US Quackademia - Evidence in "Evidence-based" Integrative Med Programs?
David Colquhoun, the man who put the needle in the homeopathy balloon of the U of M Director of Spirituality and Healing, provides the headline for this post. He cites an amazing article:
An Evaluation of the Evidence in "Evidence-based" Integrative Medicine Programs Donald M. Marcus, MD; Laurence McCullough, PhD Posted: 11/17/2009; Academic Medicine. 2009;84(9):1229-1234.
Dr. Marcus is professor of medicine and immunology, emeritus, Baylor College of Medicine
Dr. McCullough is a professor at the Cener for Ethics and Health Policy, Baylor College of Medicine
Alternative therapies are popular, and information about them should be included in the curricula of health profession schools.
During 2000 to 2003, the National Institutes of Health National Center for Complementary and Alternative Medicine awarded five-year education grants to 14 health professions schools in the United States and to the American Medical Students Association Foundation.
The purpose of the grants was to integrate evidence-based information about complementary and alternative medicine (CAM) into the curriculum.
The authors reviewed the educational material concerning four popular CAM therapies--herbal remedies, chiropractic, acupuncture, and homeopathy--posted on the integrative medicine Web sites of the grant recipients and compared it with the best evidence available.
The curricula on the integrative medicine sites were strongly biased in favor of CAM, many of the references were to poor-quality clinical trials, and they were five to six years out of date.
These "evidence-based CAM" curricula, which are used all over the country, fail to meet the generally accepted standards of evidence-based medicine.
By tolerating this situation, health professions schools are not meeting their educational and ethical obligations to learners, patients, or society.
Because integrative medicine programs have failed to uphold educational standards, medical and nursing schools need to assume responsibility for their oversight.
The authors suggest
(1) appointing faculty committees to review the educational materials and therapies provided by integrative medicine programs,
(2) holding integrative medicine programs' education about CAM to the same standard of evidence used for conventional treatments, and
(3) providing ongoing oversight of integrative medicine education
We examined the Web sites of the 15 NCCAM grantees to ascertain what evidence is presented to students and physicians and how that evidence meets EBM guidelines. Three sites--those of AMSA, the Integrative Health Program of the Department of Family Medicine of the University of Washington School of Medicine, and the Center for Spirituality and Healing of the University of Minnesota--contain comprehensive syllabi.
Homeopathy is based on the principle that an illness can be cured by administration of a highly diluted medication that, in higher concentration, produces symptoms similar to the ailment: "Like cures like."[7 (pp91-143)] Most homeopathic remedies are so diluted that they contain no molecules of the original medication.[7 (pp98-100),39]
What is the evidence for the efficacy of homeopathic remedies? A widely cited 1997 publication concluded that the results of our meta-analysis are not compatible with the hypothesis that "the clinical effects of homeopathy are completely due to placebo." After critics pointed out that 68 of the 89 trials included in the meta-analysis were of poor quality, the authors reexamined the same data two years later and concluded that "studies with better methodological quality tended to yield less positive results." A later meta-analysis, which identified only eight trials that met higher standards for quality, concluded that "homeopathy was only very marginally more effective than placebo." That report was accompanied by an editorial in The Lancet entitled "The end of homeopathy." Despite these analyses demonstrating no clear benefit for homeopathy beyond a placebo effect,[7 (pp91-143), 45] advocates continue to cite the 1997 publication as evidence for homeopathy's efficacy.
The University of Minnesota Medical School's Web site doesn't contain a monograph on homeopathy, but the site's overview section states that homeopathy is more than a placebo and cites as evidence the 1997 Linde publication.
The Quality of Evidence in Integrative Medicine Curricula
In general, the evidence base used by the integrative medicine programs whose Web sites contain relevant information includes only studies reporting positive outcomes, regardless of the studies' quality. Few publications after 2003 are cited, which include most of the best-quality trials of CAM therapies, and the sites have not been revised to take into account new data. The evidence base of these programs fails to meet the generally accepted standards of EBM, and its representation as "evidence based" is misleading. The AMSA EDCAM modules, which are used widely by integrative medicine programs, are uncritical endorsements that were written by practitioners and advocates of CAM. The University of Washington School of Medicine's site is more critical in evaluating the efficacy of alternative therapies, but its references have not been updated since 2003.
In retrospect, the premise of the NCCAM education grant program, that there was solid evidence supporting the efficacy of alternative therapies, was incorrect. Larger, more rigorous, independently funded clinical trials performed during the last decade have not confirmed the positive results of earlier trials, and systematic reviews have pointed out the methodological shortcomings of those trials. The failure of integrative medicine programs to update their database and revise their evaluations of therapies suggests a lack of genuine commitment to evidence-based medicine.
The remarkable improvement in the practice of medicine during the last 50 years was made possible by advances in biomedical science and evidence-based therapeutics. Readers of the British Medical Journal voted evidence-based medicine as one of the 15 most important medical milestones since 1840. A brief overview stated that "the systematic synthesis of evidence is the foundation of all medical discoveries and of good clinical practice." Although the evidence base is always provisional and subject to revision, rejection of evidence in favor of traditional beliefs and clinical anecdotes compromises educational standards and clinical practice.
Educational and Ethical Issues
The flawed curricula presented by integrative medicine programs constitute an educational failure on the part of health professions schools and AMSA. Evidence supporting the efficacy and safety of CAM should be evaluated by the same standards used to analyze conventional therapies. Failure to do so undermines the problem-based educational initiative that emphasizes rigorous review of current literature; it tolerates a double standard of evidence, and it promotes a poor standard of medical practice.
By tolerating this situation, health professions schools are not meeting their ethical obligations to learners, patients, or society. Academic health centers should provide exemplary care to the communities that they serve. An essential component of that mission is provision of the best information available to foster informed decisions about health care. Because CAM is promoted uncritically by the media,[7 (pp250-266), 61] academic health centers should be a source of sound information that is not otherwise available. Failure to meet this obligation confers undeserved credibility on alternative therapies and promotes their use.
These problems have arisen because, to the best of our knowledge, there is no formal oversight of curriculum content by medical schools. Oversight of curriculum content takes place in an informal manner by faculty colleagues who share responsibility for courses and clerkships. For example, a teacher who presented an outdated, unsound therapy for hypertension would be taken to task by her or his colleagues. This corrective process clearly doesn't occur in integrative medicine programs, as one of us (D.M.M.) cautioned several years ago.
This situation presents a unique challenge to health professions schools. We suggest the following steps to deal with the problem:
* appoint a faculty panel to review educational material and therapies provided by integrative medicine centers;
* provide education about CAM based on the same standard of evidence used to develop guidelines for treatments for cardiovascular diseases, diabetes, etc.; and
* carry out ongoing oversight of integrative medicine education programs.
Implementation of these procedures will face resistance. Integrative medicine faculty will raise the issue of academic freedom, but academic freedom requires accountability, and it doesn't justify ignoring educational standards. Leaders of academic institutions, and faculty who teach and practice genuine evidence-based medicine, need to acknowledge the problem and take steps to remedy it.