Here we will continue our series of articles explaining common terms you need to know for your Medicine interview. This series will also be useful even if you have received an offer from your chosen medical school in order to increase your knowledge base about the world of Medicine both before you start medical school and whilst studying at medical school.
In this article we will discuss what is meant by complementary and alternative medicine (CAM). We also discuss some vital concepts about the principles of modern medicine including introducing the recent concept of evidence based medicine. We explain the role of NICE. You should know about these principles for your Medical school interview and it is essential knowledge beyond this also. Patients may ask you on what basis are you recommending a treatment to them or what you think about them trying a particular CAM. Also this is a common scenario in OSCES which are a type of exam you will have whilst in medical school and as a doctor. Most medical schools have OSCES right from the first year. OSCES are very similar in set up to an MMI interview with multiple stations which include real and simulated patients i.e. actors and even high tech interactive models/robots which cost a fortune!
What is conventional Medicine?
As a simple explanation, think of conventional medical practice as being based on scientific and empirical reasoning. This reasoning can come from empirical data, research, clinical trials, studies, experiments, clinical experience, expert opinion etc. A vast amount of things in conventional medical practice are not yet fully understood or even known about but they are considered with a scientific approach. This is discussed later in this article.
What is complementary and alternative medicine (CAM)?
There is no universally agreed upon definition of CAM. A widely held definition is practices which fall outside the category of conventional medical practice. Individual CAMs may have no evidence at all on their effectiveness or have limited evidence. CAM is not the same as “quackery” which is the deliberate promotion and practice of dishonest or ignorant medical practices although some practices fall into quackery. The terms complementary and alternative are typically used as one category although some people make a distinction between the two by classifying:
Complementary Medicine – practices used alongside conventional medical practice. e.g. acupuncture for back pain in addition to conventional practices such physiotherapy and medication.
Alternative Medicine – practices used instead of conventional medical practice e.g. using a specific diet to treat cancer instead of conventional treatments for cancer e.g. chemotherapy drugs, radiotherapy etc.
Common examples of CAM include:
- Homeopathy
- Herbal medicines
- Acupuncture
- Reflexology
- Osteopathy
NICE and recommendation of CAM for the NHS
CAM is rarely offered in the NHS and only in limited settings based on NICE (National Institute for Health and Care Excellence) recommendations. You should know about the role of NICE for your medicine interview. In the UK, NICE gives guidance on healthcare including which treatments should be available on the NHS. NICE considers effectiveness, evidence, safety, practicality, ethics and cost to produce guidance on which treatments should be offered on the NHS.
NICE produces national guidelines to try and make practice more fair and standardised across different parts of the country. This lessens the effect of the “post code lottery” whereby what treatment you receive varies wildly simply based on where you live. As funding is a finite resource and Medicine is a scientific discipline, if you combine these two ideals, it stands to reason that NICE will aim to recommend funding cost effective treatments with good evidence. NICE have recommended CAMS in a limited range of settings where there is some evidence. For example ginger to reduce morning sickness, the Alexander Technique in Parkinson’s disease (a movement disorder), or considering acupuncture for certain conditions.
Unusual does not mean CAM
The reason that CAM is not part of conventional medicine is due to its limited evidence base. It is not because these things may appear unusual. Conventional medicine is anything but usual. Some of the cornerstones of modern medicine when thought about actually sound outrageous. For example the idea of inserting needles into babies and pumping them with live viruses to prevent them from ever becoming ill from those viruses sounds bizarre at best but this is the idea behind vaccinations. The idea of giving people with infections products actually created from bacteria, moulds, soils, animals, plants, sea life etc. to treat their infections sounds like something a witch doctor might do but this is what antibiotics and many other medications are. Live maggots can be used to clean out wounds. The concept of cutting people open with knives and doing things to their body is in essence surgery. Not to mention that you first make patients unconscious by giving them noxious gases to inhale (i.e. general anaesthetic) and then paralyse their bodies so they can’t move by injecting them with chemicals (i.e. muscle relaxants) which can also be used as poisons.
Evidence based medicine
The point from the above examples is that conventional Medicine can be strange but is based on scientific evidence and empirical reasoning. If something can be proven using robust, fair, repeatable evidence then modern medicine should have no issue in accepting its validity regardless of how bizarre the concept may be. Evidence is required before things can be accepted or a claim made even if the claim may appear obvious. “Evidence based medicine” a term you will hear a lot of as a medical student or if you read journals, takes this further. It considers how strong that evidence is. For example a meta-analysis which looks at the results of many different studies and draws conclusions based on these studies is better quality evidence than the conclusions drawn from the results of only one study. The results of a large study of many people is better quality evidence then just a single case study about one patient or the opinion of an expert etc.
So what is Evidence based Medicine? You may be asked if you have heard of it in your Medicine interview. Evidence based Medicine tries to advocate that as best as possible knowledge and decisions should be based on evidence and in combination with medical expertise and judgement and not just from the opinions, beliefs and traditions of experts, practitioners etc.
Evidence based medicine in action
To claim something works because “it makes a lot of sense that it should work”; “people including experts have done it for centuries”; “it has worked on loads of people I know”; “you can’t disprove it so until someone can we should just accept it” is not enough. It is not a scientific approach. For example it sounds very reasonable to give people experiencing a heart attack high flow oxygen. After all the heart attack is causing damage to the heart by depriving it of oxygen. Also giving people oxygen often makes them visibly look and feel better and improves their vital signs. Surely it must be better to give them oxygen and at the very least it isn’t harmful, right? This is why it was common practice for health practitioners for so long, further adding to its credibility, right? In fact, research and also real life data from studies has shown that it can actually be harmful to routinely administer high flow oxygen except in certain situations. This is because excessive oxygen actually increases the resistance in tiny cardiac blood vessels and causes free radical damage leading to something called a reperfusion injury. As a result international guidelines on managing heart attacks have updated their guidance and no longer recommend its routine use except in certain situations.
This is also an example of evidence based medicine in action to actually produce treatment guidelines based on evidence instead of relying on the common or traditional practices of healthcare professionals. In this case the evidence is scientific research to explain why oxygen has this effect. Additionally, the results of individual studies looking into outcomes after using different treatment options and also bigger meta-analysis studies which put together results of many individual studies and drew conclusions from this combination. This is far better quality evidence than just the opinion of one person or institution even if that person was a world leading cardiologist.
Natural does not mean safe
Cyanide is natural. It is also used as a poison and is lethal. Just because a particular CAM can be called natural this should not be mistaken as automatically meaning it is safe. Many CAM treatments involve plants and herbs. Many of them have no harmful side effects if used correctly. However, many of them can be harmful or even lethal. Many interact with conventional prescribed medications. A common example is St Johns Wort which is a very common herbal supplement. You can buy it in a supermarket. It can cause serious adverse effects if the person is also taking certain very common medications at the same time. Additionally CAM practices have often not been widely researched or practiced so there may be harmful effects or interactions that are not known about. It is a common misconception that because something is herbal it is safe. Herbal medications have not gone through the strict clinical trials process that conventional medicines undergo, a process which can cost billions of pounds and take decades before a drug is deemed safe for release and has evidence for its effectiveness.
What do I need to know about CAMS for my Medicine interview?
For your Medicine interview you should know that modern Medicine is based on scientific evidence and empirical data and what Evidence based medicine is in a nutshell. In Oxbridge Medicine interviews more so than non-Oxbridge medicine interviews you will face scientific questions and even unusual questions such as how much do mountains weigh? How can we prove air exists? You don’t necessarily need to know the answer (often you can’t know the answer), you simply need to be able demonstrate a logical thought process and it helps if you know the basics of how science comes to conclusions and how things must be proven.
For your Medicine interview you also need to know what NICE is and how they decide what treatments should be available on the NHS. You need to understand why NICE would not suggest something just because it sounds like it would work or is a good idea because it needs evidence, expert opinion and data to make these recommendations.
Doctors need to have empathy and respect patient’s wishes. Patients of sound mind can make an informed decision to decline any treatment for any reason. They do not have to accept a conventional medical treatment if they do not want to. This falls under the ethical principle of autonomy (see our article on the four pillars of ethics as this is essential for you to know for your UKCAT and your interview). You may see an example of a doctor patient consultation in a MMI medicine interview station. You may see bad practices such as not listening to patient’s views, or not respecting their autonomy for example by insisting they take a certain treatment. Patients can choose to make their preference known on requesting treatments, however, they cannot legally demand a treatment from a doctor if a doctor does not think it is appropriate. A common scenario is someone who thinks they need antibiotics but the doctor does not think it is indicated. This applies to any form of treatment even a lifesaving surgery or lifesaving CPR for example. Good communication skills and knowledge about ethics will help ensure that doctors and patients work together for the best possible outcome.
Summary
A lot of information has been presented here. Do you understand the essence of the subject? Could you summarise what evidence based medicine is in one or two sentences? How about NICE in two sentences? For your Medicine interview preparation this should first be your focus instead of trying to memorise every last detail. After you know the basics for multiple topics then you can start to revisit them all in even more details. Read the summary below to help you.
This article in a nutshell:
CAM are practices which fall outside of conventional medical practice. They are used alongside conventional medicine or instead of it. They have either no evidence or limited evidence for their effectiveness. The classification is nothing to do with them appearing strange or unusual as modern medical practice is often very strange as well. It is do with levels of evidence and acceptance as conventional practice. Some CAM may be classified as “natural” but by no means does this mean they are always safe. The NHS offer a few types of CAM in limited settings based on NICE recommendations. NICE are the body that give national guidance on healthcare in the UK.
Evidence based Medicine tries to advocate that as best as possible knowledge and decisions should be based on evidence and in combination with medical expertise and judgement and not just from the opinions, beliefs and traditions of experts, practitioners etc. There are different levels of evidence. For example a meta-analysis of multiple studies being of a higher level than the opinion of one expert.
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