The American Medical Student Association: On “integrating” quackery with science-based medicine

There’s a saying in medicine that we frequently hear when a newer, more effective therapy supplants an older therapy or an existing therapy is shown not to be as efficacious as was once thought, and it has to do about how long it takes for the use of that therapy to decline. The saying basically says that the therapy won’t die out until the current generation of established physicians retire and are replaced by the new generation coming up through medical schools. From my perspective, it’s a bit of an exaggeration, because in the mere 13 years that I’ve been a real doctor (i.e., an attending physician) our practices in breast cancer surgery has changed markedly. Although certain core principles of breast cancer care remain the same, there have been major changes in terms of how we deal with the axillary lymph nodes, our use of hormone therapy and chemotherapy, and our very understanding of the different subtypes of breast cancer. Of course, I have spent my entire career as faculty at two different NCI-designated comprehensive cancer centers; so my experience is not representative of that of most physicians, particularly given that I’m super subspecialized. It’s generally expected that if you’re faculty in an academic medical center you will be at the very least up to date, if not beyond at the cutting edge.

Even so, there is some truth to the observation that it takes the rise of a new generation of physicians to force out certain old ideas, which means that how we train our medical students is of utmost importance. Unfortunately, these days, it is medical students who have become a major force for promoting the “integration” of quackery into medicine (which these days is known as, appropriately enough in a way unintended by its proponents, “integrative medicine”). No, I’m not saying that all or even most medical students are prone to the blandishments of quackademic medicine, but rather that there is a large enough contingent of medical students who have gone beyond being shruggies to become activists for unscientific medicine. There are CAM clubs, CAM interest groups, and student-driven CAM electives.

And then there’s the American Medical Students Association (AMSA), specifically its various initiatives in “integrative medicine.” I fear that each successive generation of medical students is more prone to embracing unscientific medicine than the last.

AMSA and CAM: A long history together

On its website, AMSA describes itself as the oldest and largest independent association of physicians-in-training in the United States. Founded in 1950, it currently boasts a membership of approximately 68,000 medical students, premedical students, interns, and residents. The goals of the organization, as described on its website, are as follows:

• Quality, Affordable Health Care for All
• Global Health Equity
• Enriching Medicine Through Diversity
• Professional Integrity, Development and Student Well-Being

It’s hard to argue with any of these aims as goals, but, of course, as always the devil is in the details. For instance, AMSA has managed to cause some controversy with its PharmFree initiative, which is fine on the surface, but, as some argue, might have unintended consequences. Another problem is that AMSA declares itself to be all about the evidence and evidence-based medicine, as well as ethics. This would be great if it were true, but there’s one big hole in the claim. It’s a hole big enough to pilot an aircraft carrier through, and that hole is, to put it briefly, “complementary and alternative medicine” (CAM). To boil it down, AMSA promotes integrating quackery into medicine, and it does it in a big way. Let’s see how.

I first became aware of how AMSA promotes “integrative medicine” several years ago, when Dr. R. W. Donnell pointed it out to me. This led me to a document, still available on the AMSA website on a page called the ICAM Resource Center (Integrative, Complementary and Alternative Medicine), Complementary Therapies Primer (formerly “The Quick and Dirty Guide to Complementary Therapies”) and the 2006 UCSF Guide to Integrative Medicine. I’ll get to the primer in a minute. First, let’s look at AMSA’s position on CAM laid out on its ICAM webpage:

AMSA believes that students and physicians can best serve their patients by recognizing and acknowledging the availability of integrative medicine in their communities. By pursuing education in complementary and alternative medical (CAM) treatments, medical students and physicians can better facilitate the appropriate education, treatment and counseling of patients and consumers.

• AMSA believes that an empowered patient can serve as a powerful and central actor in their own healing.
• Appropriate education in CAM treatments uses scientific and ethnographic methods, including quantitative and qualitative outcomes research of efficacy and effectiveness. Although it is informed by evidence, it considers explanatory models and cultural.
• AMSA supports students who wish to work within the healthcare system to create an environment which is supportive of the whole patient.
• AMSA believes that medical students and other health care professionals need to be restored and whole in order to be empowering and healing for their patients.

Let’s look at numbers one, three, and four first. These are nothing more than CAM-speak blather worthy of one of Kimball Atwood’s installment of Weekly Waluation of the Weasel Words of Woo. For instance, there is nothing in SBM that says an “empowered patient” is a bad thing or that he can’t serve as a “powerful and central actor” in his own healing. Indeed, as I’ve pointed out before many times, paternalism is steadily going away within EBM/SBM, and most physicians of my generation and younger agree that’s a good thing for the most part. We want our patients to be engaged and provide input into their care and what’s important to them. Most of us don’t feel comfortable anymore taking a “doctor knows best” attitude in which we simply give orders and prescriptions and expect to be obeyed. This brings us to number three, which is what I like to call the “holistic” trope, in which CAM practitioners claim to be so much better than conventional medicine at caring for the “whole patient.” It’s utter bunkum, nonsense, a fetid pair of dingo’s kidneys. A good science-based primary care doctor is a holistic doctor! A good science-based primary care doctor does take care of the “whole patient.” A good science-based primary care doctor also “empowers” the patient. None of these things are inherent in or exclusive to CAM, nor are they unachievable in SBM. It’s a false dichotomy that AMSA fully buys into, lumping its CAM promotion initiatives under “humanistic medicine.” Again, I resent that — I don’t need CAM to practice “humanistic medicine.”

More importantly, let’s look at number two, how AMSA supports using both “scientific and ethnographic methods” and claims that appropriate education in CAM uses explanatory models and culture. While this is not completely unreasonable on the surface (certainly to understand how traditional Chinese medicine came about one has to understand a bit about the Chinese culture out of which TCM sprang), but notice the not-so-subtle denigration of science. Notice how AMSA considers qualitative and quantitative outcomes research and doesn’t even mention proper randomized clinical trials (RCTs), unless one assumes it to be subsumed under “scientific” methods. Odd that it’s not mentioned, though, isn’t it? Well, no, it’s not so odd. As we’ve discussed many times, CAM proponents are very much enamored of “pragmatic” research, of the sort that seeks to see how various modalities perform in “real world” settings. The problem with this emphasis is that pragmatic studies and outcomes research are not appropriate for modalities that have not yet been shown to be efficacious and safe in proper clinical trials. The reason for “pragmatic” research is to test whether treatments shown to work in RCTs do as well once they are let “out in the wild,” so to speak, where they will be used to treat patients who might not have fit the inclusion criteria of the RCTs used to test the treatment or in hospitals and settings where the capabilities for monitoring the therapy might not be as good as they were for the RCTs. Doing outcome studies on therapies that haven’t been validated in RCTs is putting the proverbial cart before the horse.

Informational resources that AMSA recommends: Quackery

Now, let’s go back and look first at the UCSF guide. It begins with a disclaimer:

Inclusion of a therapy, resource, or practitioner in this guide does not imply endorsement by UCSF, the Integrative Medicine Network, or the Osher Center for Integrative Medicine.

Too bad this disclaimer and the frequent mention that many of these modalities are pure pseudoscience and that there are no good randomized clinical trial data demonstrating the efficacy of most of these treatments is belied by the utterly credulous description of various alt-med modalities found in many of the chapters. For example, check out this description of acupuncture:

Acupuncture relies on the idea of Qi, the energy force that run in regular patterns called meridians through the body. A person’s health is influenced by the flow of Qi in the body, in combination with the universal forces of Yin and Yang. If the flow of Qi is insufficient, unbalanced or interrupted, Yin and Yang become unbalanced, and illness may occur. By inserting fine needles on the body’s surfaces at specific points to connect the meridians, acupuncture is used to regulate or correct the flow of Qi to restore health.

At the initial visit, the practitioner evaluates the patient’s current problems, medical history, available laboratory values and radiological tests, as well as a traditional physical exam of the tongue, reflex points, radial pulse, and external ear. The goal of the evaluation is to link the patient’s problems to a specific imbalance or block of Qi

Note how the description of qi is described as fact, not as an explanation that has no scientific basis for whatever effects (if any) acupuncture has on pain or disease in humans. Even in the section on scientific studies, there is no mention that qi has never been measured or detected, despite many attempts. But the description of acupuncture isn’t that bad compared to some others. At least acupuncture has a potential physiologic mechanism for doing something, as misrepresented and exaggerated as it is. OK, over time I’ve become less and less convinced of this; certainly claimed mechanisms do not persuade me. However, acupuncture does involve sticking needles in the skin. Not knowing anything else about it, one might think that something could be going on. In contrast, most homeopathic remedies are nothing more than water, pure placebo, but that doesn’t stop the fine folks at UCSF from serving up another heaping helping of credulity:

Dr. Hahnemann first formulated his principle of the Law of Similars after testing quinine, a cure for malaria. He found that it produced the symptoms of malaria in a healthy individual. However, when he discontinued the quinine, the symptoms disappeared. After several similar studies, Hahnemann found that very small doses of the substance are nontoxic and yet still work to produce the desired symptoms of the illness in healthy individuals. Homeopathic remedies are therefore diluted to different degrees so that only traces of the original substance are present. Often chemical testing will show no presence of the active ingredient. This, however, is completely consistent with homeopathic philosophy as they believe that the ingredient leaves an imprint on the remedy and it is this ghost print which then acts within the body.

There are also several testimonials, just as good as that of any seen on Mercola.com or NaturalNews.com (or any alternative medicine website selling products). For example, here’s one from a Reiki practitioner:

“I am a Second Degree Reiki Practitioner of the Mikao Usui Tradition. In the 10 years of my Reiki practice I have seen healing transformations in all my clients, on all levels (mental, emotional, spiritual, and physical). One patient that stands out most is a nurse for the U.S. Embassy that had been suffering from Shingles for nearly three years. After several hospitalizations and medical evacuations for treatment, she called me for an appointment. She was on daily doses of morphine painkillers, was exhausted and in pain all the time and had gained a lot of weight. We began weekly Reiki treatments that lasted for about six months. During the six months, she first began sleeping well, feeling more energetic, reducing her morphine and ultimately eliminating all pain medicine, and arriving at full energy balance and recovery.” — Lauretta Agolli, Reiki Practitioner

This, of course, follows a credulous description of what Reiki is, although at least the manual does mention that “Reiki is not recommended as the sole treatment for potentially serious medical conditions, and its use should not delay the time it takes to consult with a health care provider or receive established therapies.” Imagine my relief, after that lovely testimonial and the glowing description of Reiki that preceded this disclaimer.

I could go on, but what’s the point. The UCSF manual has credulous and, in some cases, promotional treatments of a wide variety of woo, including reflexology, Reiki, naturopathy, fasting, spiritual healing, and others, mixed in with the occasional less woo-filled modality, like biofeedback. But what disturbed me even more was some of the descriptions of treatments for specific diseases, for example cancer (of course). Take a look at this schizophrenic passage:

Alternative therapies may be dangerous because they are often unproven and administered in lieu of traditional treatment such as chemotherapy or radiation. Using alternative therapies instead of conventional treatment for highly curable, early-stage cancers is not recommended.

CAM therapies are also considered useful approaches to recurrence, metastatic cancers, and secondary cancers.

In actuality, as far as the cancer goes, alternative therapies are no more useful for curing recurrent or metastatic cancers than for curing early stage curable cancers. The only reason they sometimes appear useful for early stage cancers is because most such cancers are cured by the surgery, with adjuvant chemotherapy and radiation therapy serving mainly to reduce the risk of recurrence. If you undergo surgery for an early stage tumor and use an “alternative” medical therapy on top of that, you’ve almost certainly added exactly nothing to the surgery, whereas chemotherapy and radiation produce measurable decreases in the risk of cancer recurrence. Basically, you got lucky.

Worse, there are yet more credulous descriptions of all manner of cancer quackery, including megavitamins, “colon detoxification” with coffee enemas (as in the Gerson/Kelley/Gonzalez protocol), antineoplastons, the same is found for all the other diseases discussed individually, all with liberal comparisons between the woo and the dreaded “allopathic” medicine. Indeed, the only quackery I can think of that the UCSF manual does not mention, to its credit, is chelation therapy.

That’s where AMSA’s very own manual comes in. While the UCSF manual is a bit—shall we say?—reticent about promoting the quackier therapies, the AMSA manual has no such compunction. For instance, on p.20, this is what AMSA says about chelation therapy:

Chelation is used to reverse the process of atherosclerosis by removing calcium from plaques. It is used to prevent myocardial infarction and stroke, and as an alternative to bypass surgery and angioplasty. Since it improves blood flow, it is also helpful in gangrene, intermittent claudication caused by peripheral vascular disease, and poor memory due in part to insufficient cerebral blood flow. Reduction in metal ions reduces inflammation caused by free radicals, and makes chelation therapy helpful in arthritis, scleroderma, and lupus. Chelation therapy has also been used to normalize cardiac arrhythmias, improve vasculogenic vision loss, reduce cancer mortality, protect against iron poisoning and detoxification of snake and spider bites.

Chelation therapy involves between twenty and thirty treatments given at intervals of two to seven days. Each treatment takes approximately three and a half hours, and involves the intravenous infusion of EDTA, vitamins and minerals. Oral chelation is also effective for patients with mild disease, or as a preventive measure. EDTA and penicillamine (another chelating agent used in heavy metal poisoning, Wilson’s disease and rheumatoid arthritis) can be used orally, leading to reduced serum cholesterol.

The only warning given about chelation therapy provided is to point out that chelation therapy is “contraindicated in pregnancy, renal failure (the drug is cleared by the kidneys), and hypoparathyroidism (due to its calcium-binding properties).” There’s no mention that it doesn’t work, that it doesn’t clear plaques from coronary arteries, or that it doesn’t do anything for autism.

Then there’s this description of homeopathy:

The Law of the Infinitesimal Dose was formulated by Dr. Hahnemann when he experimented with dilute solutions, seeking to avoid toxicities, and found them to be more effective than full strength preparations. Homeopathic remedies are repeatedly mixed with water or alcohol and shaken (succussion), often diluting the substances to such a degree that no amount of the original medication can be found in the remedy. Some believe that the remedies retain their effect because of electromagnetic frequency imprinting, changing the structure of the diluent subtly.

Initially, as a patient is treated by a homeopathic physician, he or she may actually worsen. This is know as a “healing crisis.” As the presenting, most recent, symptoms are treated, older, underlying disorders come to the surface. Dr. Constantine Hering, the father of American homeopathy, believed that healing progresses from recent diseases to chronic maladies, from emotional imbalances to physical disorders, from superior to inferior, and from the deep structures to the superficial. This is known as Hering’s Laws of Cure. By following Hering’s Laws when treating a patient, a practitioner can successively unravel many layers of pathology, eventually recreating internal order and achieving a more permanent cure.

The skeptical take included in this guide? It’s mentioned that homeopathy has “lost favor with the medical establishment in the US” (gee, that couldn’t possibly be because homeopathy is a load of pseudoscientific rubbish with a mystical vitalistic overlay, could it?), after which a 1991 BMJ study finding that most controlled clinical trials suggested a beneficial effect of homeopathic remedies is cited. Unfortunately, there are also similarly credulous takes on a wide variety of dubious, non-science-based therapies, including aromatherapy, acupuncture, chiropractic, naturopathy, and others. I can see AMSA apologists retorting that this particular guide was written in 1995, making it 17 years old and potentially out of date. If that were the case, however, why would AMSA not remove it from its website as one of its suggested resources? Ditto the UCSF guide. Alternatively, AMSA could add a note to its 1995 guide pointing out that chelation therapy is dangerous and doesn’t work or remove that section altogether. It hasn’t. At worst, this failure implies endorsement of this particular form of quackery; at best, it implies indifference to whether chelation therapy is science- and evidence-based or not. The same could be said for all the other quackery credulously discussed in these two tomes of pseudoscience.

If the above doesn’t convince you, just peruse AMSA’s webpage for its Naturopathic Medicine Interest Group, which not only represents naturopathy as scientific but actively encourages interactions and “cross pollination” between medical students and naturopathy students, complete with a link to a list of alternative medicine conferences.

Promotion of CAM and a bootcamp for quackery

Unfortunately, AMSA goes far beyond simply providing unscientific and pseudoscientific information on its website and falling for typical distortions of language used by CAM apologists. In other words, it goes beyond words into deeds. For instance, if you peruse AMSA’s website, it won’t take you long to find several initiatives related to CAM. One example is AMSA’s Educational Development for Complementary & Alternative Medicine (EDCAM), whose goals are described as:

1. Improve medical student proficiency in CAM theory, methods, and practice;
2. Enhance medical student education of preventive health, holistic care, and self-care through clinical examples using integrative medicine; and
3. Improve cultural competence and comfort of future physicians increasingly exposed to a diversity of world populations and healing methods.

To manage that, EDCAM has created modules whose use it encourages medical schools to use in their curriculum that it refers to as Core Curriculum CAM Integration in 10 categories. These include:

1. Nutrition and Lifestyle: Diet, Exercise, Sleep and Stress Management
2. Mind-Body Medicines 
3. Alternative Systems of Medical Thought: Traditional Chinese Medicine, Kampo, Tibetan Medicine and Acupuncture 
4. Alternative Systems of Medical Thought: Yoga, Ayurveda, Native American and Yoruba Based Medicines 
5. Alternative Systems of Medical Thought: Homeopathy and Flower Essences (updated 5/03)
6. Bioenergetic Medicines 
7. Pharmacologic/Biologically Based: Herbal Medicines 
8. Pharmacologic/Biologically Based: Nutrition, Dietary Supplements and Vitamins 
9. Manipulative Therapies: Chiropractic and Osteopathy 
10. Manipulative Therapies: Therapeutic Massage

Let’s take a look at one of these, the section on bioenergetic medicines. This is a subcategory of CAM commonly referred to as “energy healing” and includes therapeutic touch, reiki, and several others. The objectives described include being able to:

• understand the concept of subtle energy, the vital force, qi, and prana and their roles in medicine, now and historically.
• define the terms bioelectromagnetic medicine, biofield therapies, biofield, frequency, electromagnetic field, magnet therapy, medical qigong, Reiki, therapeutic touch, and external qi.
• explain how energy medicine works according to our present scientific understanding and discuss what scientific questions and controversies still remain, discussing the scientific loopholes in studying bioenergetic fields.
• understand what skeptics say about energy medicine, and what scientific arguments are used to refute those claims.
• explain the present and most promising future applications of bioelectromagnetic therapies, citing some key studies showing effectiveness of bioelectromagnetic therapies.
• list the main types of biofield therapies used in the U.S. and know what they are clinically used for.
• discuss several key studies examining effectiveness of biofield therapies.
• experience some form of biofield or bioelectromagnetic energy practice.

AMSA states that “bioenergetic medicine” (BEM) can be used to treat bone fractures, soft tissue injuries, chronic venous insufficiency, osteoporosis, Alzheimer’s disease, and others. Interestingly, the most recent references cited to support these claims date back to the 1990s. Instead of stating that there is no evidence that the “life energy,” “vital force,” or qi exists, this is what the BEM section states:

The biofield refers to the complex, dynamic, extremely weak EM field within and around the human body that has been proposed as a super-regulator of health and healing (Rubik, 2002). Besides the EM components of the biofield emitted by the brain (EEG) and heart (ECG) that are well known in conventional medicine, the human biofield may also consist of more subtle energy fields as elaborated in Oriental Medicine, Ayurvedic Medicine, and other indigenous systems of medicine.

This subtle energy, vital force, or cosmic life energy is a key concept in many CAM modalities, and it is referred to by the many terms listed above from various medical systems (Rubik et al., 1994a). Such vitalistic principles underlie many CAM modalities besides energy medicine, but have been banished from conventional medicine. This fundamental philosophical difference is at the root of medicine’s divided legacy (Coulter, 1994).

Amusingly, the BEM module does cite Emily Rosa’s famous study of therapeutic touch that demonstrates that it doesn’t work and tries to refute it:

Several methodology issues were questioned in this study: 1) consistency of the distance between the experimenter’s and subjects’ hands, 2) lack of reference or use of methodology used by TT experts in 28 prior quantitative studies, 3) lack of accounting for conditions during which HEF cannot be detected by those denying desire for interaction with proper intention. Researchers have concluded in other studies that college students can sense another’s intention to interact with them (Schwartz 1995, 1998).

One notes that the two studies cited that claim that college students can detect another’s intention to interact with them appeared in a journals called Subtle Energies and the Journal of Scientific Exploration. Interestingly enough the Subtle Energies website triggered a malware warning on Safari when I tried to access it; so I didn’t. Maybe its energies are more powerful than expected! Be that as it may, neither journal is what I would describe as reputable, and neither study is a good study. (Maybe I could go into detail on another occasion.) None of the other modules are any better, either. If you don’t believe me, take a look at the homeopathy module, where one of the objectives is to “discuss the scientific controversies and questions that remain for homeopathy and explain basic evidence for and against its clinical application.” There are no “scientific controversies” about homeopathy. It is water; it is a placebo. How many times does this need to be pointed out?

Unfortunately, this is the sort of stuff that AMSA wants to place in medical school curricula, and, to a large extent, it’s succeeding.

In case that isn’t enough, though, AMSA goes far beyond informational resources, helpfully providing its AMSA Medical School CAM Directory, which allows a fast and easy search of CAM programs at various medical schools for medical students looking for CAM electives and sponsors an International Integrative Medicine Day. If that’s still not enough, AMSA offers what is in essence a boot camp for students who want to become leaders in integrative medicine, which it calls Leadership and Education Program for Students in Integrative Medicine (LEAPS into IM). LEAPS into IM is designed to groom future thought leaders in CAM and integrative medicine by choosing 30 students to take part in a week long retreat at the Kripalu Center for Yoga & Health in Berkshire Mountains of Massachusetts. If that’s not enough, there’s also a month long retreat offered known as the Humanistic Elective in Alternative Medicine, Activism and Reflective Transformation (HEART):

Specific sessions will be focused on intentional community building, complementary and alternative/holistic and integrative medicine, social justice and activism, reflective transformation including meditative practices, and personal growth skills such as communication and intention. Any clinical site visits will demonstrate ways to incorporate social justice and patient advocacy into clinical care.

There’s nothing like tying the idealistic impulses of young people to indoctrination in pseudoscience and quackery, is there?

Finally, for students who can’t travel to Massachusetts next June or give up a month of their lives for HEART, there is an online CAM course AMSA calls the Integrative Medicine Scholars Program that allows students interested in integrative medicine to learn and interact online.

Conclusion

As admirable as many of AMSA’s initiatives might be, it is very clear that, when it comes to the promotion of nonscientific medicine, AMSA is far more part of the problem than the solution. I wish it were otherwise, but it is not. That being said, I realize that the “humed” (humanistic medicine) contingent of AMSA is the minority, and my conversations with numerous medical students leads me to believe that many of them quite correctly take a dim view of AMSA’s promotion of woo in the medical school curriculum. Unfortunately, the majority of them are also shruggies, much like most of physicians they will “grow up” to join and ultimately replace, which probably explains why they don’t band together to do something about AMSA’s blatant promotion of pure quackery. How to get medical students more interested in science-based medicine and willing to confront the infiltration of pseudoscience into their main professional organization is the most pressing issue supporters of SBM have in medical education. One wonders what would happen if an SBM-minded group of students tried to form an SBM interest group within AMSA. We can only encourage, offer help to interested students, and hope.