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CAM on campus: Integrative Medicine

My previous posts have described guest lecturers at my medical school campus, invited by a student interest group in CAM. Those events continue; currently ongoing is an 8-weekend certification course in Ayurveda for the subsidized cost of $1500 (includes “tuition, syllabus, and personal guru”). I could pick on this student group, but what’s the point? There will always be medical students who organize to promote ideas that you or I disagree with, whether it be political, religious, or personal. The fact that Tim Kreider disagrees with a particular student group is not terribly interesting.

The more important issue is how CAM is treated by faculty in the curriculum. Particularly during the preclinical years, medical students are in the habit of transcribing and commiting to memory everything uttered by the professors who grade them. A lack of rigorous skepticism is frankly necessary given how much information we are required to master. Where would CAM fit in among the lectures on anatomy, physiology, and pathology?

This post describes a lecture to the first-year medical students given by a respected faculty member and high-ranking administrator at my university, whom I will call Dr. P. This lecture was a mandatory part of the core curriculum. Dr. P comes across as an intelligent, reasonable, sincere, caring, and competent physician. It just so happens that he reaches some very different conclusions on questions of CAM than do I and my role models on this blog, and these conclusions have led him to become director of CAM programs at my university and a major player in the integrative medicine movement nationally. This post and my next will attempt to summarize how Dr. P presents his message when he has an entire medical school class for an audience.

[A note on my anonymization of Dr. P: my goal in writing for SBM has never been to bring bad publicity to my medical school, which is a terrific institution in most ways that matter to me. Identifying Dr. P would make my university affiliation obvious. I write not to call out a particular professor or program or university but rather to illustrate from a student's perspective a situation that may be increasingly common at US medical schools. Feel free to criticize my decision to keep him anonymous for now, but please honor it by not naming him in the comments, if you know his identity.] 

Dr. P stressed throughout his lecture that he is not trying to advocate specifically for CAM use. In fact, he dislikes the label “alternative” because it implies abandoning “conventional” medicine. Instead he is promoting “integrative medicine” (IM), which he described as “the practice of medicine that reaffirms the importance of relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health.” (quoted by him from a consortium of IM programs) This definition by itself sounds eminently reasonable and completely consistent with everything we are taught about compassionate, professional, evidence-based practice. Indeed, after presenting this definition Dr. P said, “it isn’t different from what we do in conventional medicine.” So why do we need IM at all? Do we need a new label and concept for something we agree is already our goal? Dr. P insisted that IM is not simply a re-branding of CAM, as he knows we skeptics suspect, but rather a more open-minded and inclusive approach to care that may or may not involve particular aspects of CAM. My concern with IM, as I will describe, is that Dr. P and I seem to have different thresholds for what kind of evidence is compelling in determining an appropriate therapeutic approach. All the changes in labeling seem to me, in my most cynical moments, to be little more than a savvy marketing strategy.

Part of IM is attention to spirituality, by which Dr. P means not religion but rather values and sources of meaning. Dr. P shared with his audience that he derives personal meaning, for example, from his family and children, and he described how he engages his patients in discussions about what is important to them. Such talks, he told us, can be particularly helpful in establishing a therapeutic relationship and plan in the face of chronic or life-threatening disease. Dr. P spoke eloquently and compellingly here, and these segments of his presentation could easily fit into separate sessions on these topics that we have throughout med school. But what, I wonder, does this have to do with CAM, and why do we need IM in order to promote such discussions? This common conflation of CAM with humanism contributes to my suspicion that physicians who embrace CAM do so not because they reject science—Dr. P is a smart guy who understands statistics and methodology—but rather out of objection to the business aspect of medicine or to problems with its delivery in our current system.

Another confounder, in my opinion, is preventive care. Dr. P is a practicing internist, but both his graduate training and his academic appointments also involve preventive medicine. Part of the appeal of his message about IM is how it is wrapped up in a concern for improving disease prevention and health maintenance in primary care. I agree that this concern is a laudable goal and hopefully an uncontroversial one. What frustrated me was how Dr. P explicitly condemned “conventional medicine” for ignoring preventive care, even to the point of saying that most docs “just talk” about prevention rather than really do it! (I was stunned by this casual dismissal, particularly given that our school has faculty who actively combat lead poisoning, vitamin D deficiency, and low vaccination rates in our community, just to name a few initiatives.) Although it may be that such sentiments on crank websites reflect theoretical disputes over “true cause” of disease, I suspect that the issue for most IM-sympathetic physicians is rather the practical constraints and financial incentives that restrict physician-patient interactions. I am happy to discuss ways that physicians could more effectively promote good nutrition, exercise, and stress management. Can’t these system problems be addressed without using language about “alternative” approaches that opens the door to implausible therapies?

Dr. P introduced CAM using the NCCAM categories: alternative whole medical systems (naturopathy, Ayurveda, TCM); biologically based practices (herbs, supplements); energy therapies (Reiki, Qi Gong, TT); manipulative and body-based practices (chiropractic, massage therapy); and mind-body medicine (Yoga, meditation). His language while describing these categories was most instructive, as he refrained from making specific claims that I might offer for evaluation. He described energy therapies and alternative systems as the categories most “foreign” to our “Western” approach, whereas I would say they represent pre-modern, magical thinking that limits their value. He made the important distinction between modern DO physicians (like MDs) and osteopathic manipulation (like chiropractic), and I noticed at that point that he almost said “allopathic” before correcting himself with “conventional.” (Another deliberate marketing strategy, perhaps?) He warned us about the challenges of quality assurance and unsupported claims that plague the unregulated supplement market, though he seemed more optimistic than I about finding diamonds in that rough. He said that mind-body techniques are the “most integrated” of the CAM modalities, meaning most supported by evidence, and he seemed more impressed by their effects on psychological stress and wellbeing than purported physiological effects. The impression he gave while discussing these general types of CAM was not of an ideological booster but rather of an open-minded investigator, whose only fault might be too much hesitance to conclude that a CAM modality is worthless. He comfortably points out weaknesses and challenges while remaining enthusiastic overall.

Following the categories, Dr. P showed a few photographs of examples of CAM. He reminded us that his goal was not to teach or encourage CAM but rather to make us aware so that we can respond appropriately to patients. Photo and description of acupuncture, of course. At a photo of a child’s back covered in horrible bruises he told us that if we didn’t know about the alternative practices of “cupping” (e.g.) and “coining” (e.g.) we might mistake such marks for child abuse… Again, my interpretation differs: although I agree that knowledge about culturally-specific practices is helpful for interventions, I might argue that injuries without benefit are indeed a form of abuse, no matter how well-intentioned.

Dr. P made one of several valiant attempts at audience participation by soliciting any family or folk remedies that we had encountered at home. Crickets chirped as students kept quiet in front of 180 peers. One brave soul volunteered that his mother swears by Airborne, which got no reaction from Dr. P. (I suspect he was hoping for a remedy not quite so laughable.) Dr. P suggested as an example the common use of prunes for constipation and pointed out that we are unlikely to see anyone fund a randomized, controlled trial (RCT) for that indication. Fair enough. Failing RCT evidence, continued Dr. P, we need to look for other supporting evidence. As an example of such non-RCT evidence, he showed the abstract from a 2000 Chest publication describing an inhibitory effect of chicken soup extract on neutrophil chemotaxis in vitro, as support for grandma’s home flu remedy. While this “chicken soup for the cell” (my snarky phrase, not his) is amusing and perhaps intriguing, I cannot fathom how this level of evidence meaningfully influences clinical decision making, beyond being an excuse to give advice that we might give anyway. While the goal of this presentation was explicitly not to detail the evidential support for any particular CAM, I was disappointed that such a lame example was given. Even if I buy it, though, how does the efficacy of chicken soup for a cold have any relevance to homeopathy? Here is a danger of accepting a garbage pail category like CAM as a coherent discipline, in my opinion.

What followed next was an extended appeal to popularity, not necessarily to claim that CAM is useful per se or that we should embrace it in our practice, but at least to convince us to take it seriously as something our patients may use or want. Dr. P cited the 1993 NEJM survey that reported CAM use by 34% of Americans (see Dr. Crislip on this oft-cited report). Discussing the results of this and later surveys, Dr. P suggested that changes in relative rankings of modalities reflected rational responses to evolving evidence, specifically a fall in the popularity of Echinacea and spinal manipulation for head colds following negative RCT evidence. He showed a New York Times article describing how alternative medicine is popping up in US hospitals, though to my reading the article paints hospitals more as selling out and cashing in than as thoughtfully adopting newly proven practices. For the second time, Dr. P mentioned the consortium of 40+ medical schools with IM programs (including Harvard, you know). He noted 2006 Resolution #306 of the American Medical Association, which recommended promotion of physician awareness of the “benefits, risks, and evidence for efficacy or lack thereof” of CAM (see the students’ initial proposal and then search for the watered down amended version here), as well as practice guidelines for addressing CAM use in lung cancer patients prepared by American College of Chest Physicians.

Dr. P seemed to be familiar with common objections to his support for CAM, and he tried to deflect them by telling us how difficult it is to rely only on solid RCT evidence in practice. He readily admitted that much CAM research has methodological flaws, and he explained that many CAM therapies are too individualized for conventional study methods. Dr. P pointed out that only 20-30% of conventional medicine is based on RCTs, anyway. Although we are “focused on evidence” at this stage in our training, he said, later on we’ll see that physicians have to do the best they can with limited available evidence. I commented in my notes at this point that some of his reflections on the limitations of EBM seemed similar to what I read on SBM… though given the different verdicts reached on CAM, it seems that IM and SBM fall back on different sources of evidence when the RCTs are inconclusive!

Dr. P’s message to us was to be open and non-judgmental to patients who use CAM, which of course is appropriate. He did not counsel us to practice any CAM that we do not first specifically obtain training in, but rather to consider referring patients to qualified CAM providers when necessary. He described doing literature searches to answer patient questions, such as whether acupuncture might help with in vitro fertilization. I am sure that Dr. P is a great physician to have if you are a patient who wants CAM; so long as your desired CAM is not harmful and does not replace proven, needed care, he is willing to work with you. While that attitude may be valuable in a particular context (keep the patient happy in order to ensure she gets “conventional” care along with the CAM), I find myself wishing that Dr. P would admit that some of CAM is frankly nonsense and that not every proposed CAM indication deserves research. At least to us, if not to the patient in his office.

This talked was billed as a general introduction to CAM and IM, given in order to help us be more receptive to patients’ beliefs and practices. The details of or evidence for specific CAM modalities were not discussed, rather the field was painted with a broad brush as probably harmless and sometimes effective and increasingly evidence-based and, by the way, very popular. The presentation also conflated CAM use with compassionate and preventive care; if this is a deliberate tactic to win acceptance, it is a savvy one. The talk seemed like it would be quite attractive, or at least not at all objectionable, to a shruggie. I could not help but notice, however, that although Dr. P did not dwell on the more outlandish CAM modalities (homeopathy, Reiki), he also refrained from saying anything critical of them. He was very careful and seemed quite reasonable, making it difficult for me to offer specific criticisms despite leaving the lecture with a sense that he and I would disagree on much.

My next post will cover Dr. P’s lecture to second-year medical students on CAM, ethics, and the law. That lecture offered a little more insight than this one in how Dr. P thinks differently than some of us do on questions of CAM usefulness.

Posted in: Medical Academia, Science and Medicine

Leave a Comment (34) ↓

34 thoughts on “CAM on campus: Integrative Medicine

  1. Amy Alkon says:

    Dr. P: most docs “just talk” about prevention rather than really do it!

    Every doctor I’ve ever seen at Kaiser, my HMO, has been prevention-focused. This is especially true of my doctor. I know, I’m a very, very, very small sample size, but I’ve been a member since my 20s, and I’m now 46.

  2. kennywinker says:

    “Dr. P suggested as an example the common use of prunes for constipation and pointed out that we are unlikely to see anyone fund a randomized, controlled trial (RCT) for that indication.”

    A quick googling, reveals that yes, there have been randomized double-blind tests of the efficacy of prunes in treating constapation. e.g. http://www.nature.com/ejcn/journal/v61/n12/abs/1602670a.html

  3. BillyJoe says:

    That seems to be a common tactic. Throw in a lot of commonsense activities with the CAM so that you can say that 1 in 3 people use CAM and that there is some evidence for CAM; and never criticise the useless stuff like homoeopathy, acupuncture, and chiropractic and never mention that these modalities are mutually exclusive.

  4. David Gorski says:

    It’s more than just that. Often, prayer is lumped in with “CAM,” and given that something like 90% of the population consists of believers it’s not surprising to see that significant percentages of the population will pray when they are ill.

  5. Versus says:

    “currently ongoing is an 8-weekend certification course in Ayurveda for the subsidized cost of $1500″

    Question: subsidized by whom? the medical school?

    “Dr. P stressed throughout his lecture that he is not trying to advocate specifically for CAM use.” However: [He counseled us] “to consider referring patients to qualified CAM providers when necessary.” Sounds like advocating for CAM use to me.

    Also, did he tell the students how to determine if a CAM provider is “qualified” and when referal is “necessary?” The notion that CAM providers can be “qualified” and “necessary” is disturbing.

    I also take issue with the idea that, in addition to their many other duties, physicians must now be up-to-date on CAM practices and, if they are not, they must do the research for their patients. Given that CAM is a bottomless pit of ever-increasing “therapies,” limited only by the imagination of its practitioners, how is the physician to stay current?

    Good work, Tim. I am glad we have you as a “mole” in the IM movement.

  6. Scott says:

    As an example of such non-RCT evidence, he showed the abstract from a 2000 Chest publication describing an inhibitory effect of chicken soup extract on neutrophil chemotaxis in vitro, as support for grandma’s home flu remedy.

    My first thought on reading this was “as soon as cells outside the stomach are exposed to chicken soup, I might be impressed.” One suspects that the process of digestion might well have a meaningful impact on the utility of the remedy…

  7. windriven says:

    “Dr. P comes across as an intelligent, reasonable, sincere, caring, and competent physician.”

    And to me Dr. P comes across as a pre-scientific quack. A witch doctor with an Oxford accent is still a witch doctor. I willingly spend a considerable sum each time I visit my physician; willingly because I expect the state-of-the-art in scientific medicine. Anything less, from this consumer’s point of view, is fraud.

  8. micheleinmichigan says:

    “Dr. P spoke eloquently and compellingly here, and these segments of his presentation could easily fit into separate sessions on these topics that we have throughout med school. But what, I wonder, does this have to do with CAM, and why do we need IM in order to promote such discussions?”

    I don’t know. Why do you? From a patients perspective, I often wonder that. Yes, I have visited some doctors who communicate well and take the time to form a relationship. I have seen an equal number who are just trying to make up the time that they lost on the last patient’s chattiness. Or seem to come into the room with a lot of assumptions about your condition before you can even say go. I don’t want to be harsh. I actually sympathize that they are trying to run a business, pay employees, do the best job on the people who need it the most, etc. But, that does not build trust or a relationship for me.

    There are many ways to change a organization or culture. What sparks that change? What causes organizations to overcome the hurdles of bureaucracy, stagnation, cost concerns, to make a change. Sometimes those changes come from within, sometimes they are motivated by outside pressures.

    Would end of life care and hospice availability have improved as much without the assisted suicide movement? I believe they were/are interconnected.

    Likewise, competition is often a compelling motivator to any organization. From my point of view, many CAM practices have many problems, (safety, lack of evidence, waste of funds, etc) But, I do think that CAM’s competition with conventional medicine may benefit the patient in the terms emotional support and relationship building. It may motivate more Doctors as well as more medical schools to use or teach those principles.

    Just a side thought, that is.

  9. SkepticalLawyer says:

    Tim,

    I hope that when you get out into the world as a practicing doctor, you’ll let us all know where you are and what your specialty is. I’ll bet that there are a lot of people who read this blog who would be glad to have you as their doc.

  10. weing says:

    “But, I do think that CAM’s competition with conventional medicine may benefit the patient in the terms emotional support and relationship building. It may motivate more Doctors as well as more medical schools to use or teach those principles.”

    I think we all know those principles. It’s the insurers that don’t pay for any of this. What they need to teach is how to sneak in sufficient emotional support and relationship building into a 10 minute visit where you are also dealing with the complex medical problems the patient has.

  11. Kausik Datta says:

    I find myself very attuned to Tim’s sentiments, having had a similar experience very recently. I had an upper endoscopy done, and the procedure was performed by a physician, an MD who is an Assistant Professor of Gastroenterology, board-certified in Internal Medicine and Gastroenterology.

    I don’t want to reveal the name (for the same reasons as Tim outlined), but let’s call this physician APG, and please accept my submission that APG has had an impeccable professional training, and is well-known and liked in the professional setting, where APG is also involved in gastrointestinal and cancer research, teaching, and clinical care.

    The procedure passed off without a hitch, and I have very little residual soreness in my throat. After I woke up from anesthesia, APG sat down with me, and spoke at length, never hurrying, about several possible scenarios to be kept in mind with regard to the differential diagnosis.

    What I didn’t know was that APG is also the Director of the Center for Integrative Medicine and Digestive Center at the hospital. I could understand why CAM patients would flock to APG, who had a caring attitude, unhurried manner and great charm, and actually listened to the patients (the importance of which we have discussed in SBM several times).

    I asked APG why this entire business of alternative medicine. APG took pains to tell me how APG differentiates between CAM and integrative medicine, freely admitting that there is a lot of craziness out there. APG’s integrative approach apparently dealt with offering additional modalities, such as massages, acupuncture and so forth, to the patients if they so wanted – and if APG found that for their specific ailments, traditional medicine had no alternative yet.

    One example APG brought up was that of gastroparesis, for which there is really no therapy. For such patients, APG seemed to think that some forms of alternative medicine provide palliative care, and providing that care is essential to APG as a ‘healer’ (APG’s words – really seemed to believe that stuff).

    APG seemed to believe that APG only suggested those modalities that have some scientific evidence for them, mentioning that it was perhaps not possible to subject every modality to RCTs. What I didn’t have time to ask was whether APG ever critically evaluated the ‘evidence’ for the CAM modalities APG prescribed, or whether it was at all ethical for a physician to advocate unproven therapies for patients even in the case of an absence of alternatives.

    Overall, it was a very interesting experience – my first interaction with a traditionally-trained (in Western Medicine) ‘integrative’ medicine practitioner (outside of homeopaths, of course – homeopathy is “not-medicine”).

  12. micheleinmichigan says:

    “I think we all know those principles. It’s the insurers that don’t pay for any of this.”

    Which is one reason I feel sympathetic. But if the existence of CAM could motivate research into the benefits of emotional support and relationship building, would that be a hammer that conventional medicine could hit the insurance companies over the head with?

    Also, it’s not always time. Some practitioners have the very human tendency to talk far more than they listen.

    I’m guessing that is not a problem you have, weing, considering the length of most of your posts.

    But, I’m not saying this is a good reason to support CAM. I am only noticing that the competition may increase the amount of relationship building within conventional medicine.

  13. Scott says:

    It’s the insurers that don’t pay for any of this.

    I suspect that if any of them tried to, nobody would be willing to pay the necessarily-much-higher premiums that would require. I also question whether it would be a good use of such a highly-trained professional’s time (since that time is correspondingly costly). I’d rather have doctors doing things that require their level of medical training to do – it’s a more efficient use of personnel.

    One interesting option I can see would be to add a new role to the medical process – someone whose job is to comfort the patients, listen to them, make them feel cared for. Kind of being the compassionate face of health care, while MDs (or where appropriate, nurses) provide the technical expertise. “Patient relationship manager” or some such.

  14. micheleinmichigan says:

    “I think we all know those principles. It’s the insurers that don’t pay for any of this.”

    Which is one reason I feel sympathetic. But if the existence of CAM could motivate research into the benefits of emotional support and relationship building, would that be a hammer that conventional medicine could hit the insurance companies over the head with?

    Also, it’s not always time. Some practitioners have the very human tendency to talk far more than they listen.

    I’m guessing that is not a problem you have, weing, considering the length of most of your posts.

    But, I’m not saying this is a good reason to support CAM. I am only noticing that the competition may ultimately increase the amount of relationship building within conventional medicine.

  15. micheleinmichigan says:

    “One interesting option I can see would be to add a new role to the medical process – someone whose job is to comfort the patients, listen to them, make them feel cared for.”

    Actually, that’s not what I’m talking about. It seems to me your approach would only create more disconnect.

    When I talk about a lack of relationship building. I am talking about the practitioner that dismisses the side effects I’m describing, even though they are clearly marked in the medication literature as “talk to your doctor if you experience these side effects”.

    I am talking about a respected and much recommended practitioner who will sit in a room for 45 minutes talking about how you need not be worried about your son’s new diagnoses since it was clear that they were born with it. Without following the other specialists who are recommending various genetic testing, EKG, Ultrasounds, etc based on the diagnoses that it is congenital.

    I actually don’t have time to be nurtured and patted on the head by a stranger, but I would like a person who can treat me like an individual, not like whatever type of patient they peg me as in the first one minute of the exam.

    I know that all doctor aren’t like that. But I get frustrated because most of the ones who are like that (that I’ve met) are NOT Dr. Clueless. They seemed knowledgeable and talented, but I wonder what is going to help them, well, get over themselves. Is it competition? Is it a “Integrative Medicine” lecture in school? I don’t know.

  16. Scott says:

    I was referring principally to weing’s comments around time.

  17. James Fox says:

    Regarding cupping. While one may argue that there is some minor level of damage to the skin tissue, what we’re really talking about here is a great big hickey and not what is commonly understood to be tissue bruising. Also there is no pain involved that I’ve ever heard of in my twenty three years of investigating child abuse and neglect. I’m also not aware of any jurisdiction or state that would consider this practice abusive. I’d be very cautious calling this practice abusive unless it was a replacement for a necessary medical treatment such that there was a likelyhood of harm or specific risk to a childs functioning.

  18. Geekoid says:

    Dr’s need to be able to schedule more time with patients.
    All the Dr’s I have had have been doof Dr’s that will ask if ‘there is anything else’ This is good, but sometimes it can be uncomfortable to say anything.

    The best Dr. I had would actually start a conversation. Ask about family, interests, etc. That make the patient more comfortable with talking to the Dr’s about things that may be embarrassing, or not seem ‘important’ enough.

  19. Tim Kreider says:

    @kennywinker: Thanks for the link!

    @James Fox: Thanks for the clarification. I don’t remember being told that the marks were not painful (I may have missed it), which is definitely relevant info.

    I wonder if, historically, “holistic”-leaning docs have helped keep pressure on other physicians to be more humanistic etc, even if only through competition. If that’s true, then in a sense they are a useful foil, as we all admit that some docs are not great in this regard (or at least the system disincentivizes such behavior). I am too young and ignorant to know if my speculation here holds any truth. Anyone?

    Also, Dr. P evokes for me the interesting question of whether it’s better for patients to get their alt med safely from a knowlegable physician than from an unknown quack (assuming we’re not pushing it, just providing it to people already interested). Especially the cancer patients, right? Better they get acupuncture in the hospital than from some guru outside who might encourage stopping chemo. This question troubles me and I haven’t quite worked out a convincing response yet. (Obviously the intellectual purist in me balks, but being a purist is not practical.) Would love to hear thoughts.

  20. Kausik Datta says:

    Is it ethical for a physician to advocate unproven therapies for patients even in the case of an absence of alternatives?

  21. DevoutCatalyst says:

    “…Better they get acupuncture in the hospital than from some guru outside who might encourage stopping chemo…”

    OK. But should you be breaking the skin at multiple points when it is medically unnecessary? Couldn’t you offer an alternative to the alternative, call it “Fake Acupuncture”, and inform your patient that studies show it to be just as good as real acupuncture, but safer? (Not to mention cheaper to learn — in about an hour.)

  22. wertys says:

    Another very thoughtful post, thanks Tim. Might I also point out that one thing I find objectionable in the casual language that sCAM proponents use is to refer to SBM as ‘Western’ medicine. I like to point out that this is grossly offensive to our Eastern European, South American, Asian and many other colleagues who practise scientific medicine and make valuable contributions to science. I go on to point out that while I am not saying they are racist, the underlying assumption that only Western European medicine can be scientific is coming close to it, if not outright imperialist.

    This helpfully reframes their terminology to force them to call it ‘SBM’ or ‘scientific medicine’, and also makes their post-modern cultural relativistic arguments look as pathetic and thin as they actually are.

  23. Tim Kreider says:

    wertys, I completely agree. What really kills me is when CAM is billed as “cross-cultural”, as it often is on campus. No, I would argue, most alt med is culturally specific. Modern, science-based medicine, on the other hand, is a truly cross-cultural endeavor.

  24. @wertys:

    Interesting take on “Western” medicine. My take on it has been that the “CAM” language patrol considers it a mildly derogatory term in the PoMo sense, similar in meaning and effect to “linear,” “reductionist,” “allopathic,” “conventional,” “biomedicine,” and the rest of those cold, rigid concepts that are “privileged” in the West. (See here and here). Certainly you are correct, though, that some people will be insulted by the insinuation that they do NOT practice “Western” medicine.

    I think that the best way to expose the hypocrisy of the PoMo use of the term is to show how similar “culturally specific” terms have been misused by those whom most “CAM” enthusiasts consider anathema. Thus, several years ago in my first brush with David Katz:

    Modern medicine is “Western” only in the trivial sense that, for the most part, it evolved in the West. It is now the medicine of most of the world and is widely known to be effective where traditional practices were not. It is universal because it deals with universal facts of anatomy, physiology, pathophysiology, and all the rest. It is universal also because its methods can be tested by anyone in the world who cares to do so. This distinguishes it from craniosacral rhythms, the “human energy field,” meridians, Qi, and doshas, for example, which are undetectable, unmeasurable, and therefore unfalsifiable. To label modern medicine as Western in the postmodern “group narrative” sense—witness Dr. Katz’s use of the terms “native preferences” and “allopathic philosophy”—is akin to calling what Einstein did “Jewish physics.”

  25. Harriet Hall says:

    Kausik Datta asked “Is it ethical for a physician to advocate unproven therapies for patients even in the case of an absence of alternatives?”

    There usually are alternatives: things like pain relief and comfort care can be offered within the context of conventional medicine. If there truly is no alternative, I think it is ethical to consider an untested treatment, preferably in the context of a clinical trial. For CAM treatments that carry little risk and that are most likely placebos, I don’t think the physician should “advocate” them, recommend them, or spontaneously suggest them, but should tolerate them and cooperate when patients want to try them. I think he should say “There’s no scientific evidence that X works, but some patients have thought it made them feel better. If you want to try it, go ahead; and please follow up with me to tell me how you are doing.”

  26. JMB says:

    @Amy Alkon “Every doctor I’ve ever seen at Kaiser, my HMO, has been prevention-focused. ”
    I think you’re right. Private practice healthcare has done far better at preventive medicine than most academic physicians realize.

    @micheleinmichigan “Would end of life care and hospice availability have improved as much without the assisted suicide movement?”
    Everybody will have their own opinion about end of life care or hospice care (and it should be individualized care tailored to the wishes of the patient). I can speak only from personal experience with family, I am not a specialist in hospice care. Hospice care focuses on comfort and support of the dying patient and the patient’s family. In my viewpoint, assisted suicide is more of a fringe movement than a central issue in hospice care. Assisted suicide is still illegal in nearly all states of the USA.

    @weing “I think we all know those principles. It’s the insurers that don’t pay for any of this. What they need to teach is how to sneak in sufficient emotional support and relationship building into a 10 minute visit where you are also dealing with the complex medical problems the patient has.”
    I think you nailed it on the head.

    @Kausik Datta “Is it ethical for a physician to advocate unproven therapies for patients even in the case of an absence of alternatives?”
    Until a therapy becomes supported by scientific evidence, its use is based on a belief system (religion, aesthetics, romanticism, etc). It is against professional ethics for the professional to subject a client to the professional’s belief system. However, it is not against professional ethics for the professional to lend support to the belief system of the client. Therefore, it would be unethical for the physician to suggest therapeutic touch to a patient, even when there are no therapies that will work. However, if the patient expresses the desire to try therapeutic touch (without any suggestion from the physician), then it would be ethical to agree to the alternative therapy after a short discussion of the lack of scientific evidence. Whether or not a hospital will allow such practitioners in their hospital is still their administrative prerogative. A physician can decline the discussion based on lack of knowledge of results of local practitioners.

    @DevoutCatalyst “Couldn’t you offer an alternative to the alternative, call it “Fake Acupuncture””
    I’d suggest the TENS units used as Transcutaneous Electrical Nerve Stimulators for musculoskeletal pain. You could even replace ancient Eastern wisdom with quantum mechanics.

    @Tim Kreider “I wonder if, historically, “holistic”-leaning docs have helped keep pressure on other physicians to be more humanistic etc, even if only through competition. If that’s true, then in a sense they are a useful foil, as we all admit that some docs are not great in this regard (or at least the system disincentivizes such behavior). I am too young and ignorant to know if my speculation here holds any truth. Anyone? ”
    Thank you for the great article. When I went to medical school in the 70′s they emphasized a humanistic approach to dealing with patients which was more or less called bedside manner. I think back then there was a more sophisticated approach to placebo effect because in the 50′s and 60′s, a placebo was a pretty common treatment. Later, administering a placebo was considered grounds for losing your medical license. So now it’s come full circle, but it’s called integrative medicine instead of placebo effect. We would be given bed side demonstrations of placebo effect. For example, for a patient in pain, we would be instructed to pay attention to the time interval between administering an intravenous pain reliever, and the patient’s expression of pain relief. Depending on the nature of the pain, it would be obvious that a high percentage of patients would receive pain relief in a shorter time frame that the medication could possibly circulate to the brain. If a non medical person wants to witness the power of placebo effect, just have a fake alcoholic beverage party. Substitute near beer for real beer, or sparkling white grape juice for champagne, and watch the drunken behavior that results (fortunately without the hangovers).
    Getting back on track, when a medical student gets to the clinical rotations you will witness a wide variety of styles of patient interactions. You will see that it has more to do with personality than training. However, you will learn how to approach the patient with respect and empathy, and gain the communication skills to get the information you need from the patient about their problems and expectations. Hopefully, you will recognize how your personality will fit into the different specialties of medicine, and select the specialty that suits you (they are all specialties now, the general practitioner is a relic of the past, except on ships at sea and remote out posts). Now when you start your practice, you may or may not have the luxury of the time to cultivate the rapport with the patient. As time goes along, and you are still stuck with paying off your student loans, and come to learn the expense of running a practice, and have to fight with insurance or medicare, you will find time spent with patients is almost an unaffordable luxury. If homeopaths didn’t start earning better than minimum wage until after age 30, do have $200000 in student loans to pay off, do have $150000/year office expenses, then homeopaths would probably spend less time with the patient. Of course, with minimum time with the patient, the placebo effect is correspondingly less.
    As far as competition goes, if you end up as a primary care practitioner, then you will compete for patients for about 3 months, and then your practice will be full. If you go into a secondary specialty, most of your competition will be for the favor of the primary care doctors who steer the patients. Either way, your biggest concern will be how to deal with all of the insurance companies and Medicaid/Medicare. You will lose more patients because of patients changing insurance, than you will lose to competition.

  27. TsuDhoNimh says:

    He was very careful and seemed quite reasonable, making it difficult for me to offer specific criticisms despite leaving the lecture with a sense that he and I would disagree on much.

    That’s a classic PR tactic when you have a weak position … talk in generalities and platitudes, because if you get specific you can be nailed with facts.

  28. micheleinmichigan says:

    “In my viewpoint, assisted suicide is more of a fringe movement than a central issue in hospice care. Assisted suicide is still illegal in nearly all states of the USA.”

    I was basing my idea on the recollection of the assisted suicide movement when Kevorkian was in the news. I remembered “the opposing side” response was often something to the effect of ‘If a patient is in pain, they need better pain management or hospice care, not assisted suicide.’ Anecdotally, it seemed that hospice care and chronic pain centers became more available and prevalent through this time (statistically, I don’t know). But, of course that could have been an upward trend that would have happened regardless of the assisted suicide movement.

    “If you go into a secondary specialty, most of your competition will be for the favor of the primary care doctors who steer the patients. Either way, your biggest concern will be how to deal with all of the insurance companies and Medicaid/Medicare. You will lose more patients because of patients changing insurance, than you will lose to competition.”

    I hate it when people blow my pet ideas out of the water with things like reality and common sense. So I will admit defeat on concept that competition with CAM may encourage a health care practitioner to change his/her ways.

  29. Dr Benway says:

    The pro-CAM coalition exhibits a gradient of acceptable truths, with reasonable sounding spirituality-art-of-medicine talk at the bottom up to unreasonable “transformation of society” cults at the top. As the lower level has been allowed into the hallowed halls of academic medicine, the higher level has enjoyed an infusion of wealth and influence.

    Operation Sore Throat –infiltration and control over organized medicine– remains an objective for the guys at the top. To give just one example: the CCHR plant on a GMC oversight committee that was recently outed.

    http://forums.whyweprotest.net/123-leaks-legal/win-cchr-foi-case-uk-information-tribunal-62318/

    What’s Dr. P’s plan for keeping Patrick Holford et al our of our med schools?

  30. Dr Benway says:

    I’d have more time to spend with my patients if I didn’t have to waste so much of it debunking bullshit.

  31. Fifi says:

    wertys – “Another very thoughtful post, thanks Tim. Might I also point out that one thing I find objectionable in the casual language that sCAM proponents use is to refer to SBM as ‘Western’ medicine. I like to point out that this is grossly offensive to our Eastern European, South American, Asian and many other colleagues who practise scientific medicine and make valuable contributions to science. I go on to point out that while I am not saying they are racist, the underlying assumption that only Western European medicine can be scientific is coming close to it, if not outright imperialist.”

    Well said! Though I’d go one step further and not be as generous or kind…beware, ranting ahead…

    One can actually make a very solid argument that the whole “Western medicine” gambit is quite racist, particularly since a lot of CAM/new age beliefs also fetishize or exoticize non-European cultures. New agers and CAMsters will howl with outrage and insult when you point out that ideas about Noble Savages and Magical Exotic Others are racist – usually because they consider their appropriation and abuse of other cultures to be a sign of how they’re “good” and “enlightened” people and not exploitative and colonialist like the white men (their dads) that are oppressing them with science and rationality. It’s one way to avoid looking at how our society actually works and having to acknowledge their own unearned privileges that come with being from a certain class and/or skin colour. It’s a faux rebellious or radical stance that allows people to consume Spirit Catchers and pay white men pretending to be native american to cleanse their aura while entirely ignoring the real plight of aboriginal peoples in North America (for instance).
    It’s a bit like how the whole “goddess” thing in new age beliefs is actually quite sexist since it puts women up on a pedestal/altar and promotes imaginary ideals rather than just accepting us as individual human beings…you know, regular non-magical people. Thinking that people from other cultures (or women) are particularly magical is also denying their/our innate humanity and equality. Plus it’s ignoring reality and downright insulting to ignore the vast numbers of people of non-European descent that work in medicine and science, and make very important contributions to scientific knowledge. If anything, science is one of the more ethnically/culturally diverse professions (certainly more diverse than most yoga classes or expensive spiritual retreats!). It also ignores the history of science and medicine, which certainly don’t solely belong to Europe or Europeans.

  32. JMB says:

    Another thought about the question of competition from CAM increasing the time physicians will spend with their patient. Probably the biggest pressure the graduate physician will face is the pressure from the group they decide to join. There is pressure to be productive, which may be the limiting factor in spending more time discussing issues with patients. If you are in a primary care specialty, most visits are billed as short visits. Since much of the time will be taken up by checking records, results, writing notes, writing responses to insurance companies, etc., the portion of the 15 minutes that can be spent in discussions with the patient ends up being a small percentage. If you decide to try a concierge practice (usually not a safe option when you do not have a comfortable financial foundation), you probably will compete with CAM providers to give more listening, education, and reassurance.

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