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The false dichotomies of CAM and “integrative medicine”

Falsedichotomy

A lot of medical specialties have throwaway newspapers/magazines that are supported by advertising and somehow mysteriously managed to show up for free in the mailboxes of practitioners. In my case, I’ve found myself on the subscription list for such papers about oncology, but also general surgery (I’m Board-certified as a general surgeon). When I have to recertify in about three years, it will be as a general surgeon, which was really fun to try to do last time after having specialized as a breast cancer surgeon, and will likely be even more fun next time, when I will be 10 years further out from my general surgery and surgical oncology training. In any case, that must be why, no matter where I end up working, sooner or later I end up receiving General Surgery News (GSN).

As throwaway professional newspapers go, GSN is not bad. However, occasionally it publishes op-ed articles that make me scratch my head or even tick me off with their obtuseness. Lately, apparently, it’s started some blogs. The one in particular that is the center of attention for this post is by Victoria Stern, is called “The Scope” and is billed as “exploring the lesser known sides of surgery.” Of course, it’s a bit odd that some of the first posts on this blog are about work hour restrictions and whether they leave new surgeons unprepared to practice surgery, the debate over breast screening, and what it takes to train expert surgeons, none of which are exactly “lesser known sides of surgery.” Work hour restrictions, in particular, have been discussed in surgery journals, at conferences, and among surgeons ad nauseam, particularly whether we are training a generation of surgeons unable to deal with the rigors of practicing surgery in the real world.
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Posted in: Critical Thinking, Medical Ethics

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What’s in a name?: NCCAM tries to polish a turd

turdpolish

What’s in a name? that which we call a rose
By any other name would smell as sweet;
So Romeo would, were he not Romeo call’d,
Retain that dear perfection which he owes
Without that title. Romeo, doff thy name,
And for that name which is no part of thee
Take all myself.

William Shakespeare, Romeo and Juliet, Act II, Scene 2

You can clean up a pig, put a ribbon on its tail, spray it with perfume, but it is still a pig.

You can paint a turd red, but it’s still a turd.

There’s a colloquial phrase commonly used to describe an effort to sell or promote something that is so inherently awful or at least so flawed as to be unsalvageable without either a radical rethinking or such a major overhaul that it would be impractical or impossible to do: Polishing a turd. In this, advocates of so-called “complementary and alternative medicine” (CAM) have been very successful. Mark Crislip, in his usual inimitable fashion, just reminded us why CAM is a turd that needs polishing. Unfortunately, on Friday, I learned that the National Center for Complementary and Alternative Medicine unveiled a proposal to help it be more efficient in polishing the turd that is CAM through the clever use of language, and it wants your feedback. There were lots of other things that happened over the last few days that tempted me to write about them that will likely have to appear over at my not-so-secret other blog, but this one caught my attention and held it, given that it goes to the very heart of the deceptive use of language that is at the heart of giving CAM the appearance of legitimacy. In this specific case, NCCAM wants a new name. Dr. Briggs wants to rename NCCAM the National Center for Research on Complementary and Integrative Health (NCRCI). (I have no idea why the abbreviation of the proposed new center name isn’t NCRCIH.) Here’s Dr. Briggs explaining the rationale for the proposal and urging feedback by June 6 at http://nccam.nih.gov/about/offices/od/comments. I urge you to watch the whole video, or at least read the transcript:

Thus does Dr. Briggs propose polishing the turd that is NCCAM.
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Posted in: Clinical Trials, Medical Academia, Politics and Regulation

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Has science-based medicine already lost to pseudoscience?

After writing Saturday’s 5,000-word magnum opus about misguided “right to try” bills that are proliferating in state legislatures like so much kudzu, I thought I’d try something a bit different—and more concise. Fear not. This doesn’t mean that I’m going to become Harriet Hall as a writer, because no one does concise and insightful as well as she does, but I do on occasion want to try my hand being less logorrheic. I’ll probably fail, but at least I can pat myself on the back for trying. If I succeed, though, it’ll only make me better. I hope. I also realize that I just made it harder by blathering on for a whole paragraph before getting to the point, a habit of mine that infuriates some readers and amuses others who find my way of winding towards the point at least somewhat entertaining.

Thus endeth the nauseatingly—but briefer than usual!—self-deprecating navel gazing and beginneth the post.

The opportunity appeared to me in the form of an article that popped up in my feed on Medscape entitled, Do Clinicians Base CAM Recommendations to Patients on Evidence of Efficacy? Since “complementary and alternative medicine” (CAM) is, by and large, mostly made up of a collection of modalities either based on prescientific thinking and possessing little, if any, plausibility on a scientific basis, my first reaction was to note that health care practitioners do recommend CAM to some patients, meaning that the answer must be, “No,” and then to move on. However, I wanted to see what Dr. Désirée A. Lie, the author, said and to see what the reasons are for whatever answer she came up with. So I read on.

The article starts with a case study:
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Posted in: Science and the Media

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The new Surgeon General nominee and CAM: Is there a problem here?

Our fearless leader, Steve Novella, has informed me that he is traveling today. Unfortunately, I am preparing a talk for later today, and no one else seemed able to come up with a post; so I decided to adapt a recent post from my not-so-super-secret other blog and see what a different readership thought of it. I realize that I’m risking subjecting you all to Gorski overload, but, hey, if the world needs more Mark Crislip, why wouldn’t the world need more David Gorski too? Steve will return next Wednesday, as usual.

I don’t normally give a lot of thought to the Surgeon General because, quite frankly, in recent years it hasn’t been a position of much authority or influence. That’s why I didn’t noticed late last week that President Obama had nominated a new Surgeon General. Normally, my failure to notice isn’t such a big deal, because there really hasn’t been a Surgeon General who has really been particularly well-known or had much of an impact since Dr. C. Everett Koop, although back when President Obama first took office Dr. Sanjay Gupta’s name was floated as a possibility for the position. Obviously, he didn’t get it. (I’m guessing that being a neurosurgeon and CNN’s chief medical correspondent probably pays much better than being Surgeon General.) To be honest, I didn’t even know that the prior Surgeon General had stepped down, but apparently she did in July, leaving the position filled by an interim Surgeon General until a new one could be nominated.

The other day, I learned whom President Obama nominated to be her successor, Dr. Vivek Murthy, a faculty member at the Harvard Medical School:

President Obama will nominate Dr. Vivek Murthy of Harvard Medical School and Brigham and Women’s Hospital as surgeon general of the United States, the White House announced Thursday night.

Murthy is a hospitalist at the Brigham and is co-founder and president of Doctors for America, a Washington, D.C.-based group of 16,000 physicians and medical students that advocates for access to affordable, high quality health care and has been a strong supporter of the Affordable Care Act.

If he’s confirmed by the Senate, Murthy would replace acting surgeon general Boris Lushniak. The surgeon general serves a four-year term and the post is essentially a bully pulpit to speak out on public health issues.

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Posted in: Acupuncture, Politics and Regulation, Public Health, Science and the Media

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Cancer Treatment Centers of America: Revisiting the epitome of “integrative” cancer care

Three weeks ago, I mentioned in a post that the week of October 7 to 14 was declared by our very own United States Senate to be Naturopathic Medicine Week, which I declared unilaterally through my power as managing editor of Science-Based Medicine (for what that’s worth) to be Quackery Week. One wonders where the Senate found the time to consider and vote for S.Res.221, which reads:

S.Res.221 – A resolution designating the week of October 7 through October 13, 2013, as “Naturopathic Medicine Week” to recognize the value of naturopathic medicine in providing safe, effective, and affordable health care.

I know, I know, it probably took all of five minutes to consider and vote for this, thanks to Sen. Barbara Mikulski (D-MD), who sponsored it. In any case, as October 7 approached, I thought about how I could keep my promise to blog about naturopathy this week, and I came up with a way to do it. It’s a bit roundabout, but I think it fits. The idea derives from a discussion I was having a while back about one of my “favorite” hospitals, namely the Cancer Treatment Centers of America, in which a colleague of mine questioned why there were so many CTCA ads on NPR and why CTCA is sponsoring shows on PBS such as the upcoming The Emperor of All Maladies by Ken Burns. Although I can’t wait to see this particular series, I am a bit worried that the infiltration of quackademic medicine will make an appearance, given that CTCA is a major sponsor. (more…)

Posted in: Cancer, Homeopathy, Naturopathy

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The future of “integrative medicine” is too close for comfort

I was the other day. I’ve been on vacation this week (staycation, actually, as I stayed at home and didn’t go on any trips); so you would think it would take a lot to depress me. Unfortunately, today is the last day of that vacation; so the thought of diving back into the fray trying to fund my lab. It didn’t help that I read Scott Gavura’s Thursday post how another once-proud academic medical center, the University of Toronto, is letting the Trojan horse that is “integrative medicine” into the halls of its medical school and school of pharmacy. As I frequently say, much to the annoyance of advocates of “complementary and alternative medicine” (CAM) and “integrative medicine,” what “integrative medicine” does is to “integrate” quackery with real medicine, which neither validates the quackery nor improves the real medicine. Or, as my good bud and fellow SBM blogger Mark Crislip so aptly put it:

If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.

Yes, I’ve been trying to come up with a quote that captures the essence of “integrative medicine” better than Mark’s quote. I’ve yet to succeed; so I steal his quote whenever I need to. It’s sort of the same way that I didn’t actually coin the term “quackademic medicine” to describe the infiltration of quackery into academic medicine. (Dr. R. W. Donnell did, as far as I’ve been able to ascertain.) However, I believe I’ve done more than anyone else to use and promote the term, both here and at my not-so-super-secret other blog. As I like to say say, mediocre bloggers borrow. Great bloggers steal.

Be that as it may, Scott’s post reminded me that I hadn’t looked much at quackademic medicine, at least not at the status of its infiltration into medical academia, in a while. Then I saw a review article entitled The Future of Integrative Medicine in The American Journal of Medicine by Victor S. Sierpina, MD, ABFM, ABIHM and James E. Dalen, MD, MPH. (Note that ABIHM stands for the American Board of Integrative Holistic Medicine and ABFM stands for the American Board of Family Medicine.). The article itself has no place in any self-respecting peer-reviewed medical journal, but there it is, much the same way that quackademic woo has been intermittently infiltrating the New England Journal of Medicine. The article itself is one massive apologia for integrative medicine. In fact, it’s useful to look at because it follows a script that virtually all such articles follow, with only relatively minor variations.

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Posted in: Medical Academia, Science and Medicine

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The Trojan Horse called Integrative Medicine arrives at another medical school

Trojan Rabbit

Medicine is a collaborative practice. Hospitals are the best example, where dozens of different health professionals work cooperatively, sharing responsibilities for patient care. Teamwork is essential, and that’s why health professionals obtain a large part of their education on the job, in teaching (academic) hospitals. The only way that all of these different professions are able to work together effectively is that their foundations are based on an important, yet simple, principle. All of us have education and training grounded in basic scientific principles of medicine. Biochemistry, pharmacology, physiology – we all work from within the same framework. As a pharmacist, my role might include working with physicians and nurses to manage and monitor medication use. A team approach is only possible when you’re working from the same playbook, and with the same aim. And in medicine, that playbook is science.

That’s why “integrative” medicine frightens me so much. Integrative medicine is a tactic embedding complementary and alternative medical practices into conventional medical care. Imagine “integrating” a practitioner into the health system that doesn’t accept germ theory. Or basic disease definitions. Or the effectiveness of vaccines. Or even basic biochemistry – perhaps they believe in treatments that restore the body’s “vital force” or manipulate some sort of “energy fields”. Instead of relying on objective signs and symptoms, they base treatments on pre-scientific beliefs, long discarded from medicine. There may be entirely different treatment goals, which are potentially antagonistic to the scientific standard. Imagine a hospital or academic setting where this occurs, and the potential impact on the quality of care that is delivered. (more…)

Posted in: Acupuncture, Medical Academia, Science and Medicine, Traditional Chinese Medicine

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The difference between science-based medicine and CAM

“Alternative medicine,” so-called “complementary and alternative medicine” (CAM), or, as it’s become fashionable to call it, “integrative medicine” is a set of medical practices that are far more based on belief than science. As Mark Crislip so pointedly reminded us last week, CAM is far more akin to religion than science-based medicine (SBM). However, as I’ve discussed more times than I can remember over the years, both here and at my not-so-super-secret-other blog, CAM practitioners and advocates, despite practicing what is in reality mostly pseudoscience-based medicine, crave the imprimatur that science can provide, the respect that science has. That is why, no matter how scientifically implausible the treatment, CAM practitioners try to tart it up with science. I say “tart it up” because they aren’t really providing a scientific basis for their favored quackery. In reality, what they are doing is choosing science-y words and using them as explanations without actually demonstrating that these words have anything to do with how their favored CAM works.

A more important fundamental difference between CAM and real medicine is that CAM practices are not rejected based on evidence. Basically, they never go away. Take homeopathy, for example. (Please!) It’s the ultimate chameleon. Even 160 years ago, it was obvious from a scientific point of view that homeopathy was nonsense and that diluting something doesn’t make it stronger. When it became undeniable that this was the case, through the power of actually knowing Avogadro’s number, homeopaths were undeterred. They concocted amazing explanations of how homeopathy “works” by claiming that water has “memory.” It supposedly “remembers” the substances with which it’s been in contact and transmits that “information” to the patient. No one’s ever been able to explain to me why transmitting the “information” from a supposed memory of water is better than the information from the real drug or substance itself, but that’s just my old, nasty, dogmatic, reductionist, scientific nature being old, nasty, dogmatic, reductionist, and scientific. Then, of course, there’s the term “quantum,” which has been so widely abused by Deepak Chopra, his acolytes, and the CAM community in general, while the new CAM buzzword these days to explain why quackery “works” is epigenetics. Basically, whenever a proponent of alternative medicine uses the word “epigenetics” or “quantum” to explain how an alternative medicine treatment “works,” what he really means is, “It’s magic.” This is a near-universal truth, and even the most superficial probing of such justifications will virtually always reveal magical thinking combined with an utter ignorance of the science of quantum mechanics or epigenetics.
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Posted in: Clinical Trials, Diagnostic tests & procedures, Homeopathy, Medical Academia

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AAFP CME Program Succumbs to “Integrative Medicine”

For many years I have been using Continuing Medical Education (CME) programs offered by the American Academy of Family Physicians (AAFP). The FP Essentials program consists of a monthly monograph with a post-test that can be submitted electronically for 5 hours of CME credit. Over a 9-year cycle, a complete family medicine curriculum is covered to prepare participants for the re-certification board exams. Some examples of typical subjects are skin cancer, hand and wrist injuries, valvular heart disease, and care of the newborn. I rely on these programs to learn, review, and keep up-to-date in my specialty. Imagine my dismay when I opened the latest package to find a monograph on Integrative Medicine.

First it was called various names like folk medicine, quackery, and unproven/untested treatments, then all of those (the less rational right along with the more rational) were lumped together under the umbrella term “Alternative Medicine,” then it became “Complementary and Alternative Medicine” (CAM), and now it has been re-branded as “Integrative Medicine.” The term is designed to make unscientific treatments seem more acceptable to science-based doctors. “Integrative Medicine” is a marketing term, not a meaningful scientific category. It is a euphemism for combining Complementary and Alternative Medicine (CAM) with mainstream medical practice, unproven with proven, magic with science.  It has been critiqued many times on this blog. We have stressed that there is only one medicine, and that when a treatment is proven to work by good evidence, it is just “medicine.” When the evidence for a CAM treatment is not good, it essentially amounts to experimental treatments and/or comfort measures. Worse, sometimes CAM even persists in using treatments that have been proven not to work or that are totally implausible, like therapeutic touch or homeopathy. (more…)

Posted in: Acupuncture, Cancer, Energy Medicine, Medical Academia

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It’s a part of my paleo fantasy, it’s a part of my paleo dream

There are many fallacies that undergird alternative medicine, which evolved into “complementary and alternative medicine” (CAM), and for which the preferred term among its advocates is now “integrative medicine,” meant to imply the “best of both worlds.” If I had to pick one fallacy that rules above all among proponents of CAM/IM, it would have to be either the naturalistic fallacy (i.e., that if it’s natural—whatever that means—it must be better) or the fallacy of antiquity (i.e., that if it’s really old, it must be better). Of course, the two fallacies are not unrelated. In the minds of CAM proponents, old is more likely to have been based on nature, and the naturalistic fallacy often correlates with the fallacy of antiquity. Basically, it’s a rejection of modernity, and from it flow the interest in herbalism, various religious practices rebranded as treatments (thousands of years ago, medicine was religion and religion was medicine—the two were more or less one and physicians were often priests as well), and the all-consuming fear of “toxins,” in which it is thought that the products of modernity are poisoning us.

Yes, there is a definite belief underlying much of CAM that technology and pharmaceuticals are automatically bad and that “natural” must be better. Flowing from that belief is the belief that people were happier and much healthier in the preindustrial, preagricultural past, that cardiovascular disease was rare or nonexistent, and that cancer was seldom heard of. Of course, it’s hard not to note that cancer and heart disease are primarily diseases of aging, and life expectancy was so much lower back in the day that a much smaller percentage of the population lived to advanced ages than is the case today. Even so, an implicit assumption among many CAM advocates is that cardiovascular disease is largely a disease of modern lifestyle and diet and that, if modern humans could somehow mimic preindustrial or, according to some, even preagricultural, lifestyles, that cardiovascular disease could be avoided. Not infrequently, evolutionary and genomic arguments are invoked, claiming that the estimated 10,000 years since the dawn of human agriculture is not a sufficiently long period of time for us to have evolved to handle diets rich in grains and meats and that we are “genetically wired” to exist on a diet like those of our paleolithic hunter-gatherer ancestors. For instance, in 2004, James H. O’Keefe Jr, MD and Loren Cordain, PhD wrote an article in the Mayo Proceedings entitled Cardiovascular Disease Resulting From a Diet and Lifestyle at Odds With Our Paleolithic Genome: How to Become a 21st-Century Hunter-Gatherer that asserted in essence, just that. Over the last decade, Cordain has become the most prominent promoter of the so-called “Paleo diet,” having written The Paleo Diet: Lose Weight and Get Healthy by Eating the Foods You Were Designed to Eat and multiple other books advocating a paleolithic-mimetic diet as the cure for what ails modern humans. Meanwhile, diets thought to reflect what our hunter-gatherer ancestors ate, such as the Paleo Diet consisting largely of animal and fish that can be hunted and fruits and vegetables that can be foraged for in the wild, have been promoted as a near-panacea for the chronic diseases of aging, such as cardiovascular disease and cancer.

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Posted in: Evolution, History, Nutrition

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