Sep 09 2009
The marketing of so-called CAM or integrative medicine continues. These terms are just that – marketing. They are otherwise vacuous, even deceptive, and meant only to conceal the naked fact that most medical interventions that hide under the CAM/integrative umbrella lack plausibility or credible evidence that they actually work.
Medicine that works is simply “medicine” – everything else needs marketing.
Last week in the British Medicine Journal (BMJ) Hugh MacPherson, David Peters, and Catherine Zollman wrote a very telling editorial entitled Closing the evidence gap in integrative medicine, which Edzard Ernst has rightly characterized “a masterpiece in obfuscation.”
The essence of the editorial can be boiled down to this – proponents of integrative medicine are disappointed that scientific research has not validated their failed modalities. Therefore they want to weaken the rules of evidence so that they can get the results they desire.
But first, they begin their marketing with the branding of “integrative medicine”, taken from www.imconsortium.org:
“medicine that reaffirms the importance of the 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 (conventional and complementary) to achieve optimal health and healing”
This is not integrative medicine, which is rather the attempt at mixing unproven, disproved, and often highly implausible methods into science-based medicine. But proponents can’t go around saying directly that they want to use treatments that probably don’t work, so they brand a nice sounding term with a collection of virtues that actually have nothing to do with what they are selling.
This is obfuscation because a definition such as this should indicate what distinguishes one category from another – what makes integrative medicine different from medicine. The practitioner-patient relationship has been central to medicine since Hippocrates. The “bio-psycho-social” (whole person) approach to medicine is also nothing new – that’s what I was taught in medical school before the term “integrative” was invented. “Informed by evidence?” – I hope so. In fact, that’s a bit weakly stated. And mainstream medicine already makes use of all “appropriate” therapies – the addition of the world “complementary” is just adding another vague term without any operational definition.
So what is the difference between “integrative” medicine and medicine? None that I can detect by that statement, except the suggestion (well-hidden) of using unproven treatments. The brilliance of the marketing, of course, is that by defining your made-up brand of medicine with these virtues, you suggest that your competition lacks them – without ever having to say it.
Let’s get to the meat of the editorial. They write:
Yet when it comes to deciding whether an intervention, and which type of intervention, might be helpful for a particular patient, a worrying gap exists between the perceived potential for using integrative approaches in areas of poorly met clinical need and the availability of supporting evidence derived from good research.
Throughout the editorial the unstated major premise is that the authors know that the “integrative” modalities they want to promote work. They simply need to figure out a way to support what they already know to be true with something that can be marketed as scientific evidence. Nowhere do they give a hint that they are concerned about using science to figure out IF a treatment works.
They also do not give the slightest consideration to the fact that the evidence gap may be the result of the fact that the treatments simply do not work.
In a response to the editorial, David Colquhoun correctly points out their “special pleading” – “If your treatments cannot pass the test, the test must be wrong.” The test they are complaining about is the randomized controlled trial.
They make the usual excuses for why rigorous scientific studies are not adequate to evaluate integrative methods – they are too complex, the studies are artificial and don’t apply to the real world, and they interfere with choice and the therapeutic relationship. This is flawed reasoning on multiple levels.
First, many “integrative” methods are quite amendable to the double-blind randomized trial. Anything that can be taken as a pill – such as herbs or homeopathy – can be compared to an identical-looking placebo. Procedures are more challenging, but researchers have figured out ways to compare acupuncture to sham and even placebo acupuncture, using non-penetrating needles in an opaque sheath.
But on a deeper level they miss the point of scientific research entirely. They complain that the therapeutic relationship is part of the treatment (as if that is different than regular medicine) and therefore it cannot be separated from the treatment itself in clinical trials. But the entire point of scientific studies is to isolate variables as much as possible so that we can come to conclusions about whether or not each variable has a net positive or negative health effect in certain situations and conditions. This is what makes medicine scientific an allows it to move forward – knowing what works and is safe and what isn’t. The art of medicine is then putting it all together in a positive therapeutic interaction.
James May, chairman of HealthWatch, nailed it when he wrote in response:
Effective medicine is best measured with RCTs. Caring is not. ‘Integrative medicine’ therefore risks both damaging how we measure effective medicines (RCTs), as well as reducing caring to measurables. A better term for this might be ‘disintegrative medicine’.
He is saying, as I just did, that the authors miss the point about the purpose of medical research.
In the place of the randomized controlled trial, the authors recommend so-called “pragmatic” studies, comparison research, and case studies. These all have one thing in common – they are not blinded. They therefore do not separate out the variable of the intervention in question from the therapeutic ritual and non-specific effects. These kinds of studies are useful for guiding the application of treatments that have already been shown to work. But they are useless in determining if a treatment works.
Over the last couple of decades there has been a persistent effort to promote unscientific medical modalities with increasingly sophisticated marketing – and to the horror of many, the marketing is working. Proponents have come up with an steady stream of euphemisms for medicine not supported by science – “alternative”, “complementary”, “integrative”, and “functional”. They have marketed them as “natural” and “holistic” and assured the public that if we just researched these methods they would be proven to work. They marketed their modalities to the public, to regulators, and to academia.
Now, after decades of research, after the NCCAM spent 2.5 billion dollars of taxpayer money – the research overwhelmingly shows that these implausible methods don’t work. (It should not have been surprising that treatments that had a very low prior probability turned out not to work – the improbable, it turns out, is improbable.) For years we were told that we just needed more research and better designed research. Acupuncture studies need better placebo-controlled acupuncture.
Now “integrative” proponents are switching gears (after the research they were asking for did not turn out as they hoped), increasingly arguing that the problem is not their improbable modalities but the research technology itself. They want to switch to the kind of studies that are not even designed to determine if a treatment works or not, and are almost guaranteed to produce the results they want – results they can use to confuse the public and politicians, and to lubricate their passage into the halls of academia.
To this skeptic, this is an old and familiar strategy. When science fails to validate your belief system, blame science.
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