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Alternative therapies in academic medical centers compromise evidence-based patient care
The Journal of Clinical Investigation ( IF 15.9 ) Pub Date : 2020-03-16 , DOI: 10.1172/jci137561
Donald M. Marcus

During the past 20 years, integrative medicine centers that promote the use of alternative therapies were established in more than 70 medical and nursing schools. A survey of hospital websites and interviews with physicians, hospital administrators, and staff revealed that 15 research-intensive medical schools in the United States provide alternative therapies in their integrative medicine centers and affiliated hospitals (1). The treatments are claimed to provide benefits for a broad spectrum of diseases, including heart disease, cancer, digestive disorders, pain, autism, and autoimmune disorders. Duke Integrative Medicine offers acupuncture for treatment of 21 conditions, including rheumatoid arthritis, stroke, and essential hypertension. Johns Hopkins offers reiki therapy in which “the practitioner seeks to transmit Universal Life Energy to the client” (1). Hospital administrators state that they provide alternative therapies in response to consumer interest and that, even if those services don’t generate profits, they build the hospitals’ market share (1).

A recent article addressed the challenges of medical education in the era of alternative facts and the increasing use of social media to obtain information (2). It noted that medical educators should be “guiding our students past the barrage of misleading signals.” Unfortunately, some of those misleading signals about the safety and efficacy of alternative therapies are coming from medical educators in integrative medicine centers.

Alternative/integrative medicine

There is no generally accepted definition of alternative therapies. The National Center for Complementary and Integrative Health (NCCIH), a unit of the NIH, defines them as “health care approaches developed outside of mainstream Western or conventional medicine” (3). That descriptive definition lacks a conceptual basis and is uninformative concerning the basic difference between alternative and conventional therapies. The defining characteristic of alternative therapies is that their health claims do not meet evidence-based standards, and many, such as naturopathy, homeopathy, and energy healing, are scientifically implausible. Moreover, integrative centers further confuse consumers by laying claim to therapies that are supported by sound evidence, such as exercise and mindfulness.

What is the rationale for alternative/integrative medicine? Its advocates claim that evidence-based medicine is incapable of providing care for the whole person because advances in medical science have led to an algorithmic, impersonal model of medical practice (4). They also state that biomedicine overlooks the importance of a healthy lifestyle, preventive medicine, and mind-body interactions. The mission of integrative medicine is to compensate for these deficiencies by introducing safe, evidence-based alternative therapies into medical education and training.

It is remarkable that this misrepresentation of medical education and practice is a declaration that is not supported by any substantiating data, such as analyses of medical school curricula. Rather than being “algorithmic,” evidence-based medicine integrates the best research evidence available, the experience of the physician, and the wishes of the patient in making decisions about treatment. It is a flexible and powerful approach to making clinical decisions (5). In a 2007 poll conducted by the British Medical Journal, evidence-based medicine was included in the 15 most important advances in medicine since 1840. The biopsychosocial model of medical training and the importance of a healthy lifestyle in preventing disease have been tenets of medical education for decades (6). Evaluation of the humanistic attributes of students, residents, and faculty has long been required by medical schools and by accrediting agencies and medical boards (7).

Efficacy and safety of alternative therapies

According to a National Health Statistics Survey, the most popular alternative therapies are chiropractic, acupuncture, and herbal remedies, which are misleadingly labeled dietary supplements. In 1994, US Congress enacted the Dietary Supplement and Health Education Act (DSHEA). Without any scientific basis, DSHEA arbitrarily classified herbal remedies and other medicinal products as dietary supplements, a category that previously included only vitamins and minerals. Plant extracts are used worldwide as medicines and not for their nutritional value. DSHEA prevents the FDA from effectively regulating dietary supplements and leads consumers to mistakenly believe that herbals are safe, like multivitamins. The consequence was a rapid increase in sales of herbal and other medicinal nonvitamin, nonmineral “supplements.”

Claims for efficacy of alternative therapies are based primarily on clinical trials funded by commercial sources and professional organizations of alternative practitioners. Reviews of those trials concluded that they are uninterpretable because of their positive bias and poor quality (8, 9). An analysis of trials of glucosamine treatment of osteoarthritis revealed that all positive trials were funded by manufacturers, but no efficacy was noted in studies funded by independent, noncommercial sources. Likewise, rigorous trials supported by NIH and other noncommercial sources have failed to substantiate specific efficacy beyond a placebo effect for popular herbal supplements (10, 11), chiropractic manipulation for back pain (12), or acupuncture for knee osteoarthritis or back pain (13). Recent analyses of “all-natural” herbals revealed their lack of quality control and frequent adulteration by prescription drugs or analogs of hormones and stimulants (10, 11). In summary, expenditure of approximately $2.2 billion by National Center for Complementary and Alternative Medicine (NCCAM)/NCCIH during fiscal years 1999–2017 for clinical trials produced no sound, consistent evidence for the efficacy of any alternative therapies. However, the grants lent academic credibility to integrative medicine.

Data about the frequency of adverse events caused by herbal “dietary supplements” are limited because DSHEA did not initially require manufacturers to report problems to the FDA. Based on data from Poison Control Centers, the FDA has estimated an annual incidence of 50,000 adverse events, many of which are serious (14). During 2004–2013, 23,005 visits to emergency departments were attributed to adverse events related to dietary supplements (15). Herbal or complementary nutritional products accounted for 65.9% of the events. A prospective study of hospital admissions for drug-induced acute hepatic inflammation found that 20% of cases were caused by dietary supplements (16). Other concerns are that herbal remedies may alter the activity of conventional medications and that alternative therapists without medical training may overlook a serious, treatable condition.

In theory, alternative treatments are used only to complement conventional treatment or by patients whose conditions have not responded to conventional therapy. However, some people choose alternative therapies as initial treatments, based on misleading claims for the safety and efficacy of “natural healing.” Patients with four common cancers who chose alternative treatments as their sole initial therapy had a greater risk of death than matched controls who had conventional therapy (17).

Education

Integrative centers are also undermining evidence-based medical education. During 2000–2003, NIH provided educational grants to health profession schools to integrate evidence-based complementary and alternative therapies into their curricula. A review of the integrative curricula revealed that they were outdated, were biased, and failed to meet evidence-based standards (18).

Academic integrative medicine centers have also received millions of dollars from private foundations whose donors believe in alternative therapies. The Osher Centers for Integrative Medicine provide funds to a number of centers, including those at UCSF, Harvard Medical School, Brigham and Women’s Hospital, and Vanderbilt University School of Medicine. The University of California at Irvine received a gift of $200 million from the Henry and Susan Samueli Foundation for a new building to house the Samueli College of Health Sciences (19). The College will emphasize integrative medicine throughout the curriculum. A portion of the gift will endow up to 15 chairs for faculty with “expertise in integrative health” (19). The Sidney Kimmel College of Medicine of Thomas Jefferson University recently created a new academic Department of Integrative Medicine and Nutritional Sciences (20). The initiative is supported by a $20 million grant from the Marcus Foundation. The curriculum of the department will include “novel mechanisms of healing and emerging therapies.” The role of philanthropy in creating new and expanded integrative medicine programs in medical schools raises concerns about the distortion of medical education.

Promotion of alternative therapies has also had economic consequences. Out-of-pocket expenditures in the United States for alternative products and services in 2012 were $30.2 billion, which was approximately 24% of out-of-pocket expenditures for prescription drugs. Sales of nonvitamin, nonmineral supplements — mostly herbal remedies — were $12 billion in 2012, approximately 39.7% of all expenditures for complementary health approaches.

Conclusions

Integrative medicine centers undermine evidence-based medical practice and education. They promote unsound and potentially hazardous therapies and provide flawed curricula to health care students and graduate physicians in training. Although supportive of patients’ desire to play a meaningful role in managing their health care, physicians should adhere to standards of professionalism. The tenets of medical professionalism include a commitment to maintaining medical knowledge, a duty to uphold scientific standards, and a contract with society to provide expert advice on matters of health (21). Offering therapies that are not supported by evidence-based standards is a failure to adhere to professional tenets. It deceives patients and prevents them from making informed decisions about treatment options. Academic medical centers should be a source of sound advice for the public, instead of promoting unproven health practices.

Science is under unprecedented attack, at present. Biomedical scientists should speak up to support evidence-based health care. They should remind the public and members of US Congress that the remarkable advances in health care during the last 70 years were made possible by scientific research. Integrative medicine centers persist because of a lack of oversight by medical school faculty and administrators. Professional societies and individual scientists should urge medical schools to review the educational material in integrative medicine curricula and to establish ongoing oversight. Advocates for integrative medicine could argue that academic freedom gives them the right to express their beliefs. However, as educators and role models for learners, their primary responsibility is to uphold professional standards of integrity and science-based practice.

Footnotes

Conflict of interest: The author has declared that no conflict of interest exists.

Copyright: © 2020, American Society for Clinical Investigation.

Reference information: J Clin Invest. 2020;130(4):1549–1551. https://doi.org/10.1172/JCI137561.

References
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中文翻译:

学术医疗中心的替代疗法损害了循证患者的护理

在过去的20年中,在70多家医学和护理学校中建立了促进替代疗法使用的中西医结合中心。一项对医院网站的调查以及对医生,医院管理人员和工作人员的访谈显示,美国15所研究密集型医学院在其综合医学中心和附属医院中提供替代疗法(1)。据称这些疗法可为多种疾病带来益处,包括心脏病,癌症,消化系统疾病,疼痛,自闭症和自身免疫性疾病。杜克综合医学提供针灸治疗21种疾病,包括类风湿关节炎,中风和原发性高血压。约翰·霍普金斯(Johns Hopkins)提供灵气疗法,其中“医生试图将通用生命能量传递给客户”(1)。医院管理者表示,他们会根据消费者的兴趣提供替代疗法,即使这些服务没有产生利润,他们也会建立医院的市场份额(1)。

最近的一篇文章谈到了替代事实时代以及越来越多地使用社交媒体获取信息的时代医学教育所面临的挑战(2)。它指出,医学教育工作者应该“引导我们的学生摆脱误导性信号的bar弹”。不幸的是,关于替代疗法的安全性和有效性的一些误导性信号来自中西医结合中心的医学教育者。

替代/中西医

没有公认的替代疗法定义。NIH的国家补充与综合健康中心(NCCIH)将其定义为“在主流西方或传统医​​学之外开发的保健方法”(3)。该描述性定义缺乏概念基础,对于替代疗法与传统疗法之间的基本区别也没有提供任何信息。替代疗法的主要特征是其健康声称不符合循证标准,并且许多疗法(如自然疗法,顺势疗法和能量疗法)在科学上都是不可信的。此外,综合中心通过声称获得诸如运动和正念之类的可靠证据支持的疗法,进一步使消费者感到困惑。

替代/中西医结合的理由是什么?它的拥护者声称,循证医学无法为整个人提供护理,因为医学科学的进步导致了医学实践的算法化,非人格化模型(4)。他们还指出,生物医学忽略了健康生活方式,预防医学和身心互动的重要性。中西医结合的任务是通过在医学教育和培训中引入安全的,循证的替代疗法来弥补这些不足。

值得注意的是,医学教育和实践的这种错误陈述是一项声明,没有任何实质性数据(例如对医学院课程的分析)的支持。循证医学不是“算法”,而是融合了现有的最佳研究证据,医师的经验以及患者在做出治疗决策时的意愿。这是制定临床决策的灵活而强大的方法(5)。在2007年《英国医学杂志》(British Medical Journal)进行的一项民意测验中,循证医学被列入自1840年以来医学领域最重要的15个进展中。医学培训的生物心理社会模型和健康的生活方式对预防疾病的重要性一直是医学教育的宗旨。几十年6)。医学院,认证机构和医学委员会长期以来一直要求对学生,居民和教职员工的人文属性进行评估(7)。

替代疗法的功效和安全性

根据国家健康统计调查,最流行的替代疗法是脊椎按摩疗法,针灸和草药,它们被误导地标记为膳食补充剂。1994年,美国国会制定了《膳食补充剂和健康教育法》(DSHEA)。由于没有任何科学依据,DSHEA任意将草药和其他药品归类为膳食补充剂,而此前该类仅包含维生素和矿物质。植物提取物在世界范围内被用作药物,而不是因为其营养价值。DSHEA阻止FDA有效地调节膳食补充剂,并导致消费者误认为草药与多种维生素一样安全。结果是草药和其他药用非维生素,非矿物质“补给品”的销售迅速增长。

替代疗法功效的主张主要基于由商业来源和替代从业人员专业组织资助的临床试验。对这些试验的评论得出结论,由于它们的积极偏见和质量较差,因此无法解释(89)。对氨基葡萄糖治疗骨关节炎的试验分析表明,所有阳性试验均由制造商资助,但在独立的非商业来源资助的研究中未见疗效。同样,由NIH和其他非商业来源支持的严格试验也未能证实对流行草药补品具有安慰剂作用以外的特定功效(1011),脊椎按摩治疗背部疼痛(12)或针灸治疗膝盖骨关节炎或背痛(13)。最近对“全天然”草药的分析表明,他们缺乏质量控制,经常通过处方药或激素和兴奋剂类似物掺假(1011)。总之,美国国家补充和替代医学中心(NCCAM)/ NCCIH在1999-2017财政年度用于临床试验的支出约为22亿美元,没有任何可靠,一致的证据证明任何替代疗法的有效性。但是,这些赠款在中西医结合方面具有学术信誉。

由于DSHEA最初并不要求制造商向FDA报告问题,因此有关草药“膳食补充剂”引起的不良事件发生频率的数据有限。根据来自毒物控制中心的数据,FDA估计每年发生50,000种不良事件,其中许多是严重的(14)。在2004-2013年期间,急诊室就诊次数为23005次,归因于与膳食补充剂相关的不良事件(15)。草药或补充营养产品占事件的65.9%。对因药物引起的急性肝炎住院的前瞻性研究发现,有20%的病例是由膳食补充剂引起的(16)。其他问题是草药可能会改变传统药物的活性,而未经医学培训的替代治疗师可能会忽略严重的可治疗疾病。

从理论上讲,替代疗法仅用于补充常规疗法,或者由病情对常规疗法无反应的患者使用。但是,有些人基于对“自然治愈”的安全性和有效性的误导性主张,选择替代疗法作为初始治疗。选择其他替代疗法作为唯一初始疗法的四种常见癌症患者的死亡风险要比接受常规疗法的对照组更高(17)。

教育

综合中心也在破坏循证医学教育。在2000年至2003年期间,NIH向卫生专业学校提供了教育补助金,以将基于证据的补充疗法和替代疗法纳入其课程。对综合课程的审查显示,它们已经过时,有偏见且未达到基于证据的标准(18)。

学术性综合医学中心还从私人基金会那里获得了数百万美元的资金,这些基金会的捐助者相信替代疗法。Osher中西医结合中心为许多中心提供资金,包括加州大学旧金山分校,哈佛医学院,布里格姆妇女医院和范德比尔特大学医学院的中心。加利福尼亚大学欧文分校从亨利和苏珊·萨缪里基金会获得了2亿美元的赠款,用于建造一座新楼,以容纳萨缪里健康科学学院(19)。学院将在整个课程中强调中西医结合。礼物的一部分将最多为15位教员提供“综合健康方面的专业知识”(19)。托马斯·杰斐逊大学西德尼·金梅尔医学院最近建立了一个新的综合医学与营养科学学院(20)。该计划得到马库斯基金会(Marcus Foundation)2000万美元的资助。该部门的课程将包括“治愈和新兴疗法的新颖机制”。慈善事业在医学院校创建新的和扩展的中西医结合计划中的作用引起了人们对医学教育失真的担忧。

促进替代疗法也产生了经济后果。2012年,美国替代产品和服务的自付费用为302亿美元,约占处方药自付费用的24%。2012年,非维生素,非矿物质补充剂(主要是草药)的销售额为120亿美元,约占辅助保健方法总支出的39.7%。

结论

中西医结合中心破坏了循证医学实践和教育。它们提倡不合理且可能有害的疗法,并为接受培训的卫生保健学生和研究生医师提供有缺陷的课程。尽管支持患者希望在管理其医疗保健中发挥重要作用的愿望,但医生应遵守专业标准。医学专业精神的宗旨包括:保持医学知识的承诺,坚持科学标准的义务以及与社会签订的就健康问题提供专家建议的合同(21)。提供不受循证标准支持的疗法是对专业原则的坚持。它欺骗患者并阻止他们就治疗选择做出明智的决定。学术医学中心应该为公众提供合理的建议,而不是提倡未经证实的健康做法。

目前,科学正受到前所未有的攻击。生物医学科学家应大声疾呼,以支持循证医疗。他们应该提醒公众和美国国会议员,过去70年来,在医疗保健领域的显着进步是通过科学研究得以实现的。由于缺乏医学院校教师和管理人员的监督,中西医结合中心仍然存在。专业协会和个体科学家应敦促医学院审查中西医结合课程中的教学材料,并建立持续的监督机制。中西医结合的拥护者可能会争辩说,学术自由赋予了他们表达信仰的权利。但是,作为学习者的教育者和榜样,

脚注

利益冲突:作者声明不存在利益冲突。

版权所有: ©2020,美国临床研究学会。

参考信息:J Clin Invest。2020; 130(4):1549-1551。https://doi.org/10.1172/JCI137561。

参考文献
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更新日期:2020-04-03
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