SPECIAL ARTICLE The Tower of Babel: Communication and Medicine An Essay on Medical Education and Complementary-Alternative Medicine Opher Caspi, MD; Iris R. Bell, MD, PhD; David Rychener, PhD; Tracy W. Gaudet, MD; Andrew T. Weil, MD As society changes, medical education also must change.1 C omplementary and alternative medicine (CAM) is constantly gaining in popular- ity.2-6 Despite its widespread use, valid concerns have been raised regarding the in- tegration of CAM into the health care system.7 Certainly, the gap between allopathy and CAM is very substantive. It pertains to methodology and rigorous applications of scientific standards of evidence, among other issues, as well as to the meaning and context of illness and health. At present, it remains unclear (1) whether a true integration of conventional and unconventional therapies is even possible, (2) what this integration would look like, and (3) whether we are ready for the new era of medicine that would then result.8-10 The most commonly addressed aspects of holds true with regard to communica- CAM in the medical literature are its safety, tion among health care providers. Today, efficacy, and legislation. These issues are competent physicians are expected to have discussed and presented in detail else- a knowledge base that extends well be- where.11,12 However, what very may well yond specific diseases and disorders be one of the most difficult obstacles in the pertaining to their medical fields. The im- implementation of a true health integra- portance of communication is not merely tion is unfortunately rarely addressed: the for the purpose of dialogue: it is an essen- lack of a common language among CAM tial requirement for the optimizing of treat- providers and allopathic physicians. In this ment. Interdisciplinary medical dis- article, we use the Tower of Babel as a meta- course is therefore the “bread and butter” phor to advocate dialogue as a way to of practicing medicine. bridge that gap between these 2 camps. In It is that belief in broad-based know- doing so, we stress the important role of ledge that concerns us most when it ap- medical education in developing appro- plies to CAM. The present relative scar- priate communication skills among all city of thorough exposure of allopathic health care providers. Despite the fact that medical students to the diversity of CAM we often herein refer to a deficiency in therapies and their fundamental con- CAM training for allopathic students, we cepts13 and of students of CAM to allopa- strongly believe that this development thy and its related sciences14 is far from should be a perfectly symmetrical recip- ideal. This scarcity may result in a lack of rocal process, ie, that the depth and understanding of all health systems and may breadth of the training of CAM practition- create a risky situation in which future prac- ers should be such that they would be able titioners, allopathic and CAM alike, may not to speak the biomedical language. be optimally able to discuss in depth all le- The ability to communicate is the gitimate evidence-based treatment op- foundation of medical practice. When tions with their patients. communication with patients is impos- For most allopathic physicians, a sible, treatment is far from ideal. The same genuine understanding of the underlying concepts and practices of CAM, such as From the Program in Integrative Medicine, Departments of Medicine (Drs Caspi, Bell, acupuncture and homeopathy, is almost Rychener, Gaudet, and Weil), Psychology (Drs Caspi and Bell), Psychiatry (Dr Bell), beyond achievement.15 This lack of un- and Family and Community Medicine (Dr Weil), University of Arizona College of derstanding is not because physicians do Medicine, Tucson. not have the ability or willingness to un- (REPRINTED) ARCH INTERN MED/ VOL 160, NOV 27, 2000 WWW.ARCHINTERNMED.COM 3193 ©2000 American Medical Association. All rights reserved.
derstand CAM, but because of a with the conventional curriculum, zona, Tucson (of which all authors much simpler reason: the 2 do- will help to educate a new genera- are part), pioneers this approach, and mains do not speak the same lan- tion of physicians with a better abil- its mission is changing medical edu- guage! The root of this discrep- ity to communicate with CAM pro- cation.22 ancy, in our viewpoint, is directly viders. Such an “integrative Support of our proposition related to the entire process of medi- curriculum” is fully justified when comes from the recently published cal education of both conventional the World Health Organization clas- “Suggested Curriculum Guidelines and unconventional practitioners. sifies 65% to 80% of the world’s on Complementary and Alternative Studying pathophysiology, health care services as alternative Medicine,” developed by the Soci- principles and applications of epi- medicine.18 Indeed, in a recent sur- ety of Teachers of Family Medicine demiology, pharmacology, molecu- vey, more than 80% of medical stu- Group on Alternative Medicine.23 The lar biology, and other disciplines that dents in the United States and the guidelines, to be included in resi- are rich in concepts and methodol- United Kingdom stated that they dency training, indicate the knowl- ogy throughout medical training is would like to have more training in edge, skills, and attitudes that gradu- basically possible because we as a CAM practices.19,20 ating residents should acquire to be profession have succeeded in creat- A 1997 American Medical As- able to function as unbiased advo- ing a common language, one that sci- sociation report on “encouraging cates and advisors to patients about entifically makes sense. Like train- medical student education in comple- CAM. Using the authors’ own words ees in many other professions, mentary health care practice”21 con- “to communicate effectively with pa- allopathic medical students are re- cluded that “medical schools should tients about alternative therapies re- quired to learn both the “vocabu- be free to design their own required quires that our graduates have a rea- lary” (ie, medical terms) and the or elective experience related to sonable knowledge base in this “grammar” (ie, how to use these CAM.” A 1997-1998 survey of 117 area.”23 terms) of almost all biomedical dis- US medical schools13 found that 64% Providing medical students the ciplines. Indeed, going through offered an elective course in alterna- fundamental concepts of CAM will medical school is very much about tive medicine or included informa- hopefully contribute to our ability learning this new biomedical jar- tion about alternative medicine in a to communicate on 3 different lev- gon. If we are taught only 1 set of regular course. Topics included chi- els. First, and most importantly, vocabulary, communication is less ropractic, acupuncture, homeopa- these concepts might help make rich and therefore at times less ef- thy, herbal therapies, and mind- physicians less biased, and there- fective, and if we miss words, we of- body techniques. Sixty-eight percent fore more able to objectively or ef- ten miss concepts. of the courses were stand-alone fectively judge the appropriateness How can we expect CAM and courses, whereas 31% were part of a of CAM therapies. Second, the phy- allopathy to be integrated when required course. In trying to de- sicians will also be knowledgeable skilled practitioners in both camps velop a more consistent educational enough to impart the relevant in- are only partially familiar with the approach to CAM, Wetzel et al13 formation regarding different CAM vocabulary and grammar of the made the following suggestions: (1) modalities to their patients. Third, other? What do we allopathic prac- “Focus on critical thinking and criti- having been exposed to different titioners really know about Qi (the cal reading of the literature”; (2) models of medicine, they may serve Chinese term for vital energy)? The “Identify thematic content . . . ”; (3) as a pool of future researchers, edu- widespread use of jargon that is pe- “Include an experiential compo- cators, and open-minded skeptics for culiar to particular CAM practices nent”; (4) “Promote a willingness to the vast body of research that is so can clearly act as an impediment to communicate professionally with al- vitally needed regarding CAM and constructive dialogue.16 We must ad- ternative health care clinicians”; and integrative medicine. mit that the majority of us know very (5) “Teach students to talk to pa- The establishment of evidence- little about the basic ideas of CAM.17 tients about alternative therapies.” based CAM is highly dependent on Likewise, what do CAM providers We strongly agree; therefore, we be- the proper allocation of resources, really know about applied molecu- lieve that CAM education should not in terms of professionals and funds, lar biology? Not much, we suspect. be regarded as an “optional dessert” by the medical community. Oppo- In such a climate, communication but rather as part of the “main nents of integrative medicine usu- between both schools of thought is course.” For us, the crucial ques- ally discount CAM, citing a lack of almost impossible. Is this not a mod- tion is not how many CAM modali- scientific evidence.24 We believe that ern form of the Tower of Babel? ties will be covered in such a course, the creation of a new generation of So, how can we overcome this but will future physicians practice a CAM-educated physicians, with the language obstacle in our long march more human oriented healing? We ability to speak the “CAM lan- toward a full implementation of in- believe that a trial to study the im- guage,” will give us an opportunity tegrative medicine? The key an- pact of changing medical education to investigate what is actually be- swer, in our opinion, lies in the toward healing using an integrative hind the scenes of these unconven- medical education paradigm. We be- curriculum is warranted before a tional forms of treatment. We wish lieve that studying the “ABC lan- wide-scale application will be mer- to see special CAM departments in guage”17 of the most common CAM ited. The Program in Integrative conventional medical schools that disciplines in medical schools, along Medicine at the University of Ari- will provide a rigorous atmosphere (REPRINTED) ARCH INTERN MED/ VOL 160, NOV 27, 2000 WWW.ARCHINTERNMED.COM 3194 ©2000 American Medical Association. All rights reserved.
wherein academic reward will be a justified approach for improving cine at US medical schools. JAMA. 1998;280: 784-787. available, research facilities will be our knowledge and practice. 14. Coulter I, Adams A, Coggan P, Wilkes M, Gonyea abundant, money to support such re- A real breakthrough in CAM as M. A comparative study of chiropractic and medi- search will be duly allocated, and a legitimate form of therapy can only cal education. Altern Ther Health Med. 1998;4: there will be no shortage of re- occur when the 2 schools of thought 64-75. search expertise.25,26 Once this goal learn a common language in which 15. Ernst E, Resch KL, White AR. Complementary medicine: what physicians think of it: a meta- is accomplished, safety and effi- to communicate and consequently analysis. Arch Intern Med. 1995;155:2405- cacy can be more thoroughly ad- begin to truly collaborate. This new 2408. dressed. Assuming that reorganiz- and unique dimension of the health 16. Eskinazi D, Muehsam D. Factors that shape alter- ing this dimension of medical care system, integrative medicine, native medicine: the role of the alternative medi- schools will take much time, we are can then bring current health care cine research community. Altern Ther Health Med. 2000;6:49-53. calling for the ad hoc establish- to new horizons. 17. Zollman C, Vickers A. ABC of complementary medi- ment of interdisciplinary (includ- cine: what is complementary medicine? BMJ. ing both conventional and uncon- Accepted for publication May 18, 1999;319:693-696. ventional practitioners) forums of 2000. 18. Jonas WB. Researching alternative medicine. Nat dialogue that can serve as a bridge Corresponding author: Opher Med. 1997;3:824-827. 19. Halliday J, Taylor M, Jenkins A, Reilly D. Medical for continuous medical education for Caspi, MD, Program in Integrative students and complementary medicine. Comple- the benefit of both patients and Medicine, Department of Medicine, ment Ther Med. 1993;1(suppl):32-33. health providers. Because more and College of Medicine, University of 20. Hopper I, Cohen M. Complementary therapies and more scientists realize that do- Arizona Health Sciences Center, PO the medical profession: a study of medical stu- mains of knowledge, and their ap- dents’ attitudes. Altern Ther Health Med. 1998;4: Box 245153, Tucson, AZ 85724-5153 68-73. plication, are virtually infinite, there (e-mail: email@example.com). 21. American Medical Association Council on Medi- is now a strong metascientific call for cal Education. Encouraging Medical Students’ Edu- interdisciplinarity, one that crosses REFERENCES cation in Complementary Health Care Practices. boundaries of disciplines and insti- Chicago, Ill: American Medical Association; June tutions. A genuine need for inter- 1997. 1. Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses 22. Gaudet TW. Integrative medicine: the evolution of disciplinarity is hence not unique to a new approach to medicine and to medical edu- involving complementary and alternative medi- medicine. (For further discussion of cine at US medical schools [letter]. JAMA. 1999; cation. Integr Med. 1998;1:67-73. this intriguing concept, the reader 281:609-611. 23. Kligler B, Gordon A, Stuart M, Sierpina V. Sug- is kindly referred to an excellent ar- 2. Eisenberg DM, Kessler RC, Foster C, Norlock FE, gested curriculum guidelines on complementary ticle by Bugliarello.27) Calkins DR, Delbanco TL. Unconventional medi- and alternative medicine: recommendations of the cine in the United States: prevalence, costs, and Society of Teachers of Family Medicine Group on The widespread use of CAM patterns of use. N Engl J Med. 1993;328:246- Alternative Medicine. Fam Med. 1999;31:30-33. makes dealing with different as- 252. 24. Coulson J. Doctors need evidence on complemen- pects of the integration of CAM and 3. Fisher P, Ward A. Complementary medicine in Eu- tary medicine. BMA News Review. July 1995:16. conventional therapies not solely the rope. BMJ. 1994;309:107-111. 25. Horton R. Andrew Weil: working towards an in- 4. MacLennan AH, Wilson DH, Taylor AW. Preva- tegrated medicine. Lancet. 1997;350:1374. interest of CAM practitioners, but lence and cost of alternative medicine in Austra- 26. Ernst E. The Department of Complementary Medi- rather in everybody’s domain. Since lia. Lancet. 1996;347:569-573. cine at Exeter: the first three years. Int J Altern patients who seek alternative medi- 5. Abbot NC, White AR, Ernst E. Complementary Complement Med. May 1997:9-12. cal treatments are not “alternative medicine. Nature. 1996;381:361. 27. Burgliarello G. The interdisciplinarity imperative patients,” they have the right to be 6. Astin JA. Why patients use alternative medicine: to create new knowledge and uses of knowledge results of a national study. JAMA. 1998;279:1548- across boundaries of disciplines and insti- treated according to the same eth- 1553. tutions. In: Roy R, ed. Interdisciplinarity Re- ics and standard of treatment28 as 7. Coates JR, Jobst KA. Integrated healthcare: a way visited: Interactive Research and Education, Still those of conventional medicine. Un- forward for the next five years? a discussion docu- an Elusive Goal in Academia. Campbell, Calif: fortunately, even though at present ment from the Prince of Wales’s Initiative on In- iUniverse.com Inc. In press. tegrated Medicine. J Altern Complement Med. 28. Gillon R. Medical ethics: four principles plus at- we are far away from evidence- 1998;4:209-247. tention to scope. BMJ. 1994;309:184-188. based complementary medicine, we 8. Dalen EJ. “Conventional” and “unconventional” 29. Ernst E. Complementary medicine: scrutinizing the must strive toward it.29-33 The per- medicine: can they be integrated [editorial]? alternatives. Lancet. 1993;341:1626. ceived lack of hard data regarding Arch Intern Med. 1998;158:2179-2181. 30. Van Haselen R, Fisher P. Evidence influencing Brit- CAM greatly limits our ability to pro- 9. Anderson R. A case study in integrative medicine: ish health authorities’ decisions in purchasing alternative theories and the language of biomedi- complementary medicine [letter]. JAMA. 1998; vide our patients with enough in- 280:1564-1565. cine. J Altern Complement Med. 1999;5:165-173. formation to make informed deci- 10. Dacher ES. A personal response to “A case study 31. Fontanarosa PB, Lundberg GD. Alternative medi- sions. As a result, there are many in integrative medicine: alternative theories and cine meets science [editorial]. JAMA. 1998;280: misconceptions about CAM, mis- the language of biomedicine.” J Altern Comple- 1618-1619. conceptions that leave both physi- ment Med. 1999;5:175-176. 32. Margolin A, Avants SK, Kelber HD. Investigating 11. Ernst E. The risks of acupuncture. Int J Risk Safety alternative medicine therapies in randomized con- cians and patients with a high de- Med. 1995;6:179-186. trolled trials. JAMA. 1998;280:1626-1628. gree of uncertainty.34 We truly do not 12. Vickers A, Cassileth B, Ernst E, et al. How should 33. Ezzo J, Berman BM, Vickers AJ, Linde K. Comple- know what the “gold standard” for we research unconventional therapies? a panel re- mentary medicine and the Cochrane Collabora- care that applies to integrative ap- port from the Conference on Complementary and tion. JAMA. 1998;280:1628-1630. proaches is. All we can do at pres- Alternative Medicine Research Methodology, Na- 34. Ernst E. Complementary medicine: common mis- tional Institutes of Health. Int J Technol Assess conceptions. J R Soc Med. 1995;88:244-247. ent is to provide our patients with Health Care. 1997;13:111-121. 35. Eisenberg DM. Advising patients who seek alter- “informed skepticism.” 35 Again, 13. Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses native medical therapies. Ann Intern Med. 1997; change in medical education seems involving complementary and alternative medi- 127:61-69. (REPRINTED) ARCH INTERN MED/ VOL 160, NOV 27, 2000 WWW.ARCHINTERNMED.COM 3195 ©2000 American Medical Association. All rights reserved.