A recent opinion piece in The New York Times is an invitation to a dialogue on so-called alternative therapies, written by James Gordon. Gordon directs the Center for Mind-Body Medicine and was chairman of the White House Commission on Complementary and Alternative Medicine Policy appointed by President Bill Clinton. The piece, unfortunately, represents many of the common misconceptions about mainstream medicine and CAM (complementary and alternative medicine).
Even more distressing, the Affordable Care Act will likely reinforce current practice, which dictates surgical and pharmacological interventions that can be expensive, inappropriate, burdened by side effects and, often, ineffective.
His piece is doomed right from the start. Current practice does not “dictate” drugs and surgery, no matter how often CAM proponents claim that it does. This is simply a straw man designed by CAM advocates to create a niche for their brand. Mainstream medicine uses treatments that are backed by sufficient plausibility and evidence, regardless of modality. At least, this is what mainstream medicine strives for. We acknowledge the implementation is imperfect, and improving the standard is part of what we strive for at SBM.
Philosophically, however, mainstream medicine is not married to any particular type of treatment. It utilizes whatever works. Surgery and pharmacological therapy are certainly important parts of modern medicine, but there are many other treatments as well. These include nutrition, exercise, physical therapy, behavioral interventions, electromagnetic therapies, light-based therapies, radiation, avoidance of risk factors or triggers, and many physiological interventions such as hydration, electrolyte adjustments, oxygen supplementation, positive pressure for breathing, and more.
To portray the full range of medical interventions as “dictating drugs and surgery” is not only demonstrably wrong, it is practically libel against the medical profession. The purpose of this misdirection becomes clear in the next paragraph:
Forty years ago, as a researcher at the National Institute of Mental Health, I began to study inexpensive self-care strategies — then called “alternative therapies” — that might address the underlying biological and psychological imbalances that contribute to chronic conditions. These included nutrition, exercise and “mind-body” techniques like meditation, guided mental imagery and biofeedback.
Nutrition and exercise are squarely in the science-based mainstream medicine camp, but Gordon and others would like to rewrite history and rebrand these interventions as “alternative” in order to lend legitimacy to far more dubious treatments and the overall CAM brand.
He repeats the other very common trope of CAM propaganda, that alternative treatments address “underlying” causes, the implication being that mainstream medicine does not. This accusation always strikes me as ironic, for CAM proponents simultaneously decry science-based medicine for being “reductionist” and not addressing underlying causes. Of course, the purpose of taking a reductionist approach is to find underlying causes. In fact, science is the only tool that has uncovered real underlying causes of illness and allows us to address them.
CAM interventions, on the other hand, are often symptom-based, are overtly not reductionist, and have no hope of addressing true underlying causes.
Gordon’s list of alternative therapies, which he is now trying to rebrand yet again as “self-care strategies” (we’ll add that to the list that includes complementary, integrative, holistic, and functional medicine), includes meditation, guided-imagery, and biofeedback. These interventions all have one thing in common – they are basically indistinguishable from relaxation. There is good evidence to support the conclusion that taking time out of your hectic day to relax is good for your health. This basic physiological truth has been endlessly repackaged by CAM advocates with countless rituals, supported by research showing yet again the benefits of relaxation. What the research generally does not do is identify what is specific to the intervention and show that those specific variables have any specific advantage.
The research is generally of low quality, many studies are uncontrolled are constitute anomaly hunting. They essentially show that when you meditate “stuff happens” in the brain or body. A 2007 systematic review of the meditation research concluded:
Scientific research on meditation practices does not appear to have a common theoretical perspective and is characterized by poor methodological quality. Firm conclusions on the effects of meditation practices in healthcare cannot be drawn based on the available evidence.
Gordon goes on to oversell the benefits of nutrition for cancer prevention and “mind-body” interventions (i.e. relaxation) for HTN and diabetes. He concludes:
What was unexamined and alternative 40 years ago is now well researched. It should be fundamental. If we are going to reduce our ruinous costs and improve our declining national health, we must make self-care and group support central to all care.
What is well-researched and supported by evidence are those treatments that are already incorporated into mainstream medicine – which I briefly listed above. We don’t need to come up with a new label for diet and exercise.
The strategy here is clear, it is what I have referred to as the “bait-and-switch” of CAM, and Scott Gavura and others here have called a Trojan Horse. Pretend that science-based medicine only deals with drugs and surgery, then rebrand everything else as alternative, complementary, integrative, holistic, functional, patient-centered, self-care, or whatever. You can also take proven interventions and surround them with a useless ritual or with specific features that add nothing to the overall therapeutic effect, but do create a unique brand.
Then use the legitimate science-based treatments that you have rebranded as alternative as the thin edge of the wedge (choose your metaphor) in order to open the door to a host of truly unscientific nonsense, like homeopathy and acupuncture (which don’t work).
There is one point on which I agree with Gordon – the rising costs of health care are a definite problem in this country and more generally. The most beneficial way to address this problem is to optimize the efficiency of modern medicine – to avoid wasting money on interventions that do not work, on rituals that add nothing, or on specialists based on dubious philosophies of medicine.
We also should strive to get the most out of our biomedical research, which means we should not waste resources researching nonsense that has essentially no chance of yielding useful interventions.
Pseudoscience, sloppy definitions, poor research, marketing hype, and ineffective regulations should be the targets of any effective strategy at reducing waste in medicine in order to lower health care costs.