Medical school course examines practice of alternative medicine

The group of second-year medical students are visiting an office that, at first glance, appears similar to that of any MD. The initials following this practitioner's name, however, are "ND," and he extols the virtues of his "holistic" specialty, naturopathy --an "alternative" mode of treating disease with herbs, special diets, vitamins and cell salts.

On other treks, the students watch a veterinary acupuncturist insert tiny needles into her four-legged patients, listen to a Chinese herbal therapist explain how plants affect the body's "energy flow," and tour a school where massage is taught as a healing modality.

An alternative to what?

What's going on here? Is the School of Medicine forsaking rigorous, scientific education for some New Age bandwagon ride into the world of fringe medicine? Linda Gooding, professor of immunology and microbiology, is emphatic that the answer is no.

"We are not teaching our students to go out and do these things," said Gooding, who teaches the elective course "Complementary Medical Practices" to second-year medical students. "Instead, we offer an overview of what these medical practices are and attempt to demystify alternative practitioners by visiting their offices and seeing what equipment they use. We want our students to know these people don't have two heads and aren't practicing out of the trunk of their cars."

Why? Because Americans are turning to alternative practitioners in record numbers. With this trend, and with an increasingly multicultural patient base, today's physicians find themselves faced with the need to understand and communicate effectively about practices they were never exposed to in medical school.

In response, more than 30 U.S. medical schools--including Yale, Harvard, Johns Hopkins, UCLA, Columbia and Stanford--have joined Emory in offering courses on complementary, or alternative, medicine. In just the past year, five alternative medical journals (four peer reviewed) have been launched. Suddenly, it seems, the mainstream medical community is facing the alternative music.

The wake-up call

The "wake-up call," as Gooding puts it, came in 1993 when the New England Journal of Medicine published a survey of 1,539 adults who were questioned about their use of unconventional therapies. The results? Americans in 1990 made about 425 million visits to alternative practitioners, compared with 388 million visits to primary care physicians. While around 3 percent were looking for help with life-threatening conditions such as cancer or AIDS, the vast majority were seeking remedies for long-term problems such as obesity, chronic pain, anxiety and depression. Tellingly, 72 percent declined to tell their medical doctors about these visits.

Gooding suspects these dramatic figures are actually low. "In fact," she said, "a recent random survey of 100 people in Atlanta, published in Atlanta Medicine, showed that half those questioned had tried alternative modalities; more than 90 percent said they would use nonmedical therapy if they thought it was indicated."

Why are so many people--including, as the New England Journal study pointed out, those who are well educated and well off--exploring this unproved, and in some cases dangerous, alternative realm when they have access to the finest health care system in the world?

"Of course, when people have AIDS or cancer, they may try anything," Gooding said. "But people also seek out alternatives for non-life-threatening conditions that their physicians can't seem to help. What I try to convey in my course is that there are health care practices not taught in medical school or readily available in hospitals that nonetheless seem to have therapeutic benefit for some people."

And there are some practices, she is quick to add, that hurt people. "I'm not going to defend someone who is giving shark cartilage to cancer patients instead of chemotherapy," she said. "I have found things commonly used in the alternative community that I think are bogus, and I cover those in the course as well.

"What is called `alternative' in this country is semi-mainstream in Europe. Even the Queen of England has a homeopath," Gooding said. Third-world countries are even more reliant on non-Western treatments. In fact, approximately 4 billion people, three quarters of the world's population, depend on some sort of folk remedies, mostly herbs. And even though many modern drugs were originally derived from plant sources--aspirin, digitalis and tamoxifen, for example--she notes that herbs are frequently dismissed by U.S. physicians as either worthless or dangerous.

The burden of proof

The most common criticism of complementary practices raised by physicians is that there is little if any good scientific data to back up the claims made by its practitioners. Anecdotal benefits are often dismissed as due simply to placebo effect.

But, Gooding emphasizes, the benefits of some alternative practices have been proven. "One example is cardiologist Dean Ornish's approach to reversing heart disease through lifestyle change--through such `alternative' methods as meditation, stress reduction and diet," she said. "Now some insurance companies are reimbursing when this treatment is used." She also points to research showing that breast cancer patients participating in support groups live twice as long as those without such an outlet to share their feelings.

As Gooding discusses in her course, researching non-mainstream techniques can be intrinsically problematic--because of a lack of research money and also because of special problems inherent in looking at these therapies. "It is difficult to do research in an area when you are working outside of the predominant paradigm," she said. "Too frequently, proof is not considered proof, seeing is not believing.

"There are also legitimate problems in testing some of these therapies, especially if the physician believes strongly in his approach and patients go to him because they really believe in it. We'll never be able to set up a controlled medical trial for faith and belief."

Gooding and dermatologist Mark Ling have received a small grant from NIH's Office of Alternative Medicine to test the efficacy of combining Chinese herbs and cryotherapy to treat warts. "I don't think anyone is saying Chinese herbal therapy is superior to Western medicine, or even that it works for most things," said Ling. "But there is intriguing anecdotal and scientific evidence that some of these therapies can be effective for some diseases. I think there is gold to be mined there." Gooding believes the increasing interest in unconventional therapies may eventually result in Emory's offering CME courses in complementary medical practices for community-based physicians and Emory alumni.

Does she envision her survey course ever being required of medical students, instead of being an elective?

"Absolutely," Gooding said. "It won't happen right away, but the time is coming when physicians will have to learn more about alternative therapies. I think physicians in medical practice want to know what their patients are doing, what they are being exposed to, what's safe and what's not. Studying alternative therapies can only make them better at what they do."

--Sherry Baker, reprinted with permission of Emory Medicine

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