sábado, 12 de abril de 2014

¿Deberíamos enseñar a los estudiantes de medicina las medicinas alternativas?

En la revista British Medical Journal se plantean esta semana si sería correcto tratar con los estudiantes de medicina el tema de las medicians alteranativas. Parece que lo más sencillo sería el blanco o el negro. Los que llevamos tiempo navegando las procelosas aguas de la salud y la enfermedad sabemos que casi todos los temas complejos se dirimen en la gama de grises. Es necesario que un estudiante de medicina tenga una aproximación a esta realidad. Es necesario que cualquier profesional de la salud sepa del mismo. Pese a nuestra opinión los pacientes van a incluirlas en sus opciones, se estima que aproximádamente un 25-30% de ellos acudirá a algún tipo de terapia alternativa. ¿Seremos capaces de estar a su altura a la hora de personalizar los tratamientos y nuestro consejo?


BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g2417 (Published 28 March 2014)
Cite this as: BMJ 2014;348:g2417
  1. Graeme Catto, president1,
  2. Nick Cork, medical student2,
  3. Gareth Williams, emeritus professor of medicine and senior research fellow in philosophy3
Author Affiliations
  1. Correspondence to: Graeme Catto president@collegeofmedicine.org.uk, Nick Cork nicholascork@gmail.com
Doctors should be able to discuss the non-evidence based therapies that patients want to try, says Graeme Catto. But Nick Cork and Gareth Williams say that students risk being indoctrinated and should be taught only about interventions that have been shown to be safe and effective

Yes—Graeme Catto

“Demonstrate awareness that many patients use complementary and alternative therapies, and awareness of the existence and range of these therapies, why patients use them, and how this might affect other types of treatment that patients are receiving.1
This guidance, from the UK General Medical Council’s Tomorrow’s Doctors encapsulates lucidly and concisely why medical students are taught about alternative medicine. I find it difficult to conceive of a counterargument.

The choices patients make

To provide quality care doctors must be aware of choices patients make and be able to discuss them in an informed and non-judgmental way. Any other approach puts the doctor-patient relationship at risk. Patients are reluctant to raise issues that they believe meet with disapproval. These principles apply to complementary and alternative medicine the same way as to other lifestyle choices.
And this is a choice made by many people in the United Kingdom. The annual spend on alternative health treatments has been estimated to be as much as £5.4bn (€6.5bn; $8.9bn).2 All aspects of medical care are involved and not only in general practice. As a nephrologist I learnt that patients wanted complementary therapies to relieve some of the intractable and distressing symptoms, such as skin itch and restless legs, associated with chronic renal failure. Patients discussed among themselves the therapies they found useful. For my part I checked that there were no known interactions with their current conventional treatment and was pleased if symptoms were relieved.
With the development of the internet and social media, such suggestions for self care and for complementary therapy are much more readily available and circulate more rapidly. Serious drug interactions are fortunately not common; St John’s wort, however, increases the effect of conventional antidepressants, and evening primrose oil increases the effect of warfarin with potentially serious consequences.3

Where efficacy has been accepted

In 2000, the House of Lords Select Committee on Science and Technology produced a far sighted report on complementary and alternative medicine.4 It recognised the weakness of the evidence base and the difficulty of identifying funding for necessary but expensive clinical trials. So what has changed since then? Perhaps not a great deal. The National Institute for Health and Care Excellence recommends complementary and alternative therapies only in a limited number of conditions where efficacy has been accepted. The Alexander technique is suggested as part of the treatment for Parkinson’s disease,5 ginger and acupressure for reducing morning sickness in pregnancy,6 and acupuncture and massage for persistent low back pain.7
Complementary therapies are, however, widely used in cancer and palliative care, and the National Cancer Institute at the National Institutes of Health provides information on research activity and clinical practice in the US.8 Many of these treatments relate to relaxation and meditation techniques thought to be of value for patients with life threatening illnesses. That hypothesis gained support from an unexpected source. Elizabeth Blackburn, awarded the Nobel prize in 2009 for her work on telomerase, and her colleagues showed that increased telomere length protected not only the chromosome but the cell against the ageing process and cell death. They have further shown that meditation and relaxation increase telomerase activity and telomere length thus providing objective information on the effect of complementary medicine at the cellular level.9
These are not isolated examples. Dean Ornish and his colleagues have shown in patients with prostatic cancer that changes in lifestyle and diet have been associated with lengthening of telomeres.10 We await to see if these cellular changes are associated with an improved prognosis. Similar dietary and lifestyle changes have produced lasting improvements in patients with coronary artery disease. These interventions are now accepted as good practice in cardiovascular disease and in preventing both obesity and type 2 diabetes. In these situations, concepts that may originally have been considered as complementary to conventional medicine are now widely adopted.
One of the joys of medicine is dealing with uncertainty. The evidence base for much of our current practice is weak. I believe, as once did the GMC, that doctors “must work with colleagues and patients . . . to help resolve uncertainties about the effects of treatments.”11 That means following the scientific evidence and questioning established practice. Iain Chalmers has spoken movingly of the many infant deaths caused by the inadequately researched advice to place young children in the prone position for sleep.12 Volumes of learned articles seeking to cure peptic ulcers by reducing gastric acid secretion were shown to be irrelevant, even if scientifically valid, by the discovery of Helicobacter pylori. Good doctors have always had the flexibility to change their practice in the light of new evidence and patients have benefitted.

Partnership and support

In many clinical situations, however, modern medicine is able only to modify, not cure, the underlying condition. Optimum management of long term conditions requires partnership among the patient, the doctor, and the other members of the healthcare team. It is not surprising that many patients turn to complementary and alternative therapies when their symptoms persist. The good doctor will provide support while advising against any treatments that may be dangerous or conflict with their current drugs.
We may not require a randomised controlled trial to know that aromatherapy makes some patients feel better or that yoga has benefits. Learning to work well in partnership with patients is an essential skill for all of us and not only medical students. If you accept that premise, understanding something about complementary and alternative therapies is an essential component, like it or not.

No—Nick Cork and Gareth Williams

In 1910, the Flexner Report13 brought much needed scientific rigour to medical education in the United States and led directly to the closure of many schools that taught chiropractic, naturopathy, and homoeopathy. Now, over a century later, alternative medicine has insinuated itself into medical education in the UK.
In 2010, 18 of the UK’s then 31 medical schools responded to a survey about the teaching of so called “complementary and alternative medicine” (CAM) within the undergraduate programme.14 All 18 stated that CAM was an integral part of the curriculum, including student selected research projects in eight, and formal teaching (ranging from a single lecture to a theme running throughout the programme) in six.
Mainstream, science based medicine is far from perfect. Many shelves in the therapeutic cupboard remain depressingly bare, and the evidence base for many drugs is patchy or skewed by fashion, industrial lobbying, and publication bias. Not surprisingly, as many as 52% of UK patients have tried an alternative medicine at some point, most commonly herbal medicine, homoeopathy, aromatherapy, massage, or reflexology.15 These options undoubtedly provide comfort for some, even if only through a placebo effect.

What’s the evidence?

However, alternative therapies must be tested as rigorously as conventional drugs, and like them must be rejected if they prove to be useless or dangerous. A recent review carried the provocative title, “How much of CAM is based on research evidence?” The answer: very little. Of 685 alternative therapies investigated through adequate clinical trials and meta-analyses, only 7% showed any evidence of efficacy, and this figure may be an overestimate.16 There is certainly no scientific basis for homoeopathy, as illustrated by the world’s most popular homoeopathic remedy, Oscillococcinum, recommended for colds and flu. The allegedly active ingredient, the viscera of the Muscovy duck, is supposedly a rich source of a bacterium that has never been shown to exist.17 One duck would provide enough material to treat every person on the planet, but unfortunately there is not enough water in the solar system to produce the “therapeutic” dilution of one part in 10200.
Contrary to propaganda, these therapies are not risk free. Various systematic reviews have attributed 121 fatalities to acupuncture, chelation therapy, and chiropractic, and 1159 adverse events, including four deaths, to the use of homoeopathy.18 19 Herbal therapies—particularly ginkgo, ginseng, kava, and St John’s wort—may interact with common conventional medicines, potentially with mild to severe consequences.20

What are we teaching our students?

These shortcomings of alternative therapies are not adequately discussed in undergraduate curricula. In a recent survey of 25 medical schools,21 one third of the 95 students who responded reported that those teaching alternative medicine failed to provide evidence of efficacy. Twenty students in the same survey indicated that their self selected research project lacked scientific rigour because the supervisor was reluctant to confront evidence against alternative therapies. Moreover, students in at least one medical school are taught about alternative therapies during their first year, before fully covering pharmacology or the principles of evidence based medicine.
In this era of evidence based medicine, it seems strange that alternative therapies should have found their way into medical curricula—especially when the undergraduate teaching programme is already overcrowded. Who has driven this change? In the UK, alternative medicine has the stamp of approval of the royal family and various celebrities. It enjoys the support of some senior doctors and the grandly named College of Medicine, which collaborates to run courses entitled “Integrating complementary medicine in everyday practice”22 in line with its objective of “promoting, fostering and advancing an integrated approach to healthcare.”23

Seductive yet utterly devoid of scientific merit

The defences against the invasion of unscientific material should centre on the UK regulator, the General Medical Council, which dictates the content and emphasis of the nation’s medical education programmes and has the power to close down medical schools that fall short of the mark. In Tomorrow’s Doctors (2009)24 the GMC’s guidance is that qualified doctors should “demonstrate awareness that many patients use complementary and alternative therapies, and awareness of the existence and range of these therapies, why patients use them, and how this might affect other types of treatment that patients are receiving.” This seems entirely reasonable, but incompatible with the GMC’s guidance, in Good Medical Practice (2013), that “in providing care you must provide effective treatments based on the best available evidence.”
In medicine, there are few concepts as seductive yet utterly devoid of scientific merit as alternative therapies. Doctors must be aware that these exist, and that they have limitations and contraindications, to help patients to make informed decisions about using them or not. Beyond this, we argue that teaching alternative medicine to medical students is illogical and a waste of time. It is unethical to indoctrinate students when they might not yet have acquired the critical skills to decide for themselves whether a particular therapy is effective, safe, and affordable. Moreover, it takes a great deal of courage for medical students—especially in their junior years—to challenge or contradict their teachers.
There is no place in the undergraduate curriculum for promoting any treatments that are not underpinned by hard evidence that they work and are acceptably safe. The GMC has appointed itself the guardian of quality and scientific rigour in medical training in the UK. It should now follow the example of Abraham Flexner and ensure that teaching about alternative medicine in UK medical schools is strictly reviewed—and removed if it does not meet the basic criteria of efficacy and safety.

Artículo completo con referencias y bibliografía aquí.

7 comentarios:

draherraizmedicoypaciente.com dijo...

Lo que está claro, es que hemos de conocerlas, para poder responder a las preguntas de nuestros pacientes con la mayor concreción posible. Y como bien dices muchos las están utilizando...

Jordi Mestres Lucero dijo...

El tema de la cuestión, como bien dices, es que nos guste o no nos van a preguntar y van a acceder a ellas, así que mejor estar informado y tener claro algunas cosas básicas, para poder recomendar o no el uso de las mismas.

Alberto Sanagustín dijo...

Es recomendable estar informado de la charlatanería, pero esta no tiene límites.

Si en las facultades tuvieran que responder a todo lo que hay en esa jungla salvaje, no habría tiempo para estudiar lo que toca.

En cuanto a lo que comentas en el vídeo acerca de la comunicación médico-paciente (o terapéutica) y de que "no se puede medir ni se podrá"...por supuesto que se puede medir, se debe medir y se mide...☺

La psicología basada en la evidencia existe.☺


AngelaN dijo...

Deberíamos conocer las charlatanerías del reiki y también las que se publican en el NEJM. Habría que aprender a pensar de manera crítica pero también acercarnos a la realidad del paciente y comprender cómo y por qué recurre a ellas.

Salvador Casado dijo...

Cuando uno tiene un problema de salud que le preocupa busca soluciones. Habitualmente averiguar si tienen o no evidencia científica no es una prioridad.

Ser un profesional sanitario purista no evitará que los ciudadanos busquen soluciones dentro o fuera del sistema.

Anónimo dijo...

Al menos este año, en primero en la U Complutense de Madrid, han hablado y debatido sobre el tema.
Supongo que dependerá del profesor...aunque al final la mayoría de los alumnos pensarán como el

Guia en estambul dijo...

en iyi medikal ürünlerburada.
usted puede comprar todo aca amtes utilizar medicamentos hay que cuidar bien y tener idea sobre la medicina que estamos utilizando