Still concerned about CAM in undergraduate medical education.

(1)

VOL 5: AUGUST • AOÛT 2005d Canadian Family Physician • Le Médecin de famille canadien 1069

Letters

Corresp ondance

Still concerned about CAM in undergraduate medical education

W

e would like to expand on concerns we raised earlier¹ regarding proposals by Verhoef et al to integrate complementary and alternative medicine (CAM) material into undergraduate medical education (UME).²

Although the authors state that the approach they are taking is nonjudgmental and will not promote uncritical acceptance of any particular CAM modal- ity, we remain concerned that the procedures being advocated to create a curriculum on CAM will inev- itably lead to promotion of therapies that fall short of normal scientiﬁ c standards of evaluation.

In fact, after checking the authors’ activities and publications, we believe that this group has already judged that these therapies are bona fide health treatments.

For example, in 2003 the authors held an invitational workshop to develop a “shared national vision regarding CAM in UME.” Yet it appears that the list of participants was heavily weighted toward CAM practitioners and physicians who were vocal advocates of alternative medicine.³

In their response to our letter,⁴ the authors cor- rectly state that they did not speciﬁ cally cite two of the references that we identiﬁ ed. Th ese references, however, are examples of the faculty- and student- led initiatives in CAM that they alluded to in their article. Indeed, one of the participants invited to the workshop the authors held in 2003 to develop

“curriculum content” and “shared national vision regarding CAM in UME” was President of one of the alternative medicine clubs we listed.

Th e authors have written extensively about the desirability of, and strategies for, integrating CAM into the medical system.^5-11 In the article published in Canadian Family Physician, the authors hoped to ensure “that CAM ﬁ nds a permanent place in

the minds of practising physicians and provides the basis for truly integrated health care in the future.”² Such a desire makes sense only if there is a strong belief that many of these therapies are eﬀ ective.

Therefore, our concern is heightened by the authors’ objection to our statement that the evidence supporting CAM is not accepted by the sci- entiﬁ c community.

Complementary and alternative medicine is com- posed of many belief systems and practices ranging from the preposterous to the somewhat-plausible- but-as-yet-unproven. The sad truth, however, is that most of these practices meet the definition of quackery, and, as such, inclusion of CAM as a focused topic within the medical curriculum can- not be justiﬁ ed on the grounds of scientiﬁ c merit.

Th e authors defend CAM by stating that “many peer-reviewed studies” have appeared in “leading scientiﬁ c journals”² but it is well known that even the “good” journals can publish papers with seri- ous flaws (witness homeopathy,¹² acupuncture,¹³ intercessory prayer,¹⁴ and cold fusion¹⁵), and a much better test of scientiﬁ c validity is repeated, positive, high-quality randomized controlled trials conducted by various (nonadvocate) groups of investigators. Complementary and alternative medicine fails this test.

Even if a few complementary therapies were convincingly shown to be somewhat efficacious, this would not amount to vindication of a whole ﬁ eld that is essentially deﬁ ned by a belief in dubi- ous practices, including many that defy well estab- lished tenets of physics, chemistry, and biology.

Discussion with students about the phenomenon of CAM is meaningful only if it calls a spade a spade.

Yes, CAM use is prevalent; yes, people often feel better after using it. But the real questions of interest from a pedagogic standpoint relate to the psychol- ogy of the perception of health status, social trends, and the recognition of junk science. In particular:

• what CAM therapies are currently in vogue?

• why do people seek hope beyond proven therapies?

FOR PRESCRIBING INFORMATION SEE PAGE 1147

➛

(2)

1070 Canadian Family Physician • Le Médecin de famille canadien dVOL 5: AUGUST • AOÛT 2005

Letters Correspondance

• how can placebo effects make inert therapies appear eﬀective?

• how can doctors recognize pseudoscience (including that seen in peer-reviewed journals) and the way it is used to promote sham therapies?

If the authors believe that teaching about CAM in UME is justified by the weight of the support- ive efficacy trials, it would be most appropriate for those therapies to be clearly identified and the alleged evidence offered for the consideration of the academic community. Such therapies could then be included in the appropriate parts of the UME curriculum just as all effective therapies are. Calls for nonjudgmental integration and teaching of CAM are akin to writing a blank cheque to be cashed to the detriment of our intellectual integrity.

—Lloyd Oppel, MD, MHSC, CCFP(EM)

—Barry Beyerstein, PHD

—Dale Hoshizaki, MD

—Marley Sutter, MD, PHD Vancouver, BC by e-mail References

1. Oppel L, Hoshizaki D, Mathias R, Sutter M, Beyerstien B. Introducing medical students to CAM [letter]. Can Fam Physician 2004;50:1495.

2. Verhoef M, Brundin-Mather R, Jones A, Boon H, Epstein M. Complementary and alternative medicine in undergraduate medical education. Associate deans’ perspectives. Can Fam Physician 2004;50:847-9 (Eng), 853-5 (Fr).

3. Verhoef MJ, Epstein M, Brundin-Mather R. Developing a national vision for complementary and alternative medicine in undergraduate medical education: report on an invitational workshop. J Complement Integrative Med 2004;1:article 5.

4. Veroef M, Epstein M, Brundin-Mather R, Boon H, Jones A. Introducing medical students to CAM: response to Oppel et al [letter]. Can Fam Physician 2005;51:191-2.

5. Verhoef M, Findlay B. Maturation of complementary and alternative healthcare in Canada.

Healthc Pap 2003;3(5):56-61, discussion 72-7.

6. Verhoef MJ, Casebeer AL, Hilsden RJ. Assessing eﬃcacy of complementary medicine:

adding qualitative research methods to the “gold standard”. J Altern Complement Med 2002;8(3):275-81.

7. Mulkins A, Verhoef M, Eng J, Findlay B, Ramsum D. Evaluation of the Tzu Chi Institute for Complementary and Alternative Medicine’s Integrative Care Program. J Altern Complement Med 2003;9(4):585-92.

8. Welsh S, Kelner M, Wellman B, Boon H. Moving forward? Complementary and alternative practitioners seeking self-regulation. Sociol Health Illn 2004;26(2):216-41.

9. Boon H. Regulation of complementary/alternative medicine: a Canadian perspective.

Complement Ther Med 2002;10(1):14-9.

10. Boon H, Verhoef M, O’Hara D, Findlay B. From parallel practice to integrative health care:

a conceptual framework. BMC Health Serv Res 2004;4(1):15.

11. Boon H, Verhoef M, O’Hara D, Findlay B, Majid N. Integrative healthcare: arriving at a working deﬁnition. Altern Ther Health Med 2004;10(5):48-56.

12. Linde K, Clausius N, Ramirez G, Melchart D, Eitel F, Hedges LV, et al. Are the clinical eﬀects of homeopathy placebo eﬀects? A meta-analysis of placebo-controlled trials. Lancet 1997;350(9081):834-43.

13. Elden H, Ladfors L, Olsen MF, Ostgaard HC, Hagberg H. Eﬀects of acupuncture and stabilising exercises as

adjunct to standard treatment in preg- nant women with pelvic girdle pain:

randomised single blind controlled trial.

BMJ 2005;330(7494):761.

14. Byrd RC. Positive therapeutic eﬀects of intercessory prayer in a coronary care unit population. South Med J 1988;81(7):826-9.

15. Taleyarkhan RP, West CD, Cho JS, Lahey RT Jr, Nigmatulin RI, Block RC. Evidence for nuclear emissions during acoustic cavitation. Science 2002;295(5561):1868-73.

Safety of metformin use during the ﬁrst trimester

W

e read Dr Kelly and colleagues’ article¹ along with Dr Harris’s editorial² with great interest and considered it prudent to present data from a recent meta-analysis conducted by the Motherisk Program at the Hospital for Sick Children in Toronto, Ont.

Our data, presented at the 2005 annual meeting of the Canadian Society for Clinical Pharmacology, are encouraging with respect to the safety of metformin use in the first trimester of pregnancy. In perform- ing a meta-analytic summary, which included eight studies (only five of which could be analyzed statisti- cally), we found an odds ratio of 0.50. Examining the numbers showed three malformed babies among the 172 cases in the exposed group. There were 17 among 236 in the control group. Examining all the data available on pregnancy outcomes (including those not included in the meta-analysis due to lack of controls), we arrived at an overall malformation rate of 1.01% in 496 first-trimester exposures, which is well within what we would expect to find in the general population.

Our results also present the possibility of a protective effect of metformin during the first trimester. It is biologically possible that, by reversing insulin resistance, metformin does pro- tect against malformation. Although our data are encouraging, it is important to note that we examined only major malformations. This being said, our study does encourage future research into the safety of metformin during the first trimester of pregnancy.

—Cameron J. Gilbert, MSC

—Gideon Koren, MD Motherisk Program,

Hospital for Sick Children Toronto, Ont by e-mail