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Bravewell Puts Integrative Cart Before Science Horse

The Bravewell Collabortive is a private organization whose stated mission is to, “accelerate the adoption of integrative medicine within the health care system.” They are well-funded, and they have successfully used their money to advance their mission. They also now appear to be an effective propaganda machine, producing what they are calling a “landmark report” on the use of integrative medicine in the US. The report is indeed revealing, but perhaps not in the way Bravewell intends.

The report is simply a survey of 29 integrative centers in the US. Before presenting the major findings the report defines “integrative medicine:”

“an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual, and environmental influences that affect a person’s health. Employing a personalized strategy that considers the patient’s unique conditions, needs, and circumstances, it uses the most appropriate interventions from an array of scientific disciplines to heal illness and disease and help people regain and maintain optimum health.”

This is the standard marketing propaganda, which we have dissected many times before (so one more time won’t hurt). It is important to note that this is not a legitimate philosophy or approach to medicine, but pure marketing hype with the purpose of rebranding medical pseudoscience and quackery.  There is a growing list of terms used for this rebranding – first “alternative” or “holistic” then “complementary” now “integrative”, “personalized”, and “patient-centered.” It’s the same nonsense, only the labels have evolved (market-tested, if you will).

The report first equates integrative medicine with patient-centered medicine. This is a false dichotomy based upon a straw-man vision of science-based medicine. Medical ethics places the patient at the center of health care and all health care decisions. The physician is ethically obligated to be an advocate of their patient first and foremost.  Further, the modern (meaning in the last half-century) model of medicine is to treat the patient as a partner in their own health care (replacing the older paternalistic model).  This was a process, of course, not a sudden change.

As part of that process, and the cultural evolution of the physician-patient relationship, the term “patient-centered care” was used within the medical literature to describe this change – centering decision-making more on the patient. It was a shaking off of the last vestiges of paternalism in medicine (at least within the standard of practice, if not ideally achieved by all practitioners). The integrative movement then co-opted this term and made it their own, as if they invented it, and then ironically accused mainstream medicine (who invented the idea and the term) of not being patient-centered.  You will see this pattern repeated.

The next bit of propaganda is the description of holistic care (without using the term – I guess it’s not market-testing as well these days). This too is a fiction. In the 1980s I was taught in medical school about the biopsychosocial model of medicine – taking into account not just the biological illness but the social and cultural factors in which it is embedded, and the patient’s psychological response to their illness and the patient-physician relationship. This has been part of my training and practice from my first day in medical school. So I have always found it frustratingly odd that the integrative movement has (successfully, unfortunately) claimed that they invented this notion and that mainstream medicine is not “holistic”. We have argued on SBM (persuasively, I think) that science-based medicine is much more holistic than most “integrative” medical practices. We actually consider the patient’s biology, psychology, and social situation, whereas most alternative treatments are based upon a very narrow philosophy of all disease. They are the antithesis of holistic.

The tricky item of the integrative holistic list is “spiritual.” Mainstream medicine does consider the beliefs of the patient, and often must accommodate them in deciding on appropriate treatments. However – medical ethics dictates that we do not impose any religious belief onto our patients, neither are we judgmental. To our patients we are neutral on matters of faith, but can certainly be supportive of our patient’s use of faith as a support structure for dealing with their illness. In alternative medicine circles, however, “spiritual” can mean “faith healing” or its equivalent – actually treating the patient’s spirit or “energy”. This is not medicine – this is spiritualism and religion.

Next they throw in the “personalized” marketing term. Again, this is not a concept that is new to the integrative medicine movement. Regular science-based medicine is “individualized” (the term for what Bravewell and others now call “personalized”). The reason we take an elaborate history and perform a physical exam, followed by specific laboratory tests, is to individualize the diagnosis and treatment of each patient. There has been, in fact, a continuous evidence-based effort to more and more individualize treatments for patients, according to their age, sex, and genetic background. I often individualize treatment strategies to a patient’s educational level and socioeconomic status. This is just another false-dichotomy, another rebranding of ordinary medicine as a special feature of “integrative” medicine. It is just more marketing fiction and propaganda.

Next we get to the core fiction of integrative medicine, that it “uses the most appropriate interventions from an array of scientific disciplines.” That, of course, is a description of mainstream medicine. We use any intervention that is science-based – that has an appropriate combination of plausibility and direct evidence for safety and efficacy. Integrative medicine, rather, is the mixing of appropriate science-based interventions with treatments that are not science-based, that are highly implausible, or have been shown to not work. Otherwise they would already be part of medicine.

So what is integrative medicine? When you strip away the rebranding and co-opting of features and treatments of mainstream medicine, you are left with the usual list of pseudoscientific practices that have been trying to insert themselves into mainstream medicine for decades through a series of marketing and propaganda strategies. Bravewell has positioned itself at the forefront of that effort.

The body of the report I found to be almost entirely uninteresting and predictable – integrative centers are using integrative medicine and they feel (of course) that it works. Wow. The one bit I did find interesting was the list, in descending order, of the “integrative” methods these centers use:

• Food/Nutrition
• Supplements
• Yoga
• Meditation
• TCM/Acupuncture
• Massage
• Pharmaceutical

First we see another rebranding – calling nutrition integrative or alternative. We have pointed out numerous times on SBM that nutrition is a medical science. It is already part of mainstream medicine, and it is mainstream medical researchers who have figured out everything we currently know about the role of nutrition in health and disease. This is just one more thing that the integrative movement has tried to steal (metaphorically) from mainstream medicine to make part of its brand.

Two items on the list, supplements and TCM/acupuncture, are methods that do not work but have been the most successful in being marketed to the public. A thorough exploration of these modalities is beyond the scope of this article, but you can find numerous articles on SBM demonstrating the lack of an evidence based for the most popular herbal supplements and for acupuncture, for any indication.

Yoga, meditation, and massage are essentially exercise, stress-reduction, and  relaxation – all things commonly used and recommended by science-based practitioners. There is no evidence to support the notion that there is anything special about these particular manifestations of exercise, stress reduction, and relaxation. Most studies of Yoga, for example, have no comparison group to other forms of stretching and exercise. The implication is that there is something special or magical about transcendental meditation, for example, or Tai Chi, or specific forms of massage – again without evidence. There is no evidence that charging patients for a consultation with a specialist in one of these treatments is any more effective than just telling them to get more exercise – do something convenient and enjoyable.

About the only kernel of utility in this approach is that it may foster compliance with lifestyle changes. I say “may” because evidence is lacking for this as well. And again – there are already voices within mainstream medicine teaching a greater emphasis on patient education to foster compliance with lifestyle changes. Doctors are admittedly not very effective in changing patient behaviors, but that is because nothing is. It is very difficult to change behavior, and “integrative” practitioners have not hit upon any magical way to do so. They simply point out how bad mainstream medicine is, without acknowledging the fact that every studied method of changing lifestyle behaviors has a poor success rate. Even those that tout their success are just incrementally better than simply advising patients to quit smoking, exercise more, or lose weight.

What we need is to continue to experiment and research – to use science to figure out how to more effectively improve health behaviors in the public. Of course, if scientific research ever does develop a really effective method the integrative movement (or whatever it’s calling itself at that time) is likely to steal it and pretend that they invented it, then turn around and criticize mainstream doctors for not using it.

At the bottom of the list is pharmaceuticals. This does, perhaps, distinguish the integrative approach from some alternative approaches that are more purist in their pseudoscience. A homeopath, for example, uses only homeopathy. This appears to be a general trend with alternative practice, however. Naturopaths, for example, are fighting in many states and in Canada to get the right to prescribe actual medicine. This way they get to practice real medicine and then charge for a lot of extra stuff that is either worthless or just an expensive version of a simple healthy lifestyle. It’s quite a racket.

At the end of the report, under the category “next steps,” they write:

Providing funding for analysis of these data, which could provide important information about the efficacy of integrative medicine approaches as well as the treatment of chronic health conditions, should be a priority for funding sources and institutions.

Let me translate that for you, in the context of the whole report: Isn’t it wonderful that integrative medicine methods are being used, now let’s go see if they actually work. If there is anything that defines alternative, complementary, integrative medicine it’s putting practice before evidence. In fact, the evidence is irrelevant to practice. Practice is philosophy-based, not science-based. Evidence is an obstacle, used only for marketing purposes, not for determining which treatments are effective. That is why they keep trying to redefine scientific evidence in medicine. They need science to change to accommodate their treatments, not conform treatments to the science.

In my opinion the Bravewell Collaborative is a force for pushing pseudoscience and nonsense into mainstream medicine. This report reflects that reality.

Posted in: Science and Medicine

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25 thoughts on “Bravewell Puts Integrative Cart Before Science Horse

  1. windriven says:

    “They are well-funded…”

    What is the source of their funding?

  2. cervantes says:

    They don’t have any obvious place on their web site that discloses where their money came from, but they are what’s called an “operating foundation,” which means they are basically spending an endowment. It appears, from their history, that it comes from the George Family Foundation. I don’t know how they George’s made their money, but they appear to have plenty of it.

  3. windriven says:

    Answering my own question:

    Penny George, wife of Bill George, former CEO of Medtronic
    Christy Mack, wife of John J. Mack, former CEO of Morgan Stanley
    Blythe Brenden, Brenden Mann Foundation; think Mann’s Chinese Theatre

    A less charitable person than I might speculate that Bravewell is the product of aging trophy wives with more dollars than sense.

  4. Orac has some more details on funding: http://scienceblogs.com/insolence/2012/02/surveying_the_integrative_medicine_lands.php

    Essentially – a few wealthy and woo-friendly donors trying to promote their spiritual world-view

  5. Harriet Hall says:

    “In the 1980s I was taught in medical school about the biopsychosocial model of medicine – taking into account not just the biological illness but the social and cultural factors in which it is embedded, and the patient’s psychological response to their illness and the patient-physician relationship.”

    The tradition in mainstream scientific medicine dates back to much earlier than that. I was taught the same biopsychosocial model of medicine in medical school in the 1960s, and it was particularly emphasized in my training as a family physician. Even back in 1927, Francis Peabody argued in the JAMA for “integrating” psychosocial factors with biological factors, concluding “The secret of the care of the patient is in caring for the patient.” His essay is well worth reading today: http://cell2soul.typepad.com/files/the_care_of_the_patient-1.pdf

    I’ll repeat what I said about naturopaths: what they do that is good is not special, and what they do that is special is not good. That applies as well to all of CAM and Integrative Medicine.

  6. Jann Bellamy says:

    How sad that millions of dollars are being wasted on marketing and ineffective treatments when there so many pressing needs in U.S. health care: access to care, educating and training more primary care physicians, research, etc., etc. It’s sickening to think how many uninsured (and underinsured) people could have been treated with all of this money.

  7. Quill says:

    Yoga, meditation, and massage are essentially exercise, stress-reduction, and relaxation – all things commonly used and recommended by science-based practitioners. There is no evidence to support the notion that there is anything special about these particular manifestations of exercise, stress reduction, and relaxation.

    I don’t know about yoga and massage, but the assertion that there is “no evidence” for “anything special” about meditation is incorrect. There are a number of interesting studies that have been done. For example this one small study:

    Lutz A, Slagter HA, Rawlings NB, Francis AD, Greischar LL, Davidson RJ.
    “Mental training enhances attentional stability: neural and behavioral evidence.”
    J Neurosci. 2009 Oct 21;29(42):13418-27.

    http://www.ncbi.nlm.nih.gov/pubmed/19846729

    This is not to say that there is magical “evidence” that one can think happy thoughts and cure cancer or athlete’s foot but it is to say that current research in neuroscience has shown measurable effects of meditation. In addition, investigations into concepts such as neuroplasticity and the general shift away from viewing the brain as hard-wired support the plausible notion that a thing like meditation can do more than simply relax the body but also change brain function.

    Unfortunately in cases of people like the Bravewell group, cart-before-horse thinking turns promising new areas of research into potentially lucrative businesses whose products are sold by testimonials and often carry the ultimate imprimatur, “As Seen On TV!”

  8. Eugenie Mielczarek says:

    Many of the centers and hospitals listed by Bravewell were also funded by NIH NCCAM. The medical impact of this funding can be assessed by using NIH project reporter, checking the project proposal submitted by the institution, and reading the resulting research publications. If anyone finds a important medical breakthrough missed in our article ( Mielczarek, Engler) Measuring Mythology please let us know.

  9. A less charitable person than I might speculate that Bravewell is the product of aging trophy wives with more dollars than sense.

    I think you hit the nail on its proverbial head.

  10. Rabbit says:

    Quill:
    “the assertion that there is “no evidence” for “anything special” about meditation is incorrect. There are a number of interesting studies that have been done.”

    Indeed. So also for Yoga and many other practices. The problem, to me, is that not one such study (at least that I have been able to find) has bothered to define any of these practices operationally. What is the demonstrable difference between someone “meditating” and someone else “just sitting there”? The difference between a person “doing Tai Chi” and somebody “moving around slowly”? Between “Yoga” and “standing in a funny pose”?

    Until an empirically meaningful (not philosophical) boundary can be established between “meditation” and “sitting on a pillow,” between “acupuncture” and “sticking needles in people,” there can be no sense in discussing any evidence from studies.

  11. Quill says:

    @ Rabbit: If you click on the Pubmed link I posted and look just below the end of the abstract, you’ll find a free link to the whole paper. They do go into some detail about what kind of meditation was used and while I’d agree that it is very difficult at present to quantify different kinds of meditation it is distinct from simply sitting around all day. There are active processes involved that are not just relaxing or contemplating random thoughts and continued use of these specific processes do seem to change brain function.

    @Gorski & Atwood: perhaps yes it’s “aging trophy wives with more dollars than sense,” but I’ll guarantee you the spouses and their lawyers have a lot of sense in this matter. Why? Letting them run a business is vastly cheaper than divorce.

  12. weing says:

    Why can’t I get a loan from the fed on the same terms as those wives of those financial geniuses? Maybe the fed is becoming a zombie bank. Zombie banks only support zombie institutions and not actual ones.

  13. weing says:

    @Quill,
    Would memorizing the multiplication table change brain function?

  14. nybgrus says:

    along the lines of weing here…. yes, there is still nothing special about meditation or yoga. It is plainly understood scientific knowledge that exercise and increased flexibility (yoga) has positive health effects for myriad reasons. And that thinking and engaging your cognitive functions in a conducive environment has positive cognitive effects (meditation).

    But there is nothing special about “meditation” that isn’t similarly encapsulated by me sitting down and pondering biochemistry or simply being introspective about my day.

  15. The “changing the brain” this is also oversold. Experience changes the brain – that’s kind of the whole point of learning and memory. This study shows that practicing attention can make subjects a little better at attention – they learned to have better attention. This is not surprising, and does not imply that there is anything special about meditation as a form of relaxation. I also specifically mentioned “transcendental” meditation for a reason – there is especially no reason to assume anything special about TM from any other form of quietly reflecting.

  16. Daniel M says:

    @Quill, I suggest you read the part of Owen Flanagan’s book ‘The Bodhisattva’s Brain’ about the research into mediation and happiness. He is a philosopher of mind who has a lot of contact with the Dali Lama, and has written extensively about both mind science and Buddhism. Flanagan is extremely skeptical that the scientific research has shown anything like what the media reports about the power of meditation. He brings up a lot of interesting assumptions that the lay public wrongly makes when trying to interpret these neuroimaging studies.

  17. Quill says:

    @ Daniel M: Thanks for recommending one of Professor Flanagan’s books. I’m familiar with several and think he’s contributing mightily to emerging areas of human knowledge. Plus he writes well, always a pleasant surprise when dealing with the meeting of the physical and metaphysical. :)

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