Mar 06 2009
Last week, two events took place in Washington that ought to inspire trepidation in the minds of all who value ethical, rational, science-based medicine and ethical, rational, biomedical research. One was the Senate Panel titled Integrative Care: A Pathway to a Healthier Nation, previously discussed by my fellow bloggers David Gorski, Peter Lipson, and Steve Novella, and also by the indefatigable Orac (here and here); the other was the ”Summit on Integrative Medicine and the Health of the Public“ convened by the Institute of Medicine (IOM) and paid for by the Bravewell Collaborative, previewed six weeks ago by fellow blogger Wally Sampson. This post will make a few additional comments about those meetings.
Senator Harkin and the Scientific Method
Thanks to Dr. Lipson, I didn’t have to listen to the Senate Panel video to find out that Senator Tom Harkin (D-Iowa) made this statement of disappointment regarding his own creation, the National Center for Complementary and Alternative Medicine (NCCAM):
One of the purposes of this center was to investigate and validate alternative approaches. Quite frankly, I must say publicly that it has fallen short. It think quite frankly that in this center and in the office previously before it, most of its focus has been on disproving things rather than seeking out and approving. (from last week’s hearings, time marker approx. 17:20)
Are scientists at the NIH really too afraid of Harkin to explain to him how science works? Apparently so. Otherwise Harkin might learn that his statement is more wrong-headed than it would be for one of us to complain that the Supreme Court ought to assume that a defendant is guilty until proven innocent, rather than the other way around. In scientific inquiry, for those who don’t know, good experimental design is always directed at disproving a hypothesis, even one that pleases its investigator. The rest of Harkin’s sentiment—”seeking out and approving”—is incoherent.
The Selling of ‘Integrative Medicine’: Snyderman Trumps Weil
Spin doctors shilling for ‘integrative medicine,’ which the NCCAM defines as “combining treatments from conventional medicine and CAM,” appear to have now decided that subtler language is more likely to sell the product. We’ve previously seen an example offered by ‘integrative’ Mad Man Andrew Weil:
The addition of proven CAM to conventional medicine would be an improvement, yet this combination alone is not what could be defined as integrative medicine….Integrative medicine is defined as healing-oriented medicine that reemphasizes the relationship between patient and physician, and integrates the best of complementary and alternative medicine with the best of conventional medicine. We believe that this synthesis of humanistic medicine, patient- and relationship-centered care, preventive health, allopathy, and CAM is the model for creating an improved system of health care.
It takes someone who knows his way around a faculty meeting much better than does ex-hippie Weil, however, to understand that the surest way to usher ‘integrative medicine’ into the curricula of medical schools is to press the delete button whenever the pesky ‘CAM’ term comes up, and to replace it with a few trendy slogans that everyone can agree on. Ralph Snyderman, MD, the former Chancellor for Health Affairs at Duke University, is just such a person. As far back as 2002, Snyderman wrote:
Integrative medicine is an approach to the practice of health care based on a sound scientific approach with an emphasis on the responsibility of the physician to engage the patient in his or her own unique plan for health. Essential aspects include the recognition of the importance of the mind-body relationship and a willingness to consider unconventional modalities with informed skepticism and scientific evaluation. Above all, integrative medicine encompasses the caring bond between the patient and the caregiver, and the responsibility of the latter to enable the patient to benefit from a full array of modalities that can be shown to benefit health.
No surprise, then, that Snyderman was a key figure in last week’s ”Summit.” Here is how he introduced the topic prior to the meeting:
“What we currently have is not a health care system, but a disease care system,” said Ralph Snyderman, M.D., chair of the Summit Planning Committee and chancellor emeritus of Duke University. “The summit will explore how science and a patient-centered, prospective, integrated approach to care can make a positive difference.”
It seems that ‘integrative medicine’ now might have something to do with preventive medicine, ‘patient-centered care,’ and fixing the health care system. The Summit’s Issue Background, authored by professional writer Vicki Weisfeld, makes it official:
Integrative medicine orients the health care process to create a seamless engagement by patients and caregivers in the full range factors known to be effective and necessary for the achievement of optimal health over the course of one’s life. In integrative medicine, patients are active partners in their health and providers care for them as individuals in different life circumstances, rather than just treating their illnesses. Thus, integrative medicine takes into account biological, psychological, social, and spiritual aspects of individuals’ lives, draws the best evidence for their needs and circumstances, and engages both treatment and prevention, including diet, exercise, stress management, emotional wellbeing, and socio-environmental factors. Integrative medicine makes use of the best conventional care and the latest advances in predictive, preventive, and personalized medicine and uses all appropriate evidence-based prevention, treatment and supportive approaches. Finally, it asks physicians to serve as guides, role models, and mentors and to recall that “healing is always possible, even when curing is not.”
Widespread implementation of an integrative medicine approach would fundamentally transform our nation’s current fragmented, inefficient, expensive, and reactive “sick care” system to one that is more proactive, personal, efficient, and appropriately focused on enhancing the health of each person and the population as a whole. Five chronic conditions—mood disorders, diabetes, heart disease, asthma, and high blood pressure—now account for more than half of all U.S. health expenditures. The onset and serious consequences of these conditions may have been partly or wholly preventable. Current patterns of care do little to enhance health, prevent illness, or treat it efficiently and effectively when it occurs. The reimbursement system encourages this pattern, by financially rewarding units of service, rather than outcomes, prevention, and the integration of care processes that each patient should expect. Little encouragement, through incentives or care patterns, is offered to individuals to take active part in their own care to enhance wellness and minimize disease.
Hmmm. No ‘CAM’ mentioned there. Nor will you find it until the bottom of page 3, where it is dressed up as “proven complementary approaches,” without further comment:
In 1910, the Flexner Report changed American medicine by insisting that doctors should be trained to diagnose and treat illnesses using the scientific tools of the day. Since then, the medical sciences have splintered into more and more specialties concerned with narrower and narrower aspects of the human body. Medicine’s focus on pathophysiology alone, and the reductionist perspective, do not well serve the many patients whose complex problems are incompletely understood
and treated by “find it and fix it” approaches.
As the Flexner centenary approaches, it is again time to reevaluate the training in U.S. medical schools…This requires taking a broader view of individual patients that takes into account the social, family, and physical environments in which they function as well as the patient’s own empowerment and motivation. It requires use of the best conventional medicine and cutting-edge diagnostic and treatment methods in combination with appropriate mentoring, compassion, and proven complementary approaches.
You don’t see it again until p. 9:
Some elements of an integrated approach to health care also have their roots in practices that began under the rubric of complementary and alternative medicine (CAM). The effectiveness of such approaches has been strengthened as experience and evidence has [sic] been gained.
Aha, you’re thinking: we’re about to find out what those mysterious, “proven complementary approaches” are! Think again, because here is the rest of the paragraph:
In 2003-2004, the National Center for Complementary and Alternative Medicine sponsored a series of grants to strengthen awareness and knowledge about complementary and alternative medicine practices among medical students. The goal was to broaden the array of evidence-based techniques that physicians have at their disposal. A common finding from these projects was that culture change, including faculty development, was a necessary accompaniment to curriculum changes, and the result is a growing presence of relevant courses in the nursing and medical curricula. Expansion of these trends will require additional research, resources, incentives, continuing education courses, licensure requirements, and, perhaps, ultimately, reimbursement incentives.
It seems that ‘experience and evidence’ have shown that the only way to foist implausible medical claims into medical and nursing school curricula is to dupe medical and nursing students, bribe faculty members, and twist some arms. Or, perhaps, to pretend that ‘integrative medicine’ does not involve prescribing non-existent drugs, manipulating non-existent ‘energy fields’ and non-existent ‘rhythms,’ balancing non-existent ‘qi’ in various non-existent organs through non-existent ‘meridians’ and non-existent ‘acupuncture points,’ correcting non-existent ‘subluxations,’ diagnosing and treating diseases by examining non-existent homunculi on ears, eyes, and feet, hosing non-existent toxins out of colons, and all the rest.
How much easier it must be, when faced with a profession that has become maddeningly wedded to science—that vexing ”reductionist perspective”—to pretend that one’s pet project doesn’t include such anti-scientific drivel (well, maybe it includes a little of the socially acceptable sort: “mindfulness meditation, acupuncture, massage and biofeedback…nutritional practices and dietary supplements” is what you get in this essay). Instead, why not claim that the program is about ‘patient-centered care,’ prevention, improving access to care, improving reimbursement for primary care physicians, making health care less expensive, considering psycho-social aspects of patient care, improving communication skills among health care professionals, and other uncontroversial topics?
So what if these have long been recognized as worthy goals, both individually and in the aggregate, since well before ‘integrative medicine’ or ‘CAM’ began to contaminate rational discourse in medical schools and government? So what if ‘integrative medicine’ has nothing new to add to them? This is all of little concern to the savvy chairman, who knows that the most important determinant of smooth sailing at a meeting is to avoid saying anything that might awaken the participants.
Is ‘Integrative Medicine’ Preventive Medicine?
Does ‘integrative medicine’ have anything to add to preventive medicine? You’d sure think so if you’d emerged from a 40-year coma last week to read the Issue Background:
Since integrative medicine begins from the perspective of maintaining and promoting individual health, it is necessarily closely attuned to the array of behavioral and environmental factors that put health at risk. Inevitably, the health system must look beyond the individual patient to broader social and environmental influences. As mentioned, many environmental factors require public health advocacy and intervention. However, even individual behavior, such as smoking and exercise, is susceptible to social and environmental approaches. Widespread anti-smoking advocacy and supportive public policies, like anti-smoking rules in workplaces and public spaces, increased tobacco taxes, and consumer education programs have changed the environment in the United States from a pro-smoking to largely anti-smoking culture. Similarly, public policies that promote exercise by building bike, jogging, and walking trails, corporations and city planners that encourage office and residential buildings to include gyms and showers, and an array of other public policies support a health-promotion culture. Health professionals have credibility in public discussions of such policies and can do a great deal for their own patients and the community by endorsing such pro-health initiatives. Medical researchers and health policy analysts can develop the clinical research and public policy assessments on which sound public policies can be based.
Really, now. That such spin was apparently composed with a straight face can only be a measure of how few people will read it. Which, alas, is exactly what the Bravewell crowd has in mind, and why Snyderman is such a brilliant choice as Propaganda Chief. The prevention hype is everywhere; here’s Harkin again, this time from his written statement:
We need a paradigm shift that places a much greater emphasis on preventing disease and keeping people healthy rather than merely treating people once they become sick. Integrative care can help us achieve this goal.
But has ‘integrative medicine’ or any of its ‘CAM’ progenitors contributed anything to real preventive medicine, as introduced yesterday by Peter Lipson? Have any of the preventive measures that most physicians can think of right off the bat—oh, in no particular order, by no means comprehensive, and not without uncertainties about usefulness or best uses: immunizations, blood pressure measurement and treatment, cholesterol screening and treatment, mammography, occult blood in stool, colonoscopy, smoking cessation, folate and iron in pregnancy, other prenatal care, bone density, weight, diet, exercise, pap smears, skin exams for melanoma, prostate-specific antigen, and many more—been introduced by ‘integrative medicine’? Let’s look. First, a list of
Preventive Measures Supported by Science that have been Advanced by Modern Medicine and Public Health
Section 1. Preventive Services Recommended by the USPSTF
Section 2. Recommendations for Adults
* Aspirin/NSAIDS for Prevention of Colorectal Cancer
Bladder Cancer in Adults, Screening
Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing
Breast Cancer, Chemoprevention
Breast Cancer, Screening
Cervical Cancer, Screening
Colorectal Cancer, Screening
Lung Cancer Screening
Oral Cancer, Screening
Ovarian Cancer, Screening
Pancreatic Cancer, Screening
Prostate Cancer, Screening
Skin Cancer, Counseling to Prevent
Skin Cancer, Screening
Testicular Cancer, Screening
Vitamin Supplementation to Prevent Cancer and Cardiovascular Disease, Routine
Heart, Vascular, and Respiratory Diseases
Abdominal Aortic Aneurysm, Screening
Aspirin for the Primary Prevention of Cardiovascular Events
* Carotid Artery Stenosis, Screening
* Chronic Obstructive Pulmonary Disease, Screening
Coronary Heart Disease, Screening
* High Blood Pressure, Screening
Lipid Disorders in Adults, Screening
Peripheral Arterial Disease, Screening
Asymptomatic Bacteriuria, Screening
* Chlamydial Infection, Screening
Genital Herpes, Screening
Hepatitis B Virus Infection, Screening
Hepatitis C in Adults, Screening
Syphilis Infection, Screening
Injury and Violence
Family and Intimate Partner Violence, Screening
* Motor Vehicle Occupant Restraints and Avoidance of Alcohol Use While Driving, Counseling
Mental Health Conditions and Substance Abuse
Alcohol Misuse, Screening and Behavioral Counseling Interventions in Primary Care to Reduce
* Illicit Drug Use, Screening
Suicide Risk, Screening
Tobacco Use and Tobacco-Caused Disease, Counseling to Prevent
Metabolic, Nutritional, and Endocrine Conditions
Diet, Behavioral Counseling in Primary Care to Promote a Healthy
Hormone Therapy for the Prevention of Chronic Conditions in Postmenopausal Women
Iron Deficiency Anemia, Screening
Obesity in Adults, Screening
Physical Activity, Behavioral Counseling in Primary Care to Promote
Thyroid Disease, Screening
Type 2 Diabetes Mellitus in Adults, Screening
Low Back Pain in Adults, Primary Care Interventions to Prevent
Osteoporosis in Postmenopausal Women, Screening
Obstetric and Gynecologic Conditions
* Bacterial Vaginosis in Pregnancy, Screening
Breastfeeding, Behavioral Interventions to Promote
Gestational Diabetes Mellitus, Screening
Rh (D) Incompatibility, Screening
Section 3. Recommendations for Children
Blood Lead Levels in Children and Pregnant Women, Screening
Dental Caries in Preschool Children, Prevention
Hip Dysplasia, Screening
Idiopathic Scoliosis in Adolescents, Screening
* Lipid Disorders in Children, Screening
Newborn Hearing Screening
Overweight in Children and Adolescents, Screening and Interventions
* Sickle Cell Disease, Screening
Speech and Language Delay in Preschool Children, Screening
Visual Impairment in Children Younger Than Age 5 Years, Screening
Appendix A. How the U.S. Preventive Services Task Force Grades Its Recommendations
Appendix B. Members of the U.S. Preventive Services Task Force 2001-2004
Appendix C. Acknowledgments
Appendix D. ACIP Recommended Immunization Schedules
* New recommendations 2007 to March 2008.
Preventive Measures Supported by Science that have been Advanced by ‘Integrative Medicine’
The Misleading Language and Weakly Waluation of the Weasel Words of Woo series:
- Lies, Damned Lies, and ‘Integrative Medicine’
- Integrative Medicine: “Patient-Centered Care” is the new Medical Paternalism
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