Sold Out! Our doctors in training...

Speaking of troubling continuing medical education and the growing confusion of pseudoscience with credible science in medicine and academia...

Medical professionals paid for the opportunity to get CME credits last week to learn alternative modalities — from laying on of hands (without touching the person) that was purported to grow bones, mantras said to increase the gray matter and size of the brain, and healing through ‘energy’ balance. The first symposium on alternatives by Yale’s Integrative Medicine program said it “Sold out!”

The symposium host

Yale’s Integrative Medicine website says that it’s a “recently established program designed to provide a sustainable, central forum at Yale for interdisciplinary, inter-institutional, and international collaboration, research, and education in complementary, alternative, and integrative medicine. Through open-minded exploration and rigorous scientific inquiry, we aim to improve awareness and access to the best in evidence-based, comprehensive medical care available worldwide, with the goal of optimizing health and healing for patients and health care providers.”

According to its original press release:

Yale School of Medicine is hosting its 1st annual Yale Integrative Medicine Scientific Symposium April 2 to explore the best of conventional and complementary/alternative medicine [CAM]... The day-long program will begin with optional morning meditation or yoga stretch... Topics will include, among others: the history of complementary/alternative medicine in America; the effects of therapeutic touch on growth and differentiation of bone-making cells; therapeutic massage; yoga; increased cortical thickness linked to meditation; the psychology of illness and the art of healing; traditional Chinese medicine; acupuncture for post-operative nausea and low back pain in pregnancy, and potential applications of traditional Chinese medicine in cancer.

The Yale representative on the Steering Committee and Advisory Board for Integrative Medicine at Yale is David L. Katz, M.D., MPH, FACPM, FACP. He is also the founder and direct of the Integrative Medicine Center at Griffin Hospital in Derby, Connecticut, as well as an associate professor of Public Health and director of the Prevention Research Center at Yale University School of Medicine. Dr Katz is probably best known among the public for his online weight loss program and Flavor Point Diet book [which says you can lose weight by eating less variety and eating flavor-themed meals] and monthly columns for Oprah’s magazine. He’s also regularly quoted in the news, such as saying that recent studies support that less screen time can prevent childhood obesity, that obesity is contagious, and transfats are poisons.

For those unfamiliar with integrative medicine, last month’s issue of Integrative Medicine: A Clinician’s Journal interviewed Dr. Katz, where he described the new program at Yale. The founding principle of integrative medicine, he said, is “training a conventional practitioner... a pediatrician, a family practitioner, and an internist and teach them how to do acupuncture and herbal medicine.” Their program’s second approach is to have conventionally trained practitioners work alongside naturopaths, which, he said, “has the most potential to make integrative medicine the standard practice.”

Co-director of the Yale Integrative Medicine center, naturopath Ather Ali, ND, MPH, said their program includes alternative therapies such as naturopathic care, herbal medicine, homeopathy, nutritional counseling, acupuncture, Chinese medicine and therapeutic touch.

Residents are taught a thought process that Dr. Katz calls “evidence hierarchy.” He said it is a way “to choose a therapy that is systematic yet allows for individualized, holistic care. Thus, we can be systematic when we assess whether an herb, drug, nutritional supplement, homeopathic remedy, or a combination is the most prudent choice for a particular patient.”

This highlights how even the term “evidence-based medicine” doesn’t always have the meaning you might think.

Dr. Katz admitted CAM is cheap care to provide. “As far as the business structure goes,” he said, “we use midlevel providers”—

So while I’m overseeing the clinic, a nurse practitioner does much of the hands-on care for the patients. And similarly, on the naturopathic side, Dr Ali is the director, but we also have a naturopathic resident. The hiring of a resident offers an array of benefits. To be blunt about it, doctors in training are inexpensive labor. You spend a lot less money on a naturopathic resident than you would on an experienced practitioner... We save money on the cost of the medical care by employing a resident, but we also expand the impact of the clinic by training the kind of practitioner we think is necessary to help change the way healthcare gets done.

There are two other financial components to their integrative medicine program, he explained to the journal. One is grant support and the second is the hospital and residency training program, which can absorb costs. Still, he said, paying the bills is a fundamental problem. The center tries whenever possible to get insurance reimbursement, he said, but:

We are providing care that is at the margins of what insurers pay for. They want to see evidence. The problem there is that we have an absence of evidence...There’s a lot of stuff out there that we simply don’t know. That doesn’t mean it doesn’t work.

This interview may have raised a few other questions among readers that we’ll examine. Some of this information may also help to explain the saturation of popular culture with unsound information about food and preventive health, and it’s increasing entry into academic and medical settings, over the past decade .

Sales and politics

The 2000 White House Commission on Complementary and Alternative Medicine Policy recommended integrating CAM into the nation’s medical, medical education and insurance systems. This policy recommendation received considerable negative feedback from the scientific community (which few among the public probably ever heard) because it degraded established guidelines for medical care standards — those had traditionally held that until there is credible evidence that a medical intervention is safe, effective and cost-effective, it shouldn’t be included in clinical practice or taught as complementary to medical practice.

The February 27, 2008 issue of U.S. News & World Report acknowledged that until the mid-1990s CAM was considered quackery by academic institutions and the science and medical community, but “a large pot of federal and foundation research funds — now close to $250 million per year from NCCAM and the National Cancer Institute, plus tens of millions more from private donors such as the Bravewell Collaborative” has changed that.

In fact, since 1999, the National Center for Complementary and Alternative Medicine (NCCAM) has spent $983.135 million supporting alternative modalities – a 60-fold increase in tax-payer funding since 1992.

As we’ve looked at previously, financially-strapped schools have proven ripe ground for promoting CAM education, too. Increasingly, CAM isn’t just an elective class, but is being integrated throughout curriculums, making it mandatory for students in order graduate with medical and nursing degrees. Incorporating CAM into nursing and medical school curriculums has been incentivized by significant government grants made available through the NCCAM’s Complementary and Alternative Medicine Education Project Grants that were established in December, 1999 to “play a proactive role in accelerating” the incorporation of CAM into the Nation’s medical and nursing curriculums. Between 2000-2002, alone, NCCAM awarded 15 grants to universities to develop integrative medicine curriculums.

On February 29, 2008, the CAM Practitioner Research Education Project Grant Partnership Competitive Renewal gave grantees the opportunity to continue CAM education programs for another four years, with up to $200,000 per year. Applicants were reminded that grants must include a citation promoting the government’s Healthy People 2010 goals for preventive health initiatives.

All 18 hospitals on U.S. News's most recent “America's Best Hospitals” superselective Honor Roll provide CAM of some type, it reported. Fifteen of the 18 also belong to the Consortium of Academic Health Centers for Integrative Medicine and 36 U.S. teaching hospitals are pushing to blend CAM with traditional care to get in on the money. While some include techniques already recognized by mainstream medicine (such as movement, relaxation, and massage for helping to lower stress and anxiety) to give CAM greater legitimacy, CAM by definition includes uses and claims for modalities that are unproven (once they're shown effective, they're no longer alternative). Lack of evidence for effectiveness should not be confused with never having been tested (and shown to be little more than placebo) or for having scientific plausibility based on known laws of science. Sixteen years of NCCAM-funded research on CAM has yet to prove otherwise.

The National Institutes of Health and NCCAM in their 2002 report on CAM use, defined CAM, and modalities lacking evidence, as also including:

Acupuncture
Ayurveda
Biofeedback
Chelation therapy
Chiropractic care
Diet-based therapies (vegetarian, macrobiotic, Atkins, Pritikin, Ornish, Zone)
Energy healing therapy
Folk medicine
Guided imagery
Homeopathic treatment
Hypnosis
Meditation
Megavitamin therapy
Natural products (nonvitamin and nonmineral, herbs, plant extracts, enzymes, etc.)
Naturopathy
Prayer for health reasons
Qi gong
Reiki
Tai chi

Some have questioned if CAM-trained doctors are able to practice as primary care physicians and if we can trust their judgments. The concern that probably most comes to mind is whether these doctors are being taught the scientific process and how to recognize sound evidence from modalities that negate all known laws of science and biological plausibility. When making medical and treatment decisions for patients and giving advice, most patients probably hope so. But...

It would appear not.

What are they teaching?

What might once have been inconceivable for inclusion in science-based academic disciplines, alternative curriculums are teaching "other ways of knowing." These programs, being adopted by growing numbers of medical and nursing schools across the country, are unlike long-established educations. Here is a glimpse how.

Yale School of Medicine is one of 40 medical schools across the country that are members of the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM). It was formed in 1999 [click on image to enlarge] and, today, includes some of the nation’s most prestigious university medical schools offering full CAM programs.

“The Consortium’s mission is to help transform medicine and healthcare through rigorous scientific studies, new models of clinical care, and innovative educational programs.” To understand what this really means, we have to look at the actual curriculum.

The CAHCIM’s curriculum guidelines were published in a statement of core competencies for the practice of integrative medicine, in a 2004 issue of Academic Medicine. The key components for effective implementation of teaching integrative medicine, according to the CAHCIM, are experiential learning and education in self care and reflection. “The root word of education, educari, means to lead forth the innate wholeness of each student,” it said. CAM doesn’t lend itself to “straightforward” teaching methods that require the presentation of facts as in traditional education, it said, as that “may not be sufficient to develop a real understanding...to capture the sensate experience” that comes in having students experience CAM directly on themselves.

Traditionally, medical education has given students expertise in core sciences and taught them how to apply the scientific process — to critically and logically evaluate observations, accurately test and replicate ideas, and make decisions based on verifiable data and scientific plausibility. Medical care standards that are taught, ideally try to be based on what has solid evidence of efficacy and represents the best science to date.

In contrast, the Consortium’s core curriculum for integrative medicine involves “a way of living and being for physicians:”

Values. The graduating doctor must demonstrate: “collegial relationships... a broad definition of professionalism... recognize the relevance of feelings, beliefs, life experiences, meaning, and faith to his/her professional behavior... recognize the value of his or her own full human experience... an ongoing commitment to personal growth... pursuit of meaning as fundamental to the process of healing... recognize the sometimes unknown factors that influence health and healing.”

Knowledge. The graduating doctor must be able to: “discuss how beliefs shape an individual’s interpretation and experience... identify the strengths and limitations of biomedical knowledge... example different ways of knowing... describe mind-body-spirit relationships in illness and health... describe the basic concepts in the most commonly used CAM modalities such as chiropractic, herbal and nutritional medicine, and mind–body therapies, and of one or more of the widely used traditional systems of medicine such as Chinese medicine and Ayurvedic medicine... identify potential legal and ethical implications related to the inclusion or exclusion of CAM... government regulation of herbal medicines and dietary supplements.”

Skills. The graduating doctor must be able to: “demonstrate an ability to assist in developing self-care programs... communicate effectively... design a personal self-care program... demonstrate an ability to utilize the principles of evidence-based medicine in analyzing integrative medicine approaches, including...utilizing databases, peer-reviewed publications, authoritative textbooks, web-based resources, experiential knowledge of CAM practitioners, and participatory observation to gather relevant information, evaluating the information for scientific quality and clinical relevance...”

Grading

Rather than semesters of examinations and practice evaluations ending in intense board exams that traditional students take to evaluate their knowledge of medical science and practice, the Consortium endorses very different tools “to measure competencies in integrative medicine.” It recommends testing students using “emerging means of learning in these educational settings” that include personal narratives, interviews and focus groups with students and faculty about beliefs, and student journal reflections. Experiential knowledge, a state of being, has no right or wrong answers.

While there are also a number of tools that are available, the one specifically recommended by the Consortium to be given before and after courses over the course of students' training to assess students’ competencies and track their learning, is the Integrative Medicine Attitudes Questionnaire. The development and validation of this tool were described in a 2003 issue of BMC Medical Education. This 29-item form was developed from focus groups of 111 internal medicine physicians in academic centers (fewer than 20% of those contacted responded) and 85 healthcare providers attending an American Holistic Medical Association conference. The form was found to “differentiates between those who readily embrace more integrative approaches and those of a general population of providers” and reliably measure attitudes towards CAM, “specifically openness to new ideas and paradigms.” The authors supported its use “as a first step in understanding willingness to use these approaches to healing.”

In other words, incredibly, these attitude questions are measures of students’ gullibility and belief in CAM and to ensure that no critical questioning or scientific thinking has found its way into their receptiveness to CAM. Those who succeed in alternative modalities have been convinced to be uncritical.

The most significant challenge in introducing integrative medicine into conventional medical schools, according to the Consortium, is that “alternative health care systems often challenge the paradigm of understanding human health and illness that underlies modern biomedicine.” Integrative modalities call for reevaluation of the biomedical paradigm and integration of CAM’s “alternative ways of understanding health and illness.” These are alternative ways of knowing that believe in unseen, unmeasurable energies and a healing “vital force” that transcends the laws of chemistry, physics, biology, nutrition, microbiology, toxicology-pharmacology, and other sciences.

Examples of the results of these ‘other ways of knowing’ can be seen throughout university health curriculums. For example:

Coming up

The next educational opportunity for healthcare professionals offered by Yale’s Integrative Medicine is on April 30^th. According to the program, the seminar will be given by Dr. Mark Hyman, M.D., co-director of Canyon Ranch; editor-in-chief of the peer-reviewed Alternative Therapies in Health and Medicine and editorial board member of Integrative Medicine: A Clinician's Journal; and practices through Harvard Medical School’s Brigham and Women's Hospital where he has taught Complementary and Integrative Medicine.

JFS readers are already familiar with Canyon Ranch from when the former Surgeon General, Richard Carmona, joined them as vice president of their Life Enhancement Company. Canyon Ranch is a “wellness and life enhancement company” that started in Tucson, Arizona, and now has elite spas around the country. It generates $140 million a year offering guests stays with fitness and spiritual classes, self-discovery, integrative health, workshops to develop positive lifestyle habits, a personal advisor, and it “focuses on the spiritual health of guests who participate in Energy Medicine, reiki, acupuncture, qi gong or healing touch.” A week at this spa costs one from $4,560 to $12,180. Since 2005, Canyon Ranch has a joint venture with the Cleveland Clinics (the source of much of our health news), offering executive wellness programs.

You may not immediately recognize Dr. Hyman’s name, but you will his preventive health teachings. He lectures widely on longevity and life extension medicine, optimal wellness and anti-aging diets. He is the author of (best-selling) books such as The Detox Box: A Program for Greater Health and Vitality; Ultra-Metabolism: The Simple Plan for Automatic Weight Loss, NutriGenomics, The Ulta Simple Diet, and 5 Forces of Wellness: Living an Active, Age-Defying, Disease-Free Life.

In a recent issue of Life Extension Magazine, he described his book, Ultra-Metabolism: The Simple Plan for Automatic Weight Loss. He “promises that if you choose the right foods and supplements for your body, you will awaken your fat-burning DNA and never struggle with your weight again” while also promoting life-long wellness and extending lifespan.

If that sounds like “nutrigenomics” and functional food as medicine, it is. He claims he can unravel someone’s genetic blueprint and customize the proper dietary chemicals and nutrients for their genes to optimize health and slow the aging process.

“The wrong kind of oxygen can cause cellular damage” he says, adding that “free radicals damage DNA, promote wrinkles and throw a kink into normal metabolic processes, promoting weight gain and diabetes. Antioxidants, found in colorful plant foods, teas, red wine, cocoa, and many supplements, help reduce the number of free radicals in the body and help restore a healthy metabolism.”

The core of his ultrametabolism prescriptions are claims that the causes of obesity, chronic disease and aging are the foods we eat. Similarly, “the proper foods keep your body’s metabolism in balance and help fight off obesity, heart disease, and other illnesses,” he says. He says that inflammation causes weight gain and that sugar is the greatest inflammatory substance in the diet, followed by transfats that can “switch your metabolism on and off.” He also claims that “toxins from food and the environment can make you fat” and that you can detoxify your body with the right balance of nutrients in plants and by taking supplements. He also recommends the use of infrared saunas for weight loss.

How likely are attendees at the Yale seminar to question or hear critical analyses of these ideas, to recognize their biological implausibility based on known science, or to learn of research that’s disproven them? Sadly, not likely.

It’s alarming to realize the magnitude that scientific illiteracy and an animosity to science are casting a shadow on today’s practice of medicine and on healthcare professionals. It’s equally unfortunate that nonscience is being integrated and tacitly accepted and unchallenged in medical education, at even the country’s most prestigious universities.

What will this trend mean for the future of medicine? Or, for government health policies and regulations? We’ve already seen how it’s degraded the integrity of diet and health information reaching consumers, harmed the credibility of healthcare in the eyes of consumers, and taken advantage of the public’s trust.

© 2008 Sandy Szwarc