A July 17 Health article about alternative therapies getting increasing attention in the medical school curriculum incorrectly described echinacea as a non-herbal treatment. Echinacea, also known as purple coneflower, is an herb.
Earning a Spot in The Curriculum
Tuesday, July 17, 2007
Rosemary Wilson, a 53-year-old Connecticut homemaker, has spent the past 20-odd years trying to fix whatever it is that's wrong with her back. She's seen neurologists, an orthopedic surgeon, an osteopath and a physical therapist. She has also sought help from chiropractors, a massage therapist and, most recently, an acupuncturist.
But she's not mentioning these last three to her primary care doctor.
"When I mentioned chiropractic to him, he literally rolled his eyes," says Wilson, who also reports being chewed out by her OB-GYN for trying the herbal remedy black cohosh to deal with menopausal hot flashes. "I've given up trying to talk to the doctor about it. Why should I bother? I wish they [doctors] were more open to it."
By "it" Wilson means complementary and alternative medicine. CAM, as the field is known in medical circles, includes dozens of practices, from Chinese and Ayurvedic systems to meditation and massage.
While CAM and conventional medicine have long held each other at arm's length, major medical schools have begun to incorporate information about these non-conventional techniques into their curricula. The idea is that doctors need to know about CAM -- if only to keep up with what their patients are already doing to heal themselves.
In the early 1990s, a handful of medical schools-- the University of Maryland's and Georgetown's among them -- established centers for the study of non-conventional medicine. Today, a consortium of 38 medical schools, including most of the major ones, is working to integrate CAM into mainstream medicine while maintaining Western standards of care. Among the group's chief tasks is to determine which non-conventional practices, by virtue of science demonstrating their safety and efficacy, should claim part of a medical student's limited learning time.
Many CAM treatments rely on practitioners' skill and intuition, and vary from patient to patient, making them hard to research through conventional, Western-style studies. And even where research has been done, in many instances the findings are inconsistent or inconclusive.
In the end, medical schools must weigh the value of solid science against the value of long-standing tradition and cultural beliefs. As Michael Cirigliano, associate professor of medicine at the University of Pennsylvania medical school, puts it, "If you see patients, you need to have an idea of what CAM is about." But he adds, "No one gets treated with complementary medicine until they have a [conventional medicine] diagnosis."
Even for those CAM practices that do merit a space in the curriculum, the space is usually small -- taught through electives and single lectures, with only a few threads woven into the central curriculum. At the very least, though, medical students at most schools are being taught to ask about the use of CAM treatments when they take patient histories. By so doing, they can guard against potentially harmful interactions between conventional practices and medicines and alternative ones; some herbal remedies, for instance, interfere with the way the body metabolizes therapeutic drugs. And whether they're being taught specific CAM practices or not, medical students are increasingly encouraged to respect patients' cultural and ethnic backgrounds, which may include CAM practices.
So which non-conventional treatments are medical schools most comfortable with? And which do they feel need more research to earn a med student's attention? Based on conversations with officials at four major medical schools -- Maryland, Johns Hopkins, UCLA and the University of Pennsylvania -- here's a report:
Acupuncture. The alternative therapy most widely embraced by medical schools is the ancient Chinese system for treating medical problems by stimulating key body points -- often by using very fine needles -- to manipulate "energy fields." Although there has been no scientific documentation about these fields or the precise mechanism by which acupuncture works, it has won recognition as a helpful treatment for osteoarthritis of the knee, as well as for nausea and fatigue in cancer patients.
Mind/Body Medicine. Guided imagery, meditation and other practices that harness the mind to promote health and healing have been adopted by conventional medicine as a means of managing stress and pain. While a recent analysis of 813 studies concluded that "no compelling evidence" exists yet to prove the theurapetic value of meditation, some studies have suggested that mind/body exercises, in conjunction with conventional methods, can help treat cardiovascular disease and even bolster the immune system. That these methods pose no physical or psychological risk to the patient and are inexpensive adds to their appeal. Among mind/body interventions, one of the hottest research topics is the placebo effect: Doctors want to know whether a patient's expectation that a treatment will work ultimately affects that patient's outcome.
Herbal Therapies. Herbal medicine is "easier to present to med students [because] it's a bit closer to pharmacology" than some other CAM treatments, says Rick Scott, of the University of Maryland's Center for Integrative Medicine in Baltimore. But he agrees with Mary Jo Kreitzer, a founding member of the medical school consortium, that herbal medicines remain controversial, with a lot of uncertainty about how safe they are and how well they work.
St. John's wort, for example, may be useful in treating mild (but not moderate to severe) depression; however, because the herb can alter the way the body processes drugs, it should be used with caution. Another example: In a recent study, black cohosh did not help ease menopausal hot flashes.
Among biologically based treatments that do not involve herbs, studies of dietary supplements such as glucosamine (to treat arthritis) and echinacea (for upper respiratory illness) have been inconclusive, while evidence supporting folic acid's utility in preventing certain birth defects has been convincing.
Manipulative and Body-Based Methods. The science behind chiropractic treatment, massage therapy and other practices in which the body is physically manipulated to promote good health is sketchy and inconclusive, according to a review of research by the NIH's National Center for Complementary and Alternative Medicine. It's particularly hard to study methodically and to measure results. Still, Cirigliano says of chiropractic treatment, "The only issue I have with [chiropractors] is that they know their limitations. They're not going to cure lung cancer."
Energy Medicine. According to Scott, "The area that will take a little bit longer is frontier medicine, or energy medicine. It's more difficult to research" than conventional medicine because, like acupuncture, it's founded on a belief in energy fields. This category includes such approaches as therapeutic touch, distant healing, prayer, and the laying-on of hands. ·
Jennifer Huget is a regular contributor to the Health section. Comments:email@example.com.