Unwelcome complements

It is the start of term and the teaching clinic for complementary therapies at the University of Westminster in central London is gearing up for another busy year.

The so-called "polyclinic" offers inexpensive treatments in 11 therapies to the public. For £20 a session you can choose from a menu ranging from homoeopathy to acupuncture to craniosacral therapy.

It will soon be humming with life as students of all years begin observing or administering the therapies under the tuition of the 70 or so practising academic staff and tutors.

The clinical experience - students must clock up 500 hours - is a major component of all the BSc honours degrees in complementary and alternative medicine (CAM) offered by the university. Westminster offers the largest number of science degrees among the 40 BSc and BSc (honours) in complementary medicine available at 14 UK universities.

Some other universities also have teaching clinics, but the size of Westminster's ten-room facility, currently in its tenth year of operation, is truly impressive.

It is overseen by David Peters, clinical director of the School of Integrated Health, which runs the degrees out of its department of complementary therapies. The courses are flourishing, he says, despite recent controversy about CAM, which included a staff rebellion at the University of Central Lancashire over plans to introduce new science degrees in acupuncture and Chinese herbal medicine.

Books published this year aimed at exposing "bogus" therapies have also received wide publicity. They include Trick or Treatment? Alternative Medicine on Trial co-written by Edzard Ernst, who holds the Laing Chair in Complementary Medicine at the Peninsula Medical School at the University of Exeter, and who describes himself as an "evaluator" of CAM. Ben Goldacre, national newspaper columnist and author of the recently published book Bad Science, who also runs a website of the same name, has addressed the issue in similarly negative terms. But the critics do not seem to put students off.

Student numbers
Year	Students studying CAM	Students studying chemistry
2002-03	2,985	19,015
2003-04	4,000	18,525
2004-05	5,685	18,520
2005-06	6,805	18,375
2006-07	6,765	19,585
Source: Higher Education Statistics Agency

"We thought with all the publicity we would not do so well, but it has been a very good year. We are over target with 180 first-year students, and we have the second-highest employability rate in the university," Peters says.

Meanwhile, less than a mile down the road - but a world away from CAM - is an academic unlikely to pay a visit to the polyclinic. David Colquhoun, professor of pharmacology at University College London, is among those at the forefront of a growing campaign of opposition to what critics call "pseudo-science degrees" on the grounds that the vast majority are not based on empirical evidence.

Colquhoun calls it "quite incredible" that the subjects are being taught in universities, and the labels of BSc and MSc for such degrees are, he says, "particularly offensive".

With the focus on training CAM practitioners rather than producing critical thinkers, students are also being taught "gobbledegook" mechanisms to explain their therapies that have "no plausible scientific basis", he says. Colquhoun campaigns, he says, because he believes it is "worth it" to defend what universities should be doing, and adds that many scientists share his view.

"No respectable university should provide a course that preaches the mumbo-jumbo of meridians, energy flows and Qi (the principles on which acupuncture is based) as though they were science," he argues.

Colquhoun is shortly expecting a ruling from the Information Commissioner on whether he can have access to teaching materials used by one institution. If he is successful, they will doubtless appear on the blog he runs, which aims both to expose the degrees to public ridicule and enlighten vice-chancellors, who he believes are so busy seeing the courses as cash cows that they are not aware of the content of the degrees being taught at their institutions.

Colquhoun suggests that the rise of the therapies and the courses is a wider problem for society in general: the "denial of rationality" and "betrayal" of 18th-century Enlightenment values. It is a controversial argument articulated in a number of books and is based on the belief that society is witnessing a retreat from the rationalist legacy bequeathed by the Enlightenment.

Whether or not this is true, it is certainly the case that since the 1980s CAM - the collection of therapies emphasising a holistic approach to healthcare that are not presently considered part of conventional diagnosis and treatment - has been growing in popularity.

Cam course student acceptance
Year	Number
2002-03	353
2003-04	384
2004-05	487
2005-06	612
2006-07	846
2007-08	960
Source: Universities and Colleges Admissions Service

It is estimated that 20 per cent of people in the UK access CAM regularly, spending about £1.6 billion annually. As use has grown, so too have student numbers, more than doubling over the past five years. In 2006-07 about 7,000 students were enrolled on CAM courses at university level. In the past academic year, 960 students accepted places on CAM degree courses through the UK Universities and Colleges Admissions Service.

Around the time his book was launched, Ernst gave a demonstration on homoeopathic medicine to the media during which he showed how a homoeopathic remedy for insomnia was made. Following the homoeopathic principle of "like cures like" and "small doses", he pipetted a drop of coffee into water and diluted it again and again. His point: that "the plausibility of homoeopathy is zero".

Ernst says the debate is characterised by beliefs held with an almost religious conviction, with "believers" in both alternative and anti-alternative medicine camps. He stresses that although he is seen by CAM supporters as the latter, he is neither, and wants only to talk facts.

He does not object to vocational training in the subjects to ensure that patients come to no harm, but his view is that the degrees have no place in universities. "(Their) basis is not academic, the mode of action is almost certainly wrong ... (and) if there is the evidence I think it belongs in medicine," he explains.

It is understandable, given the adverse publicity, that academics delivering the subjects feel under siege, although vitriolic and personal attacks, along with speculation about financial motives, come from both sides in the wider debate on CAM.

Peters, along with Brian Isbell, head of Westminster's department of complementary therapies, explains that they have spent the past 25 and 15 years, respectively, building up their school.

The recent history of CAM in universities begins in the mid-1980s, with a centre at the University of Exeter. This, however, folded in the early 1990s, with Westminster taking up the mantle in 1993 and others following suit.

Peters does not see complementary medicine - at least in the context Westminster is looking at it - as part of the "great tsunami of irrationalism about to sweep the world".

"There is bound to be a bit of a turning point (after years of positive publicity), but I think we have felt very unfairly criticised. It is a bit of nerve that those who have never touched a patient in their life think they can comment on what clinical practice is and isn't OK."

Tim Duerden, co-programme leader of complementary medicine and health sciences at the University of Salford, is another CAM academic who feels that the debate is steeped in double standards. He questions why CAM degrees are being attacked when science degrees are also available in sociology, psychology and economics. "If CAM is not appropriate for a BSc then so many other areas aren't appropriate," he points out.

Duerden sees the situation as "very much a rehearsal" of arguments those subjects went through decades ago before it was concluded that a BSc could be about phenomena that were "socially or psychologically measurable" rather than just "physically measurable".

The point, say the CAM academics, is that they are producing quality practitioners conversant in both conventional and alternative models of healthcare at a time when health services - inundated with people with chronic conditions - need it most, and more people than ever are accessing CAM. Courses, they say, aim to ensure a high quality of care in the National Health Service and by private practitioners. How can you improve scientific research into CAM if therapists aren't being educated?

Compared with a purely vocational education, universities offering courses in CAM produce graduates that are "research-aware" and "research-minded", they argue. Strikingly, most of the courses are taught at post-1992 universities, which have traditionally been less research-focused.

The arguments for teaching CAM resonate with Michael Pittilo, vice-chancellor of The Robert Gordon University and a trustee of The Prince's Foundation for Integrated Health.

Pittilo argues that the "significant body of knowledge" that surrounds CAM makes it appropriate for study at degree level. "It could be argued that some of that is mythical, that the body of knowledge is wrong in its relationship to science but ... that does not mean it is not worthy of study."

He believes that the amount of science on offer in the degrees should determine their label. "If there is a significant amount of science - 60 per cent of CAM is hard science - then I have no problems. I cannot see why that and more traditional systems could not be taught side by side."

Pittilo believes that the anti-CAM campaign is preventing the development of valuable programmes. As chair of a Department of Health steering group on statutory regulation of practitioners of acupuncture, herbal medicine, traditional Chinese medicine and other traditional medicine systems, he called for an honours bachelors degree to be the threshold entry for inclusion on the register of therapists.

The Government had indicated earlier that it wanted to regulate the fields to make them safer, as it does for osteopathy and chiropractic. Science degrees would thereby be at the heart of the professions.

To see CAM acquire a veneer of respectability by means of state endorsement is a sensitive issue for those who oppose the degrees. The controversy seems set to ignite again with the Government announcement that it is reconsidering whether or not to press ahead with statutory regulation.

Ultimately, however, the debate comes down to whether CAM works. And here the believers and non-believers seem irreconcilably divided (see below).

Peters and Isbell say that there are "clinical phenomena" that seem to be "useful in real practice", even if effects do not show up in conventional scientific trials. "Something is certainly going on, and we think universities are the place to find out (what)," Peters says.

He agrees that if, indeed, CAM turned out to be "pure placebo - and there is a debate about what placebo is" - the subjects would not be fit to be taught as science degrees.

In their favour, the courses do seem to contain a large amount of science. For example, in addition to their training as practitioners, students on Westminster's three-year BSc honours courses undertake a minimum of five health science subjects, including anatomy and physiology, as well as a research project.

Duerden says Salford's courses also contain a large science component. He argues that the "very variable" evidence base for CAM makes it ideal to really test students' critical thinking. He adds that sociology and the philosophy of science are also included, which means that students are more able to function as "critical advocates" of the scientific model.

But, critics argue, it is when the courses start to stray into the teaching of practice that the "mumbo-jumbo" sets in. Science and the practice of the therapies collide.

"You cannot have degrees in things unless you have some evidence that they work. The evidence has to come before degrees, not afterwards," Colquhoun says.

Colquhoun points to teaching material he has obtained to make his case against CAM being on the curriculum. The PowerPoint slides for a University of Westminster lecture on "energy/vibrational medicine" set out how to diagnose using "energy testing", a "pendulum or dowsing rod" and even "intuition".

Slides used in a homoeopathy lecture also at Westminster, obtained by Times Higher Education, cover the subject of "spider remedies", where extracts derived from different types of spider appear to be used to treat different temperaments and conditions.

Isbell says it is "invalid" to sample one lecture from a course and draw conclusions. He says that several homoeopathic remedies are derived from spiders and may be prescribed for patients displaying a range of different symptoms. But, as with all CAM taught at Westminster, training is also given so that practitioners recognise symptoms they cannot treat and can refer a patient to a doctor.

Of the "energy/vibrational medicine" presentation, he says that the content is designed to "introduce" the students to some of the models that come up in CAM. "It would be an injustice to our students if they graduated and didn't know the vocabulary that could be used by a patient."

Duerden describes the explanations of CAM modes of action using energy flows as "metaphorical". Peters believes that practitioners do feel something "which sometimes feels tingly and energetic" but that it would be "absolutely wrong" to teach that this was "concrete reality". "Qi and healing energy are a way of short-handing certain kinds of experience," he says.

So how do students reconcile the conflicting models they are taught? Lisa Sherman is a graduate of Westminster's BSc in acupuncture. Completing her studies in 2006, she now has a CAM practice in Islington, north London, with two other graduates from her year; she also works at Hammersmith Hospital. She has a degree in molecular biology from King's College London.

She says sometimes her work is about integrating the different models of conventional and complementary medicine and at others it is about holding paradoxical beliefs. She likens it to the behaviour of light that, according to physics, can act as both waves and particles. "One works better sometimes and the other works better at other times," she says, arguing that both are "internally logical" and can be used to diagnose and successfully treat illness.

But concerns persist about the content of courses, even from those inside the CAM discipline. One lecturer, speaking on condition of anonymity, says he has seen practices such as the "tasting" of herbal medicine to determine whether it can treat illness, the use of pendulums to diagnose symptoms and even students being encouraged to treat cancer by using CAMs - despite it being illegal to claim CAM can treat cancer under the terms of the Cancer Act 1939.

He explains that the basic problem is that although students may be taught a core of medical science in the early years, it is then separated from the teaching of the CAM therapies and clinical work by a "massive damp-proof course".

"Once it has been studied and passed it is effectively dropped. There is almost nothing scientific in the teaching beyond the core modules. Lecturers in the complementary therapies rarely refer back to them and, students say, actively block discussion.

"And you can see why. It puts the mumbo-jumbo into total contradiction ... They get into clinic and they can do whatever they like. Diagnosing and treating are often based on pure fancy."

He says many students, like their practising lecturers, are also quick to shrug off their science. "It is the easiest thing to do when the subject is not only hard intellectual work but also challenges your own prejudices.

"Most students come into the courses thinking they are 'healers' and want to get into the clinic ... This is romantic medicine for people who don't want to do the hard work of learning how to think critically."

So why, then, do the courses persist? Colquhoun believes there is almost certainly a "bums-on-seats" financial interest, which is undoubtedly a factor, although it also seems to be driven by those keen to develop the specialism.

He is also critical of the "utterly vacuous" validation processes courses go through. The quality of all UK university courses is regulated by the Quality Assurance Agency, but it does not judge content, he explains. Rather, universities' committees of experts who "believe the same baloney" approve them. He agrees that the QAA should not dictate what is taught, but the "badges of respectability" it gives make a mockery of the situation.

Others, including Pittilo, disagree. He says: "Provided that there is a proper system of bringing in vigorous peer review - and that should not just include people from the discipline - then I think (the system) works very well."

As to the way forward, perhaps there is some middle ground. Although Ernst believes homoeopathy has had its day, he advocates more research into CAM to identify worthwhile interventions. The problem, he says, is that CAM research is not a priority for major funders.

A professor of nursing at the University of Sheffield could perhaps have an answer. Roger Watson describes how his views on CAM have "changed over the years". At one time, he considered all CAM to be "nonsense", but now sees a "growing body of evidence for a very few, selected, therapies".

He does not think that there should be stand-alone degrees in CAM, but he supports a general science degree in complementary therapies that would take in acupuncture but cast out homoeopathy.

Meanwhile, back at Westminster, Peters is contemplating the future. The new vice-chancellor has announced that the School of Integrated Health is to merge with the School of Biosciences as part of a streamlining plan.

Rumour has it that there has been a near-riot among Biosciences School staff, who want no association with the "unscientific" subjects. Peters admits it will be a challenging time. "It is going to mean we get into closer conversations than maybe we have had so far," he says.

Course providers
The 14 UK universities that offer BSc or BSc (honours) degrees in CAM
University	No of BSc/BSc honours degrees	Subjects
Anglia Ruskin	2	Complementary medicine (aromatherapy); complementary medicine (reflexology)
University of Wales Institute, Cardiff	1	Complementary therapies
Central Lancashire	4	Acupuncture; complementary medicine; herbal medicine; homoeopathic medicine
East London	2	Complementary therapy; complementary therapy (extended)
Greenwich	2	Complementary therapies; health sciences for complementary therapies
Leeds Metropolitan	1	Complementary therapies
Lincoln	2	Acupuncture; herbal medicine
Middlesex	4	Complementary health sciences; complementary health sciences (Ayurveda); herbal medicine; traditional Chinese medicine
Napier University, Edinburgh	3 (see notes)	Complementary healthcare (aromatherapy); complementary healthcare (reflexology); herbal medicine
Glyndwr	2	Chinese medicine; complementary medicine practice
Salford	4	Complementary medicine and health sciences; complementary therapy in practice (top up); counselling and complementary medicine; traditional Chinese medicine (acupuncture)
Thames Valley	1	Complementary medicine in healthcare
Westminster	11	Chinese medicine: acupuncture (with foundation degree); health sciences (either with or without a foundation degree) in complementary therapies, herbal medicine, homoeopathy, naturopathy and nutritional therapy
Wolverhampton	1	Complementary therapies
TOTAL	40
Source: Ucas list of 63 courses for “complementary medicine” including 40 BSc or BSc (honours) degrees offered by 14 universities
All degrees are BSc (honours) except in the case of Napier University, which offers all degrees at ordinary level and only herbal medicine at honours level.
The University of Derby offers a BA (honours) in complementary therapies.
Many universities also offer foundation degrees in complementary therapies, which are not listed in this table.

CAN CAM CONVINCE THE SCEPTICS? LEADING THERAPIES AND THEIR KNOWN EFFICACY

Aromatherapy: Plant essences used for therapeutic purposes, usually with massage. May improve quality of life for cancer patients and is likely to have a positive effect on anxiety and back pain, but no compelling evidence for use on any other medical complaint.

Acupuncture: Insertion of needles into the skin at special sites, known as points, for therapeutic or preventative purposes. Beneficial for nausea and vomiting, neck pain and osteoarthritis of the knee.

Herbal medicine: Medicinal use of preparations made from mixtures of plant material. Different from phytomedicine practised in many European countries, which is integrated into conventional medicine and where a doctor or pharmacist prescribes a single herb known to be effective for a particular condition. A number of herbal extracts are thought to be effective for various conditions, although traditional herbalists' practice of using individualised mixtures is not supported by good evidence. The risk-benefit balance has to be assessed individually for each herbal preparation, and many are untested.

Homoeopathy: Therapeutic method using highly diluted preparations of substances. Its two main axioms are the "like cures like" principle - a remedy that causes a certain symptom in healthy people can be used to treat such symptoms in patients - and the notion that, by serial dilution, a remedy does not get less but more effective. The evidence of effectiveness is encouraging for chronic fatigue syndrome only. For all other conditions, it is either ineffective, unlikely to be beneficial or has unknown effectiveness.

Reflexology: Treatment employing manual pressure to specific areas of the body, usually feet, which are thought to correspond to internal organs. The effectiveness remains unproven for any indication.

Traditional Chinese medicine: Based on complex philosophical theories, where disease is regarded as a result of blockage of vital energy. It is an umbrella term for approaches developed in ancient China, including acupuncture and Chinese herbal medicine. As a whole system, TCM has not been adequately tested for efficacy and may involve serious risks.

Source: Oxford Handbook of Complementary Medicine by Edzard Ernst and others, 2008

ON THE EVIDENCE: CAM DEFENDERS FIGHT BACK

Critics of complementary and alternative medicine (CAM) argue that based on randomised controlled trials (RCTs) - the gold standard of evidence-based conventional medicine - much CAM simply does not work for almost all the conditions it claims to treat.

Defenders of the degrees fight back. Firstly, they say that some CAM does show positive effects, over and above placebo effects, and the criteria for meta-analyses (when results of several RCTs are combined) can be biased.

But they also argue that it is utterly inappropriate to use the "lens" of conventional medicine to test CAM because it does not capture the way the therapy is practised.

Homoeopathic remedies, for example, are prescribed on an individual basis so conventional clinical trials cannot test them. Added to this are arguments that science is only one way of looking at the world and that the conventional model still has much to learn.

Those defending CAM also claim that the mechanisms ascribed to particular therapies have scientifically observable effects. Traditional acupuncture points have lower skin resistance, auras can be related to electromagnetic fields around the body and homoeopathy can be explained in terms of the "memory" of water, they say.

Scientists argue that there is no evidence for these claims, and that RCTs can easily be designed to take account of CAM's idiosyncrasies.