Teaching integrated health at Barts and the London

FIH: Can you tell me how you became interested in integrated health?

Chris Fowler:  I started off as Dean for Education at Barts and The London in charge of all undergraduate education about six years ago.  Soon after I started, we had a visit from the General Medical Council. They asked us, 'do you teach complementary and alternative medicine on the course?' My answer was a blunt 'no'.  This caused some amusement and consternation among my colleagues because it was quite clear that it was a leading question from the GMC and though what I said was true, it was clear that this wasn't a diplomatic response! 

Personally, I'm not particularly sympathetic to complementary medicine - my take on it is if I thought something worked worked, I'd be prescribing it.  I am very much more taken by ‘integrated health’ and the notion that individuals have a right to make health decisions for themselves. As I've got older, it is increasingly clear to me that quite often orthodox medicine isn’t the whole answer anyway. If people can get better using something for which there isn't a particularly strong biomedical basis, I am all for it.   I also truly believe that people have the right to be told what is on offer and to make their own decisions. 

If you're going to teach people to be proper doctors working in a health service that truly values patient choice, then even those doctors who are not alternative therapy fans need to have strategies that reconcile their beliefs with the needs of the patient.   And I also think that sometimes you need to protect the patient from involvement in things that are exploitative or dangerous - you only have to look in the paper to see people offering dubious therapies.

FIH: ... which can cost money

Chris Fowler:  Yes, quite a lot of money changes hands, and sick people are vulnerable.  As a doctor, you have a duty to protect people from harm. 

FIH: And if you have no idea what these therapies are, you can't make judgments.

Chris Fowler:  Yes, and I think it's very important for doctors to be informed of the sort of choices that patients are making.  For one thing, people quite often don't take what you prescribe them anyway - many tablets just sit in bathroom cupboards.   So having started from writing 'no' on the GMC's form, I am now convinced that our course must include both an understanding of the sorts of things that patients are exposed to, as well as coping strategies for the doctor to deal with what can be sometimes perceived as a threat.  If your patient tells you that they are relying on a therapy that you don’t personally believe in, how should you respond?

FIH: If indeed your patients tell you about it at all...

Chris Fowler: The other question is how much you should intrude. You might find yourself sowing doubt in a way that is actually unhelpful to the patient.

FIH: What's the reaction within Barts and The London to these issues?

Chris Fowler: There's still difficulty within medical schools in dealing with these matters.  We recently had a proposal that we should have a course related to homeopathic medicine. The suggestion was not acceptable to the School because the topic was deemed to be unscientific and without an evidence base.  A cynic might say that if you dismiss things because they have no evidence base, then you have to dismiss many things that we do in orthodox medicine as well. However, we are a Medical School with a very high scientific reputation and we have to protect that.

I have to be careful within the medical school that I promote the concept of integrated health tactfully, because there's a counter-tension of people saying we should be teaching more anatomy and physiology and that we actually want our medical graduates to be medical scientists.

FIH: What made you want to get involved with FIH?

Chris Fowler: The reason I was interested in the Foundation for Integrated Health was the fact that although it encompasses some of the things we've just been talking about, the Foundation is also thinking about integrated health in terms of lifestyle choices, in terms of environments and the impact of the way you conduct yourself on your health. One of the things that doctors are not so good at, and ought to be better at, is facilitating healthier living in general.

FIH: Is there a sense that an integrated health model puts too much pressure on doctors - that they have to become universal social workers dealing with multiple facets - and writing up their notes - all in ten minutes?

Chris Fowler:  There is some truth in that. Recently there's been an Inquiry into the problems with the Modernising Medical Careers system, which left some junior doctors struggling to apply for jobs using a new process.  Interestingly, one of the questions that the report of the Inquiry throws up is: what do we want from doctors?  

The modern doctor ought to be an educationalist, because increasingly patients have access to the same information that you have.  When I had a nasty rash I went to look it up on the internet - I didn't find exactly what it was, but I got quite close!  What you need as an informed patient is someone to interpret the information and act as a knowledge manager - someone who puts things into perspective and engages with you and the information.   Doctors can’t pretend to hold all the answers any more, but they should still be able to give a balanced opinion about the choices on offer. This doesn't necessarily fit very well the way that doctors have been educated in the past, when the emphasis was on accumulating biomedical knowledge. 

FIH: Mark, can you tell us something about how complementary approaches have been taught at Barts to date?

Mark Carroll:  I offer a course on a number of complementary therapies, not so much focusing on the therapies themselves, but looking at the evidence about whether they work. Working with the Foundation on these subjects, and the health and wellbeing angle, seemed like a good opportunity to organise the whole subject.  In the past we’d dealt with this area in a rather  uncoordinated way.

FIH: How do students respond to the course?

Mark Carroll: The range of responses isn’t so wide because it’s an optional course.  Students generally come to it because they have an interest. A few come because they couldn’t get their first choice and they can be a bit grumpy. But on the whole I see the positive ones.

FIH: Would you say the School’s proposal was groundbreaking?

Mark Carroll: Not groundbreaking as such - there are other medical schools thinking this way.  What's original about this project is that we're joining disparate ideas together into a coherent whole. I don't think that's been done before.

FIH: How do you see your integrated health curriculum developing in the next few years?

Chris Fowler: I’d like it to be a mainstream, compulsory part of the programme. I think it’s good that the students who are interested can do it, but all doctors need to know what their patients are experiencing and help them to interpret what is on offer. If doctors understand complementary alternatives, they will be better placed to help people to avoid missing out on things that might do them good or conversely prevent them being exploited. 

One of the most important things is for doctors to have strategies for dealing with quite challenging situations - patients saying 'I don’t want to carry on having chemotherapy, I want to take x,y or z alternative' - whatever it is. How do you respond to that?

We need to set objectives for the course that are well defined and strong.  I want students to think 'This makes real sense'. We’re saying, if you do this, you will achieve better outcomes and you’ll be a better doctor. If we can appeal to even the most biotechnical medical student, then that would be a big step forward. We want to give them enough information and understanding so that students can say 'I’ve done the integrated health module and I now know those things.'

FIH: Can I talk to you about multi-culturalism... many people coming to a doctor don’t think their health practices are ‘alternative’, they are just doing what their mum did or grandma did in their ancestral country. 

Chris Fowler: We do have a diverse group of students, and a diverse local population. The teaching staff is less diverse. I don’t think we’ve really taken on board the variety of health experiences and health backgrounds that our students and local people have. I think it's an important aspect of integrated health that we should take account of. If we’re training doctors to work in East London it would be useful for them to have a breadth of understanding the approach to health in other cultures.

Mark Carroll: Many complementary therapies derive from South East Asia. There was a lot of scepticism initially about whether the evidence for acupuncture stood up.  Biomedical scientists pooh-poohed it because you can't find meridians in the body.  But now there are controlled trials that show it can have an effect under some conditions.

Chris Fowler:  The reality of life is dealing with uncertainties and intellectual tensions. Many options do appear to produce benefits, but they are at odds with standard biotechnical concepts and are unsupported by evidence.  That's intellectually tricky to handle.  If we want to place more emphasis on choice, inclusivity and lifestyle interventions sometimes without an evidence base, how can that be reconciled with the fact that we’re a top medical school with a high scientific reputation?

If you’re trying to create wise doctors as well as clever ones, they need to realise there’s more to life than we thoroughly understand. Before the middle of the nineteenth century - perhaps before the beginning of the twentieth - almost all health interventions by orthodox doctors were mumbo jumbo and ill people still got better. And they got better for a variety of reasons. I think that people who don't understand that are not wise doctors. I’m not suggesting that we should go back to pre-scientific medicine, but there is evidence that there is more to being a good healer than meets the eye!