologic basis of disease—it is enough to say that courses in the pathophysiology of disease have been taught in all medical schools for decades. Moreover, students and residents are taught to take a pathophysiologic approach to the analysis of symptoms such as dyspnea or chest pain. The initial sections of Harrison's Principles of Internal Medicine20 have been devoted to this type of analysis for decades.
The second allegation—that medicine ignores the body's potential for natural healing and encourages an excessive reliance on dangerous pharmacologic agents to “merely suppress symptoms”—is, like the first, not warranted. The principle of “primum non nocere” (i.e., “first, do no harm”) has been a central precept of medical care for over two thousand years. This maxim is attributed to the Greek physician Hippocrates, who wrote in Epidemics, “As to diseases, make a habit of two things—to help, or at least do no harm.”21 Implicit in this statement is recognition of the natural recuperative powers of the body. Prescribing antibiotics for viral respiratory infections22 is frequently cited as an example of the inappropriate use of pharmacologic agents. However, guidelines for the appropriate use of antibiotics have been available for some time, and the shortcomings of individual practitioners cannot be attributed simply to basic defects in medical training. There are many factors that account for the overuse of antibiotics,23,24 including pressure from patients, but the guidelines can be utilized effectively.25 Current guidelines for the treatment of many diseases, including essential hypertension,26 osteoarthritis,27 and diabetes mellitus, emphasize the importance of non-pharmacologic approaches such as weight reduction and exercise.
Medicine Ignores Prevention of Disease
A third criticism is that traditional medicine ignores disease prevention and health promotion. This is not the case: preventive medicine has been taught in medical schools and postgraduate training for decades, and guidelines28 have been formulated for immunizations and to screen for hypertension, diabetes mellitus, and breast, prostate, and colon cancer. Non-pharmacologic (life-style) approaches to health promotion, including the importance of a balanced diet, weight control, exercise, and stress reduction, have received increasing attention, and probably were not sufficiently emphasized until the last quarter of a century.29 A recent supplement of Academic Medicine was devoted to the teaching of preventive medicine in the undergraduate medical curriculum.30
To the extent that any basis is provided by proponents of alternative medicine for their criticisms of medical education, it consists of undocumented anecdotes about the medical and humanistic shortcomings of traditional physicians, and of miraculous cures achieved by alternative practitioners.3,19 The medical “failures” are attributed to basic defects in what physicians are taught rather than to human fallibility, the complexity of modern medicine, and the constraints on practice imposed by managed care. Although it is evident that the alleged systematic defects in medical education do not exist, there is always room for improvement. Medical school curricula and postgraduate training programs are continually evolving,31 and more emphasis is being placed on health promotion and physician—patient interactions.
FUNDAMENTAL DIFFERENCES BETWEEN TRADITIONAL AND ALTERNATIVE MEDICINE
Before considering the real issues that distinguish alternative from traditional medicine, it is important to decide how to define alternative medicine. In their surveys, Eisenberg and colleagues2 defined alternative modalities as “intervention neither taught widely in medical schools nor generally available in US hospitals.” Although this functional definition is useful for epidemiologic studies, it does not take into account the advocacy of alternative medicine by some medical educators, or the presence of alternative practitioners in some health science centers. A more fundamental distinction is the conceptual basis of the therapeutic modality. Truly alternative practices differ from traditional medicine in their concepts of the causes and treatment of diseases, and in their attitude toward evidence.
Two of the most important advances in medical science during the 20th century were the realization of the power of the placebo32,33,34,35 and the development of sophisticated methods for the design and interpretation of controlled clinical trials. A more recent development is the promotion of evidence-based medicine,36,37 i.e., use of the “best available external clinical evidence” by individual practitioners in patient care. This approach has been greatly facilitated by the development of criteria to evaluate the quality of evidence,38 and the availability of systematic reviews of clinical data by the Cochrane Collaboration and others. Evidence-based medicine is not cookbook, automated medicine. It is a powerful approach that can be utilized to supplement clinical experience and the needs and preferences of the patient.39 In contrast to these efforts to base diagnostic and therapeutic decisions on the best evidence available are many belief-based alternative therapies and healing systems.
Many alternative therapies, including traditional Chinese and Ayurvedic medicine, homeopathy, and healing touch, are based on a vitalistic view of health and disease,40 and are truly alternative to evidence-based medicine. Although these healing traditions differ in their specific formulations, as well as their historical and cultural content, they share a belief in a vital energy (qi, prana, or spiritual vital force) whose disruption or imbalance causes disease, and in the cure of diseases by mobilization of the vital energy. These beliefs are shared by Western advocates of alternative medicine, including Dr. Weil: “Doctors believe that health requires outside intervention of one sort or another, while proponents of natural hygiene maintain that health results from living in harmony with natural law.”19
Some prominent advocates of alternative medicine reject the concept that the efficacy of these therapies needs to be, or can be, validated by randomized, controlled trials. The editor of the journal Alternative Therapies in Health and Medicine wrote, “Many alternative interventions are unlike drugs and surgical procedures. Their action is affected by factors that cannot be specificed, quantified and controlled in double-blind designs. Everything that counts cannot be counted. To subject alternative therapies to sterile, impersonal double-blind conditions strips them of intrinsic qualities that are part of their power.”41
A more subtle problem than outright rejection of controlled trials is the citation of publications that support the efficacy of alternative therapies without considering the quality of those studies.8,42,43 Reviews of acupuncture,44,45 chiropractic,46,47,48 and herbal medications49,50 conclude that although there are some data to support the efficacy of these treatments, firm conclusions cannot be drawn because of defects in study design. In the discussion of a systematic review of healing, Abbot made these comments about research into complementary therapies, “Too little research has been done, and that which is published is too often ill-conceived, ill-reported, often by experimenters with more enthusiasm than expertise.”51
There are some investigators45,47,52,53,54 who adhere to rigorous standards for evaluating alternative treatments. The new director of the National Center for Complementary and Alternative Medicine (NCCAM), Dr. Stephen Straus, has stated his strong support for analysis of alternative medicine by means of randomized controlled trials.55 It is important to acknowledge that many therapies used by traditional medicine are not supported by the highest quality of evidence.56 However, a fundamental difference between alternative and conventional medicine is the acceptance by the latter of the need for better trials, and a willingness to continuously rethink and revise therapeutic guidelines as new data become available,57 in contrast to the reliance of alternative medicine on tradition and belief.
TEACHING ALTERNATIVE MEDICINE
How should medical schools respond to the prevalent use of alternative modalities by the public, and to the pressure to create programs in integrative medicine?6 The answer is clear: by developing new educational programs for physicians and the public, and by fostering research on alternative therapies. Physicians need to be well informed about the conceptual basis, efficacy, and safety of alternative therapies. This material should be incorporated into the required curricula of medical schools and graduate training programs, and not relegated solely to electives,58,59 whose content may not be critically evaluated.
Without additional education about alternative medicine, physicians cannot obtain accurate information from patients about their use of alternative modalities, or provide information and guidance. Why people use alternative therapies60,61 is a complex subject that is beyond the scope of this article. However, physicians must assist patients in making informed choices about health care, and they should be receptive to discussing alternative medicine with patients who request information. Physicians should be especially sensitive to the needs of patients with intractable medical conditions, such as cancer, chronic pain, and degenerative neurologic diseases, who seek relief and hope in alternative therapies. Eisenberg62 has formulated thoughtful guidelines for counseling patients who seek alternative therapies.
In addition to educating health care professionals, there is an urgent need to provide more reliable information to the public. Many alternative treatments, especially herbals and nutritional supplements, are self-prescribed. There is a flood of books, articles, and advertisements that enthusiastically promote the benefits and safety of these materials. Moreover, the huge amounts of money spent on herbs and supplements, and the relative freedom from Food and Drug Administration oversight in making claims, have drawn large pharmaceutical companies into the promotion and sale of “nutraceuticals.” This situation presents a unique challenge to the health care professions to communicate to the public in a more effective and dynamic manner about the uncertain benefits and potential hazards of these materials. The information must be disseminated on the Internet63 and in lay publications that are the primary source of information for many people. In view of the broad range of alternative therapies, I suggest that societies representing health care professionals, including those in pharmacology and nutrition, as well as clinical practitioners, form working groups to develop educational materials.
There is also a need for more high-quality research on alternative modalities to provide a basis for evaluating their safe and rational use. Many valuable medications have been derived from herbs, and botanicals remain a promising source of new therapeutic agents.64 However, recent information65,66 about the development of renal failure and urothelial carcinoma in individuals who received the herb Aristolochia fangchi, and the evidence that St. John's wort increases the rates of metabolic degradation of many medications,67 demonstrate the hazards of medicinal use of unregulated herbal preparations. Acupuncture can produce analgesia for operative procedures in some individuals, and it is plausible that it could be a useful adjunct for treatment of chronic pain syndromes, but more rigorous controlled trials are necessary. Treatments whose efficacy is demonstrated by high-quality controlled trials will inevitably be incorporated into medical practice.
Finally, I believe that “integrating” unproven alternative practices and remedies into medical school and residency training would be a mistake. It would confer undeserved legitimacy on alternative therapies, it is diametrically opposed to the development of evidence-based medical practice, and it would compromise the scientific and scholarly foundations of medical education.68,69
1. Kaptchuk TJ, Eisenberg DM. The persuasive appeal of alternative medicine. Ann Intern Med. 1998;129:1061–5.
2. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States: 1990-1997; results of a follow-up national survey. JAMA. 1998;280:1569–75.
3. Gordon JS. Manifesto for a New Medicine. Your Guide to Healing Partnerships and the Wise Use of Alternative Therapies. Reading, MA: Addison—Wesley, 1997.
4. Gaudet TW. Integrative medicine: the evolution of a new approach to medicine and to medical education. Integrative Med. 1998;1:67–73.
5. Weil A. The significance of integrative medicine for the future of medical education. Am J Med. 2000;108:441–3.
6. Marshall E. Bastions of tradition adapt to alternative medicine. Science. 2000;288:1571–2.
7. Testimony of Andrew Weil, MD, director, University of Arizona Program in Integrative Medicine. 3/28/2000. Committee on Appropriations, Labor, Health and Human Services and Appropriations. <www.senate.gov/∼appropriations/labor/testimony/weil.htm
8. Micozzi, M. Characteristics of complementary and alternative medicine. In: Micozzi MS (ed). The Fundamentals of Complementary and Alternative Medicine. New York: Churchill-Livingston, 1996:3–9.
9. Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. Rocklin, CA: Prima Publishing, 1998.
10. Houston WR. The doctor himself as a therapeutic agent. Ann Intern Med. 1938;11:1416–25.
11. Association of American Medical Colleges. Learning objectives for medical student education—guidelines for medical schools: report I of the Medical School Objectives Project. Acad Med. 1999;74:13–8.
12. Chrousos GP, Gold PW. The concepts of stress and stress system disorders. JAMA. 1992;267:1244–52.
13. Sternberg EM. Emotions and disease: from balance of humors to balance of molecules. Nature Magazine. 1997;3:264–7.
14. NIH Technology Assessment Statement. Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia. Rockville, MD: National Institutes of Health, 1995.
15. Iribarren C, Sidney S, Bild DE, et al. Association of hostility with coronary artery calcification in young adults. JAMA. 2000;283:2546–51.
16. Krantz DS, Sheps DS, Carney RM, Natelson BH. Effects of mental stress in patients with coronary artery disease. JAMA. 2000;283:1800–2.
17. Sternberg EM. Neural-immune interactions in health and disease. J Clin Invest. 1997;100:2641–7.
18. McEwen B. Protective and damaging effects of stress mediators. N Engl J Med. 1998;338:171–9.
19. Weil A. Spontaneous Healing. How to Discover and Enhance Your Body's Natural Ability to Maintain and Heal Itself. New York: Ballantine, 1996.
20. Fauci AS, Braunwald E, Isselbacher KJ, et al. Harrison's Principles of Internal Medicine. 14th ed. New York: McGraw-Hill, 1998.
21. Strauss MB (ed). Familiar Medical Quotations. Boston, MA: Little, Brown and Co., 1968:625.
22. Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA. 1997;278:901–4.
23. Watson RL, Dowell SF, Jayaraman M, Keyserling H, Kolczak M, Schwartz B. Antibiotic use for pediatric upper respiratory infections: reported practice, actual practice, and parent beliefs. Pediatrics. 1999;104:1251–7.
24. Avorn J, Solomon DH. Cultural and economic factors that (mis) shape antibiotic use: the nonpharmacologic basis of therapeutics. Ann Intern Med. 2000;133:128–35.
25. Gonzales R, Steiner JF, Lum A, Barrett PH Jr. Decreasing antibiotic use in ambulatory practice. JAMA. 1999;281:1512–9.
26. The Sixth Report of the Joint National Commission on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Arch Intern Med. 1999;157:2413–46.
27. Hochberg MC, Altman RD, Brandt KD, et al. Guidelines for the medical management of osteoarthritis. Part I. Osteoarthritis of the hip. American College of Rheumatology. Arth Rheum. 1995;38:1535–40.
28. Guide to Clinical Preventive Services. Report of the U.S. Preventive Services Task Force. Alexandria, VA: International Medical Publishing, 1996.
29. Breslow L. From disease prevention to health promotion. JAMA. 1999;281:1030–3.
30. Pomrehn PR, Davis MV, Chen DW, Barker W. Prevention for the 21st century: setting the context through undergraduate medical education. Acad Med. 2000;75(7 suppl):S5–S13.
31. Griner PF, Danoff D. Sustaining change in medical education. JAMA. 2000;283:2429–31.
32. Shapiro AK, Shapiro E. The placebo effect in medical history. In: The Powerful Placebo, from Ancient Priest to Modern Physician. Baltimore, MD: Johns Hopkins University Press, 1997:1–28.
33. Harrington A. The Placebo Effect. An Interdisciplinary Exploration. Cambridge, MA: Harvard University Press, 1997.
34. Talbot M. The placebo. New York Times Magazine. 1/9/2000,34–43.
35. Brown WA. The placebo effect. Scientific American. 1998;278:90–5.
36. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine. New York: Churchill-Livingstone, 1997.
37. Greenhalgh T. How To Read a Paper, The Basics of Evidence-based Medicine. London, England: BMJ Publishing Group, 1997.
38. Haynes B. Advances in evidence-based information resources for clinical practice. ACP Journal Club. 2000;132:A11–A14.
39. McAlister FA, Straus SE, Guyatt GH, for the Evidence-Based Medicine Group. Integrating research evidence with the care of the individual patient: user's guide to the medical literature. JAMA. 2000;283:2829–36.
40. Kaptchuk TJ. Historical context of the concept of vitalism. In: Micozzi MS (ed). Fundamental Complementary and Alternative Medicine. New York: Churchill-Livingston, 1996:35–48.
41. Dossey L. How should alternative therapies be evaluated? An examination of fundamentals. Altern Ther Health Med. 1995;2:6–10.
42. Pelletier KR. The Best Alternative Medicine. New York: Simon and Schuster, 2000.
43. Spencer JW, Jacobs JJ. Complementary/Alternative Medicine. St. Louis, MO: Mosby, 1999.
44. Ernst E, White AR. Contradictory systematic reviews: acupuncture for back pain. Focus on Alternative and Complementary Therapies. 2000;4:66–7.
45. Berman BM, Singh BB, Lao L, et al. A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Br J Rheumatol. 1999;38:346–54.
46. Cherkin DC, Deyo RA, Battie M, Street M, Barlow W. A comparison of physical therapy, chiropractic manipulation and provision of an educational booklet for the treatment of patients with back pain. N Engl J Med. 1998;339:1021–9.
47. Ernst E. Complementary treatments for back pain—the facts. Focus on Alternative and Complementary Therapies. 1999;4:3–5.
48. Shekelle PG. What role for chiropractic in health care? N Engl J Med. 1998;339:1074–5.
49. Ernst E. Harmless herbs? A review of the recent literature. Am J Med. 1998;104:170–8.
50. Winslow LC, Kroll DJ. Herbs as medicines. Arch Intern Med. 1998;158:2192–9.
51. Abbot NC. Healing as a therapy for human disease: a systematic review. J Altern Comp Med. 2000;6:159–69.
52. Eisenberg DM, Delbanco TL, Berkey CS, et al: Cognitive behavioral techniques for hypertension: are they effective? Ann Intern Med. 2000;118:964–72.
53. Ernst E. Research at the Department of Complementary Medicine, University of Exeter. Advances in Mind-Body Medicine. 1998:14:151–6.
54. Ernst E, Fugh-Berman A. Complementary and alternative medicine needs an evidence base before regulation. West J Med. 1999;171:149–50.
55. Stephen E. Straus. 3/28/2000; Statement before the Senate Appropriations, Labor, HHS, Education and Related Agencies. 〈http-//nccam.nih.gov/nccam/ne/appropriations-s.html
56. Dalen JE. “Conventional” and “unconventional” medicine. can they be integrated? Arch Intern Med. 1998;158:2179–81.
57. Grady D, Wenger NK, Herrington D, et al. Postmenopausal hormone therapy increases risk for venous thromboembolic disease. Ann Intern Med. 2000;132:689–96.
58. Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses involving complementary medicine in US medical schools. JAMA. 1998;280:784–7.
59. Ruedy J, Kaufman DM, MacLeod H. Alternative and complementary medicine in Canadian medical schools: a survey. Can Med Assoc J. 1999;160:816–7.
60. Beyerstein BL. Alternative medicine and common errors of reasoning. Acad Med. 2001;76:230–7.
61. Astin JA. Why patients use alternative medicine: results of a national study. JAMA. 1998;279:1548–53.
62. Eisenberg DM. Advising patients who seek alternative medical therapies. Ann Intern Med. 1997;127:61–9.
63. Jadad AR, Gagliardi A. Rating health information on the Internet. navigating to knowledge or to babel? JAMA. 1998;279:611–4.
64. Tao X, Ma L, Mao Y, Lipsky PE. Suppression of carrageenan-induced inflammation in vivo by an extract of the Chinese herbal remedy Tripterygium wilfordii
Hook F. Inflamm Res. 1999;48:139–48.
65. Nortier JL, Martinez MM, Schmeiser HH, et al. Urothelial carcinoma associated with the use of a Chinese herb (Aristolochia fangchi
). N Engl J Med. 2000;342:1686–92.
66. Kessler DA. Cancer and herbs. N Engl J Med. 2000;342:1742–3.
67. Moore LB, Goodwin B, Jones SA, et al. St. John's wort induces hepatic drug metabolism through activation of the pregnane receptor. Proc Natl Acad Sci USA. 2000;97:7500–2.
68. Angell M, Kassirer JP. Alternative medicine: the risks of untested and unregulated remedies. N Engl J Med. 1998;339:839–41.
69. Fontanarosa PB, Lundberg GD. Alternative medicine meets science. JAMA. 1998;280:1618–9.
Alternative Medicine: The Importance of Evidence in Medicine and in Medical Education