Many hospitals today offer a variety of nonconventional treatments, and dozens of medical schools teach courses in alternative medical systems. Proponents of this integrative approach argue that it is simply an attempt to provide patients with the most comprehensive care available. Critics believe it's unethical for medical professionals to offer scientifically unproven treatments, and allege that for hospitals and medical schools, it's all about the bottom line. In these excerpts from their interviews, NCCAM director Stephen Straus, founder of the University of Arizona's Program in Integrative Medicine Andrew Weil, Harvard University's Marcia Angell and Tom Delbanco and medical historian James Whorton debate the pros and cons of "integrative medicine."
Tell me about the Consortium of Academic Health Centers for Integrative Medicine, and what you're trying to do with it.
[The consortium] has been in existence for several years but it's now become quite formalized. At the moment we have twelve member schools, Duke, Harvard, Columbia, Georgetown, University of California, San Francisco, University of Maryland, the University of Arizona, University of Michigan, Jefferson and so forth. … We now have probably another ten schools knocking at the door, wanting to be admitted.
The purpose of this group--really it's quite out there--is to transform health care through radical reform of medical education and merging biomedicine with everything else that's out there. Our hope is that we can get up to twenty-five member institutions at which point we'll say we represent one-fifth of the nation's medical schools. And I think we can then go to institutions like the National Board of Medical Examiners and the American Association of Medical Colleges and begin demanding changes in how medicine is taught.
My focus has always been on the radical reform of medical education. My contention is that the root of the problem is how we're training doctors. We need a new generation of doctors out there who've been trained differently to meet the needs of consumers today. …
How do you think doctors of tomorrow should be taught differently?
I propose teaching nutrition. I propose teaching the basics of botanical medicine and the basics of mind-body interactions, and at least a general survey of alternative medical systems and learning about what their strong points and weak points are, and learning about the body's natural potentials for healing. I mean all those things that are now missing from standard medical education.
Do you think this is realistically going to happen?
Absolutely, I think there's no question. It's still a consumer driven phenomenon. The schools are being dragged, kicking and screaming, in this direction but they have no choice because the health care system is in total economic collapse. The market forces dictating this are overwhelming. It's not just that more consumers are spending more money on this than on standard medicine, it's at the same time, these standard medical institutions are imploding. Given that kind of reality I think medical schools, medical educators have no choice but to pay attention to what people are demanding. …
My sense is that if you look at the opposition to this, at least within the academy, there is a clear generational component. There is a group of older academic physicians who really aren't happy at what's happening. I think they will pass from the scene and facilitate acceptance of all this. Then I think there is also some resistance from the basic scientists. When a movement like this starts at a medical school, usually starts among the clinical faculty. The basic scientists often resist because they have all the prejudices of that world, that this is at best, unscientific and at worst, anti-scientific.
…You will hear from people in the research community that medical education should only change in response to research findings. I don't think that's how things change. My experience is that people believe what they want to believe, and whatever research produces they'll continue to do what they do. In fact there's even been some studies showing that the practice patterns of doctors do not change in response to published results of randomized controlled trials that contradict what they've been doing. I think the way things change is by changing the culture of medicine. …
What do you think has to change in the culture?
To me the major thing that has to happen is to shift the focus of medicine from disease and symptoms and treatment to health and healing. The major thrust of my writing has been about the innate mechanisms of healing in the human body, much more than about alternative medicine. That's why I don't like being called a guru of alternative medicine.
I have tried to call attention to the fact that the body--I mean it's hardly a new idea--has incredible potential for self-diagnosis, for repair, for regeneration. When I approach a patient, my first thought is always why is healing not happening in this person? What's blocking it? What can I do as a physician to facilitate healing? That's a different perspective. …
That's what I mean by this change of perspective: at best, treatment facilitates healing, it impinges on natural healing mechanisms of the body, unblocks them, it allows them to operate. … Similarly I think that looking at people as whole persons, not just physical bodies, that people are also mental, emotional beings, they're spiritual entities, they're community members, all of those other dimensions of human life are very relevant to health and healing. …
What sort of resistance have you encountered from the mainstream medical community?
A little over a year ago I was asked to be the keynote speaker at the Council of Deans annual meeting of the American Association of Medical Colleges. I said what I had to say about the radical need for changes in medical education and so forth. I was interested in what the resistance was in that group. And I sensed that there were three different kinds of resistance. The first was enormous resentment that these changes were being dictated by consumers. There was a real feeling that changes in medical education should only come about as a result of advances in medical research. …
The second kind of resistance that I heard was that this is a slippery slope, that if we begin teaching about botanical medicine in medical school, next we'll be teaching about astrology and crystal healing and where will it all end? And the foundations of western science and rationalism will crumble. My answer to that is that that's the whole point of what I'm trying to do in integrative medicine, it's trying to teach discrimination to medical doctors. You look at this whole mixed bag of alternative medicine which ranges from very intelligent to very foolish and some dangerous. And you want to sort through it and separate out the wheat from the chaff to find out what's worthwhile there, what's not worthwhile, what can be incorporated into mainstream medicine and what can't be incorporated. That's the whole point of integrative meditation.
The third kind of resistance which was interesting was I think just simple fear of censure by peers. I'll give you an example of why I think that. The day after my talk I was on a panel with Steve Straus from NCCAM and it was moderated by the dean of the University of Maryland School of Medicine, who I thought rather flippantly asked this group of deans, after we spoke, "Well, now how many of you are ready to start teaching integrative medicine?" One hand tentatively went up and immediately came down when the person looked around. A few days later they gave a written poll to these deans and eighty percent of them said that they were in favor of teaching integrative medicine. …
While I take responsibility for publishing David Eisenberg's survey and I think it was a good survey and it addressed an important question--how many people are using these things--I don't take responsibility for all of the ripple effects, some of which I think are quite negative. One of them is the fact that medical schools began to say, "Hey, there's a market for this stuff, let's get on the bandwagon here and advertise ourselves as being friendly to alternative medicine." And they did that and they began to set up courses and centers and institutes that to my mind were pandering to a market. They weren't teaching alternative medicine in the sense of teaching about the evidence in support of it, or what it is, or who's doing it, they were going beyond that. They were offering it and they were proselytizing. Because everything is a market now, they were trying to attract customers that way. And insofar as that was the fallout from the Eisenberg piece, I regret it. … I'm very dismayed that the academic establishment decided you know, "Oh goody, we'll jump on this."
What do you think about what's being taught in American medical schools like Harvard about alternative and complementary medicine?
I think that you should teach something about alternative and complementary medicine, or whatever the term du jour is for it. You should teach about it because it's a real phenomenon out there and it has to do with medicine. So you ought to teach about it as a phenomenon, and then you should also teach about the various disparate practices that fall under that rubric: homeopathy, therapeutic touch, herbal remedies. You should teach what is known about the evidence. You should teach about the scientific evidence. Do we know it works? Do we know it doesn't work? Do we know nothing about it and is it just merely speculation and assertion? That's the kind of teaching that should go on in medical school, but in fact, [that's not happening].
Just this month in the Journal of Academic Medicine there was a very good survey of this, done by some scholars at the University of Indiana Medical School, and they found that almost all medical schools do in fact offer courses in alternative medicine but they are not about it, and they certainly are not critical courses looking at the evidence for it. They are proselytizing courses and the teachers are proponents and often practitioners of these therapies for which there is no proof whatsoever, and they're indoctrinating the students in it. That's quite different, and that's my concern about teaching it. …
What's happening at Harvard?
In general I think Harvard has been very lax in its evaluation of complementary and alternative medicine. It seems to be applying a double standard, one standard to new treatments for heart failure and a different standard for things that are labeled "complementary and alternative medicine." It shouldn't do that. It should be embarrassed by that. It's not alone. Most of the other major research institutions are doing exactly the same thing. They too are setting up institutes funded by wealthy philanthropists who are believers in complementary and alternative medicine. They shouldn't do it either. I don't think Harvard is any worse, but it's not any better either.
Why are they doing it?
Well I think there are two reasons. And you should ask them, but I think there are two reasons, one is it's good marketing. People want it, particularly the people that teaching hospitals' practitioners would like to attract. These are well insured people who are relatively affluent, relatively well educated. These are the people who by and large subscribe to alternative medicine. Any HMO, any hospital is going to want to attract them. They don't cost as much.
I think that people who believe in alternative medicine would just be amazed at the extent to which they play into the hands of the establishment trying to save money. If you're an HMO and you offer yoga for example, this is very good niche marketing for two reasons, you're getting people who are likely to stay healthy and you're offering a service that's very cheap compared to say a prescription drug benefit. So if you're an HMO and you get paid so much per head and you get to keep that money if your patients don't cost very much, and you offer yoga, it's cheap and you get people who aren't going to get sick and you keep all that money as profits at the end of the day. And if on the other hand you were to offer a prescription drug benefit, that would break the bank and you would attract old people, sick people, people for whom that's important. So that's what's going on there, and I think that the Harvard teaching hospitals are doing the same thing. So I think that's one reason, it's good marketing.
I think another reason that the medical schools are so willing to set up centers and institutes dedicated to essentially promoting complementary and alternative medicine is because they do get this infusion of money, first from wealthy philanthropists, but now from the NIH. And now that the National Center for Complementary and Alternative Medicine has real grants, real money, sizable grants to offer, they want them. And the academic medical centers, I'm sorry to say, have their eye on the bottom line at all times. …
What's wrong with hospitals offering patients alternative therapies?
When the Harvard teaching hospitals offer acupuncture or therapeutic touch they're usually doing it for pain. They're doing it for a subjective symptom. And they're doing it for patients who would like to have it. I was offered therapeutic touch at the Mass General two years ago for post-operative pain. I declined. But if I had said yes, I would have gotten totally implausible, impossible treatment given to me for pain at the Mass General Hospital. They're not offering it to you for cancer, thank goodness. When they offer it to you for pain, they're counting on the placebo effect. If you believe in it, then you're at least going to report that your pain is better. And if you don't believe in it you're going to decline it, as I declined it. So they figure it can't do any harm. May make their pain feel a little bit better, and it can't do any harm. And they're also going to give them conventional pain relief too. So it's good marketing--people like it, it's another choice. Consumers like lots and lots of choices and here's one for you.
But I think it's very bad and it's very bad for two reasons. One, it's unethical in the sense that you should not use a placebo except in a research setting. When you do a clinical trial and you use a placebo, what you're saying to the people who enter the trial is, "Some of you may be getting a dummy pill, or a placebo, is that okay with you?" And then people say, "Yes, it's okay." But when you're giving it in the context of treatment, they don't say, "Would you like therapeutic touch, it's a placebo?" so it's deceptive in that sense. It implies that it works. And I think it's wrong to give a placebo if, if you're not honest about it. … I think placebos are unethical, except in a research setting. So that's number one.
Number two, it puts the Mass General Hospital's imprimatur on this. By the very act of offering it, they are saying this works. I mean, you have just gone to what some of the locals call man's greatest hospital, you expect the most sophisticated care in the world, and you get it. And then you're offered this? The only thing a member of the public can possibly conclude is that this must have been found to work or the Mass General Hospital wouldn't offer it. So I think that's wrong, it's misleading on two counts. …
It also uses personnel who could be put to better use. At the time that I was offered the therapeutic touch at the Mass General Hospital, my daughter happened to be a resident there and I knew very well that they were short staffed in many respects and mainly they were short staffed of nurses. And yet my understanding is that nurses were going to be used for this. At least there was a nurse talking to me about it. So I think it's a misuse of resources. …
Is it ethical for hospitals to offer alternative services?
The question of what's ethical in alternative medicine is very complicated. My own view is pretty simple. If you say to someone, "We've got something here that may help you," I have no problem with that at all. On the other hand, if you say to someone, "We've got something here that's better than a placebo, that's better than another medicine," and there's no basis in scientific fact to make that claim, I get furious, because it's misleading.… They are selling something to someone who is often poorly equipped to evaluate the risks and benefits of what they're selling, who often has to pay a lot of money for that, and who often might gain more from going away for a weekend and taking it easy, or buying a good book or going to a concert, or just stop worrying about their own health. …
One of my real fears about hospitals getting into the business of alternative medicine is that it will be offered to the people with money, but poor people won't get them. The people who have the biggest burden of illness, the people in most need of everything are those who don't have any dollars. One of the things I hate about some of the things I see in hospitals now is the growing push toward the two-class system of care. We'll give you everything if you've got some dollars and if you don't have them, please stand aside. Alternative medicine is a beautiful example of that.
What does the phrase 'alternative medicine' really mean?
What do we mean by "alternative medicine" or "complementary medicine?" I, as a board certified internist on the faculty at Harvard Medical School, am not a fan of any of these labels - complementary, alternative, unproven, disproven, unconventional, integrative even. I'm in favor of "comprehensive health care." I think that's at the common core of all of this. What are the best options for a given patient in a given situation? And the goal is not to integrate a little of this and a little of that, but to create a comprehensive health care program which we now call "integrative care," which incorporates the best of conventional evidence-based Western bioscience with evidence-based complementary therapies.
How do you see the conventional and alternative approaches to medical care fitting together?
Do we want to imagine that physicians, MDs, can be credibly trained acupuncture or herbal medicine in a matter of months? I think not. On the other hand, can fellows in a Harvard program or a program at any other university be trained sufficiently to know when to refer [a patient] to an acupuncturist or a chiropractor or massage therapist [and] how to co-manage a patient who is being seen by one of those licensed providers?...Yes, I think we can.
It would be wonderful, would it not, if in every part of this country, in every hospital, there was at least one doctor in every discipline - oncology, rheumatology, internal medicine, and family medicine - who knew a lot about herbs, acupuncture and massage and could say,..."This is not safe, I wouldn't do that." And, "I know from where I'm speaking, I spent a lot of time with them, I would not do that." Wouldn't the population feel safer?
Wouldn't it be great if there were physicians who were expert in medicine as we know it, conventional biomedicine, who knew enough about complementary techniques and the approach to patient care to advise patients about the use or avoidance of individual therapies? And wouldn't it be great if their mindset was one of facilitating patient participation and encouraging the patient to do things that they could for themselves? That's the future, I think that's what the public wants.
More than half the medical schools in the country have adopted at least some instruction in alternative medicine into their curriculum. In some cases it's part of their required curriculum, in other cases it's an elective for the medical students. But still at most medical schools now there is an opportunity for the allopathic students to learn something about alternative medicine.
There's money involved now.
My guess is that there's more incentive of that sort for the hospitals than for the students… . The Eisenberg study showed that enormous sums of money were being spent on alternative medical services, that there was a great consumer demand for it. I think that encouraged hospitals and health care plans to provide those services--partly to meet the desires of their clientele, partly for the money that was involved. …
One of the most striking things for me when I look at the situation today is to see how rapidly the system has accommodated alternative medicine. We've seen two hundred years of bitter conflict between the two, allopaths denouncing all alternative systems as quackery as a danger to the public health, and now in the last few years in some institutions we're seeing a range of alternative treatments provided, in some cases before we have very solid evidence that these are effective. It is strange to a historian to see how rapidly we've made that transition. I can't see that it's been made purely for scientific reasons because we don't have as solid evidence as we'd like for the efficacy of some of the treatments. I hate to have to suspect it's made for economic reasons because there is so much consumer demand for it, but I'm not sure how else to account for it. …
It's got to be economic.
I think so, but I think also the physicians who have been trained in the last twenty to thirty years have been educated, especially doctors in family medicine, in the same kind of philosophy that the alternative doctors have been espousing for a couple of centuries. They're finding some common ground that makes them open to what they're claiming, perhaps to a degree they shouldn't be. Perhaps they've gone from being too critical perhaps to being not critical enough. It's the sort of thing that only time will tell. Once we get more data on the efficacy of these therapies we may see that this was a major turning point in the history of medicine or we may see this was a phase that was a little bit crazy.
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posted november 4, 2003
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