Could alternative medicine practitioners take the lead in health policy?

Recently, I attended a conference on integrative medicine. It was a lovely conference and I learned a lot: about Chinese therapies used for cancer, about osteopathic manipulation, and about the growing community of doctors that respect the value of complimentary medicine practices and are working to integrate them into their general practice.

I also left with a sense of dissatisfaction with what I know of the allopathic medical education experience and a series of questions about how it is taught.

For example:

1. Why isn’t the musculoskeletal system covered more in allopathic medical school? As highlighted by a recent article featured on Kevin MD.com, allopathic medical students graduate with very little confidence in their abilities to help with musculoskeletal issues. This is alarming given that back pain is one of the top complaints that bring people to their doctors (and that I’m learning the musculoskeletal exam right now and am kind of terrified if that is the only exposure I am going to get to those issues).

 

The article rightly points out that DO students graduate with greater confidence in their ability to deal with musculoskeletal issues, but offers few solutions. Should we all have gone to DO school? Why aren’t allopathic schools or residency/fellowship programs offering more chances to learn osteopathic manipulation? A Google search revealed one abstract about an osteopathic elective for allopathic family medicine residents but no signs of whether this program has continued or whether any other programs like this exist.

2. Why isn’t nutrition a bigger part of conventional medical school education? I realize that time is limited in the world of medical education. However, nutrition plays a huge rule not only in obesity, the biggest public health epidemic of our time, but also, according to Dr. Dean Ornish, nutrition could also be huge in preventing heart disease and prostate cancer. Yet as of 2004, medical students across the US only averaged about 24 contact-hours of nutrition education during medical schools

On average, that may not sound so bad, but it does mean that over half of the schools that responded to the 2004 survey required 20 contact-hours or less of nutrition education. Considering at least two of those hours will just be a list of the biochemical properties of the major vitamins (because I know my “nutrition education” at medical school certainly included that), it is a bit inexcusable why we don’t learn more about nutrition. For one thing, our future patients will already know that being fat is bad for you and that you should take your vitamins. If anything, that should be where our nutrition education starts, and not where it ends!

3. Why is alternative medicine still considered a therapy for the rich? This is partly a rhetorical question because obviously, a great deal of insurance-related policy is behind the reason that most alternative medicine practices are paid for out-of-pocket. Even if Medicaid currently pays for chiropractice or acupuncture treatments in some states, that does not mean that they pay as much as people are willing to pay out-of-pocket or that they would pay for the lengthy personal follow-up visit that is required for the personal, holistic approach intrinsic to basically all therapies that fall under the umbrella of complementary and alternative medicine.

 

The doctors that presented at the conference seemed to accept this approach to offering complementary therapies. One even mentioned that not accepting insurance was the compromise that she had to make with her institution to allow her to continue to take as much time with her patients as she felt was needed. I felt that this acceptance was easy in the hospital where the conference takes place, surrounded as it is by downtown Chicago and its office buildings and condos made of glass and stone. Yet I wonder how such a comment would sit if we held the conference at my home institution next year, surrounded as it is by the Chicago Southside community and its very different set of demographic considerations.

In the end, I was left wondering about alternative medicine’s reticence regarding policy concerns. I recognize that this could be a skewed view presented by this particular conference (whose emphasis was on building awareness and warm feelings towards medical students towards alternative medicine), but I could not help wondering, are we really doing everything we can to better protect the time that a doctor spends with a patient? What would happen if doctors advocated for greater access to processed foods? Aren’t these areas where alternative medicine practitioners could lead in policy changes that all physicians should be hoping for?

Given how difficult it (apparently) was for doctors to even present a united front on health care reform last year, I recognize that it would also be difficult for doctors to rally around these seemingly simple policy issues. But I wonder – has it ever been tried? And if not, why not?

Emily Lu is a medical student who blogs at Medicine for Change.

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  • Scott Parker

    Hi, Great article. I started as a chiropractor and in my 30s went back to medical school. After graduation, I realized that I would have to wait to start my residency until after my daughter graduates high school. Anyway, she will graduate soon and I will then do residency. As someone who has been on both sides of the fence, it is my opinion that all health specialties can and many times work together quite well. I currently work in Occupational Medicine and there is a need for all. Thank you for the great article.

  • http://naturalhealthnews.blogspot.com Dr Gayle

    Please don’t call it alternative or complementary, its really first medicine or natural healing. Natural medicines were in the NF up to about 1972 and taught in many medical shccols until post WW2 when Big PhRMA turned to petroleum based pharmaceuticals (oh for the benzene ring), and it has continued to get worse.
    Decades ago nutrition was in the curriculum. DCs get the most hours in MS and ORTHO compared with DOs and lastly MDs. Just how it is.
    H & P has fallen by the wayside. Don’t throw drugs at people, listen to them.

    And stop letting Big INS run your practice.

  • Brian

    wrt point number 1:
    How would you suggest “allopathic” medical schools cover the musculoskeletal system more? Put another way, what exactly is it that you’re arguing for? Are you suggesting that MD schools start teaching OMM? If so, on what basis would you suggest this? Certainly not on any sound scientific foundation.

    I’m curious how you’ve made the leap to concluding that because “DO students graduate with greater confidence in their ability to deal with musculoskeletal issues”, they must actually be better able to do so.

    You then ask, “Should we all have gone to DO school?” For what? To learn OMM? If you’re so fascinated by it, perhaps you ought to have applied to a DO school; personally, I’ll take my medical education with a heavy dose of science, hold the magic. This is of course not to argue that OMM is entirely hogwash; but enough of it is that I have serious reservations about, for instance, the idea that the medical school I attend would integrate it into the curriculum.

    As for 2, I don’t think there’s anyone who seriously argues that diet and nutrition play an important part in overall health. I wonder, however, how you would suggest expanding nutrition education in medical school.

    For 3, why on earth should insurance cover acupuncture or chiro? Because they’re popular? So is astrology, but you don’t see too many insurance companies lining up to pay for readings.

    • Primary Care Internist

      what about reiki, therapeutic touch, prayer, or yoga? should insurance cover these things? already, mandates of coverage requirements for things like chiro are driving up insurance costs. what’s more important? getting weekly spinal manipulations for chronic low back pain, or being covered for diabetes meds & primary care visits that actually work???

      • gzuckier

        of course, chiro is at least as effective as surgery for low back pain, and a heck of a lot less expensive or disabling for the patiuent http://www.nejm.org/doi/pdf/10.1056/NEJM199510053331406

        the fact is that a heck of a lot of what med school teaches now is hogwash, guesses, superstition, and stuff that “seems logical”, just as in the past.

        it’s not that I’m in favor of accepting the alternative hogwash unquestioningly, so much as not in favor of accepting mainstream hogwash unskeptically either.

        • ninguem

          For ACUTE back pain. That’s what the NEJM study cited was all about.

          It makes a world of difference.

          If someone wants to learn spinal manipulation, there are all sorts of courses out there. Michigan State University, the American Academy of Osteopathy, they welcome MD’s. I’ve been to their courses, sometimes I’ve seen more MD’s than DO’s in the classes.

    • Commenting

      “hold the magic” ? Really? Why do so many professionals still not believe in simple remedies. I realize that all they teach in school is to cut flesh and push drugs but some of us prefer neither ….if possible.

      My younger sister was an avid runner. Ran several miles per day and did it for years until she was broadsided by a drunk driver who ran a red light. She could barely walk for a few weeks. Several Doctors she went to wanted to do back surgery. She was reluctant and it’s a good thing because a friend suggest an older
      Chinese Doctor and he told her she didn’t need surgery.

      He wasn’t a Chiro. He was a licensed GP.
      He fixed her back without surgery and the only time I ever heard her complain about back pain was about 6 years later when she was 8 months pregnant.

      • Brian

        Cool story.

        Out of curiosity, what do you mean by “simple remedies”?

  • Brian

    PCI, don’t even get me started on Reiki or therapeutic touch. The blood boils.

    • Primary Care Internist

      did you know that therapeutic “touch” doesn’t even involve touch? i once saw a nurse trained in this treating another nurse’s high blood pressure by running her hands over her chest and “whooshing away the bad energy”.

      you gotta love the “debate” though.

      • gzuckier

        yeah. buddy of mine did study of reiki vs standard treatment for something or other as a project in epidemiology school, somewhat reluctantly, on the suggestion of his partner for the project, who was a believer. guess what the results showed (spoiler: there were no surprises in the results)

  • Dr Strangelove

    You know what they call alternative medicine that has been scientifically proven? Medicine.

    Students should not be taught something unless there is a scientific backing. “Because we feel it works” does not fly with me.

    • gzuckier

      we still can’t decide whether antibiotics are indicated for routine kids’ ear infections.

  • doc99

    Before blanket acceptance of “Natural Healing, Herbal Medicine, Complementary (not complimentary) Medicine, Shamanism, etc”, Please demonstrate the evidence that the beneficial effects are significantly better than placebo. Dr. Pho, if you are going to promote Comparative Effectiveness, I suggest you start here.

  • http://www.littlepatientbigdoctor.com Haleh Rabizadeh Resnick

    Dear Doctors,

    I like this insightful article. A doctor who is not completely smitten with his medical education and who is willing to remain open minded- refreshing.

    (1) Simply because something is “alternative” “holistic” “natural”- call it what you may- does not mean that by definition a practicing doctor should dismiss it because it hasn’t been put to scientific rigor yet. It may work for your patient- be a practicing scientist- not a static MD.

    (2) And simply because it is hard to imagine how to add more to the demanding medical school curriculum it is not reason to dismiss the value of what is missing- be willing to learn what you don’t know.

    I have recently written the book, Little Patient Big Doctor: One Mother’s Journey to raise awareness of these very issues and I am so happy to see these dialogues happening.

    • Brian

      Ms. Resnick:

      There is a saying that I particularly like, difficult to properly attribute, that goes something like this:

      “Keep an open mind, but not so open that your brain falls out.”

      No one here is saying that these things should be dismissed out of hand for lack of evidence. There are two prongs to this: First of all, what evidence has been accumulated thus far seems to indicate that many “alternative”, “holistic”, and/or “natural” treatments are pure hogwash (homeopathy, reiki, therapeutic touch, crystal therapy, I’m looking at you), and at best are nothing more than applied placebo effect.
      Second, event if I grant your statement that a doctor shouldn’t dismiss alternative therapies because they haven’t “been put to scientific rigor yet”, it does not follow that these things should be included in the mandatory medical school curriculum. That’s putting the cart before the horse. Prove it works, and then we’ll talk about including it in the curriculum.

      Your second point belies your assumption that “what’s missing”, i.e., information about “alternative” medicine, has value. The fact that medical school curriculum is so packed isn’t the reason why the “value of what’s missing” is being dismissed. It’s that it hasn’t yet been demonstrated that “what’s missing” has the value you seem to think it does.

    • gzuckier

      and let us not forget, a large proportion (majority?) of modern pharmaceuticals are based on some folk remedy or witch doctor’s herbarium.

      • Brian

        I don’t know that I’d say a “majority”, but yes, there are and have been several examples of pharmaceuticals that have “natural” roots. That’s what the entire field of pharmacognosy is all about. It’s one thing to say that this or that herb has an effect, however, and entirely different thing to say “Hey, I wonder what it is in this herb that has its effect. How much do I need? How does it work? How much is safe?” Otherwise, you’re just flying blind.

        Also, hopefully it goes without saying that not everything “natural” is good.

  • Molly Ciliberti, RN

    Alternative medicine isn’t medicine; it is bunk science. We finally got rid of snake oil salesmen so why do you believe in something that is undoubtedly just placebo effect and call it medicine?

  • Molly Ciliberti, RN

    While visiting China as a cultural exchange, we went to the largest Chinese Medicine School and Hospital in Beijing. They told us that it is only useful for chronic problems such as menstrual cramps and low back pain. They said if you are really sick you should use western medicine. I am not kidding that is what they said.

  • http://www.littlepatientbigdoctor.com Haleh Rabizadeh Resnick

    Brian- When I refer to what is missing in medical school I speak about knowledge of nutrition. It is very sad when I ask my pediatrician if my daughter can have kiwi fruit at six months of age and his response was “It’s okay to have it if Gerber makes it in a jar- otherwise I wouldn’t try it yet.” I can go on without countless examples of doctors simply not having knowledge of basic nutrition.

    As for “alternative” medicine- I think that often it may be invalid but a good doctor as a student of science should not dismiss it at hand when a patient has interest in pursuing it. For several reasons
    1. It may work for this patient
    2. It builds credibility and a relationship with your patient
    3. It may have a positive placebo effect
    4. It takes a reluctant patient from a position of victim to one who is willing to try something- and if it doesn’t work, they’ll appreciate your attempt to work with them and then will be more diligent with what you may have to offer.
    5. Being a healer/doctor is about building a relationship with your patient and you need to go with your patient sometimes where you may not want.
    Haleh

  • http://www.TheHealthCulture.com Jan Henderson

    The “evidence” supporting the “truth” of allopathic medicine is increasingly coming under scrutiny (http://bit.ly/hTI9hN), and the results of that scrutiny are making their way into public visibility. For example, a recent commentary in JAMA (no less) describes how researcher bias, presentation bias, and publication bias disrupt the ethics of clinical research (http://bit.ly/e3c2ke).

    As the public comes to understand that medicine is not a science in the way physics, chemistry, and astronomy are sciences, the more the medical profession will need to abuse alternative practices.

    Thanks for your excellent questions, Dr. Lu, and may you continue to be graced with an open mind.

  • http://www.medicineforchange.com/ Emily Lu

    Thank you all for your comments. They really helped me refine my thoughts about this issue (that were frankly unformed when I wrote this reflection on my experience at the Integrative Chicago conference!). I’ve written up my further thoughts on this issue at my blog here: http://www.medicineforchange.com/alternative-medicine-medical-education-and-health-policy-an-update/