Integrative medicine combines the practice of medicine with alternative medicine. Proponents tend to take a paragraph or two to say this, but that is what remains when boiled down to its essence. By putting this more concise definition together with Tim Minchin’s often-quoted observation about alternative medicine, you get: integrative medicine is the practice of medicine combined with medicine that either has not been proved to work or proved not to work. If it is proved to work, it is medicine.
I couldn’t find an official start date for integrative medicine, but it seems to have been around for about 15-20 years. (Osher Center for Integrative Medicine at the University of California, San Francisco, an early adapter, opened in 1997.) Yet despite some lofty pronouncements about transforming patient care, there is still no good evidence that integrative medicine improves patient outcomes. It seems unlikely that such evidence is forthcoming. It is illogical to assume that adding therapies that do not work, or are proven not to work, would benefit a patient except by inducing the ethically problematic placebo response.
Whatever its goals initially, integrative medicine now appears to serve two purposes. First, it attracts funding from wealthy patrons (Samueli, Bravewell) and the government (the military, NCCAM). Second, it is a marketing device used by hospitals, academic medical centers and individual practitioners. As an added bonus, alternative medicine is usually fee-for-service because very little of it is covered by insurance. And whatever its charms as a money-making device, given the lack of proven health benefit it is fair to ask: is integrative medicine worth it? To answer that question, let us look at what might be called the supply side of integrative medicine practitioners’ delivery of alternative medicine. Here we run into some unpleasant facts proponents seem unwilling to acknowledge: integrative medicine’s collateral damage. The alternative medicine services and products offered by integrative medicine practitioners do not exist in a vacuum. They are supplied by chiropractors, naturopaths, acupuncturists, and reiki masters, among others. They include dietary supplements, botanicals and homeopathic remedies. Let’s look at just a few of the less savory aspects of these practices and products we’ve discussed at SBM. (SBM devotees can skip this part. You’ve heard it all before.)
Chiropractors purport to diagnose and treat imaginary subluxations. They claim they can treat asthma, allergies, ADHD, menstrual problems, endocrine disorders, and a host of other conditions and attract patients with practice-building schemes. They also promote the idea that they are primary care physicians able to diagnose and treat the general population, including children. (A claim convincingly refuted by one of their own studies.) Their use of disproven diagnostic techniques and treatments is well-documented: applied kinesiology, cranial sacral therapy, and machines which purport to detect nutritional deficiencies, to name a few. Their disproven treatments can cause stroke and death although there is no systematic data collection, so the real incidence is unknown. Many chiropractors are anti-vaccination.
Naturopathy is simply a collection of treatments, not a systematic approach to human health. As he has done before, David Gorski summarized naturopathy practice nicely just last week:
The problem with naturopathy, of course, is that it is so diffuse and encompasses so many different forms of quackery that it’s hard to categorize. Basically, it’s anything that can be portrayed as “natural,” be it traditional Chinese medicine, homeopathy (which is an integral component of naturopathy, something that should tell you all you need to know about naturopathy), herbalism, energy healing, Ayurvedic medicine, the four humors, or whatever. Add to that a number of bogus diagnostic modalities, such as applied kinesiology, live blood cell analysis, iridology, tests for imaginary “food allergies” and “nutrient deficiencies” that conventional medicine doesn’t recognize, plus an overwhelming emphasis on purging the body of “toxins,” unnamed and named but all unvalidated by science, and it rapidly becomes apparent that naturopathy is a veritable cornucopia of pseudoscience and quackery. Seemingly, there is no quackery that naturopathy does not credulously embrace . . . Basically, naturopathy is a hodge-podge of quackery mixed with science-based modalities magically “rebranded” as “alternative” and “natural.” In that, naturopathy is the ultimate in “integrative medicine,” in which quackery is “integrated” with science-based medicine.
Naturopaths have simply invented diseases to treat, use bogus diagnostic methods and are anti-vaccination. Naturopathic care is associated with worse outcomes and you needn’t look any further than David Gorski’s post on Tuesday to see the horrible consequences of their practices. Yet they are making a huge effort to become licensed primary care physicians in all 50 states, with the same scope of practice as M.D. and D.O. primary care physicians. Like chiropractic, there is anecdotal evidence that their treatments can cause injury and death, although their failure to systematically collect data means the true incidence is unknown.
Acupuncture is an elaborate placebo although proponents continuously attempt to portray it otherwise. It is based on the pre-scientific notion that energy (or “qi”) flows through the body which, when blocked, causes health problems. Unblocking this energy with needles supposedly restores the proper flow. None of this has any plausible basis in human physiology. Acupuncturists, like chiropractors and naturopaths, use bogus diagnostic devices, as well as offering iridology, Kirlian photography and other disproven methods. Again, there is anecdotal evidence of harm cause by acupuncture but the true incidence is unknown because of lack of data collection.
Dietary supplements and homeopathy
The extremely lucrative dietary supplement industry refuses to reveal its effectiveness and safety research to the public and fights all efforts to make it do so. It opposes government funding of additional safety research. Homeopathy is nothing more than fraud and unregulated fraud at that. The federal government has defaulted to a private agency run by homeopaths to police its own industry. Two medical toxicology organizations recently stated, flat out, that no one should take dietary supplements, botanicals or homeopathic products, a warning that will no doubt be ignored by alternative medicine providers because evidence of safety or effectiveness is not a requisite for their practices.
“Mind and body” practices
Favorite offerings of integrative medicine centers include “energy medicine” techniques like reiki, reflexology and cranial sacral therapy. None of these have any plausible basis in human physiology. All have been studied in clinical trials and none perform any better than placebo.
In sum, alternative medicine practitioners regularly take patients’ money for treatments we know are ineffective, unsafe or both. They diagnose conditions we know don’t exist using bogus diagnostic methods. Alternative medicine injures and even kills patients with treatments that provide no benefit. And practitioners spread anti-vaccination misinformation, even to the point of supporting anti-vaccination organizations.
Alternative medicine doesn’t exist for the convenience of integrative medicine. Nor could it. Providing the limited supply of alternative medicine used by integrative medicine practitioners is not an economically sustainable model. The sole purpose of alternative medicine is to put into practice its varied (and conflicting) philosophies and to make money doing so. Alternative medicine schools don’t send their graduates out into the world to become handmaidens to integrative medicine practitioners. And alternative medicine practitioners aren’t going to stand for some role subordinate to medical doctors, limited in their practices to what integrative physicians think they should be doing. In fact, alternative medicine practitioners regularly denigrate medical doctors. Nor do dietary supplement and homeopathic remedy manufacturers make products for consumption on the recommendation of integrative medicine practitioners. They make products to sell to the public and they want to make as much money as possible, often without regard to whether their products are effective and, for some, without regard for safety.
I have to assume that even the most devoted integrative medicine practitioner would not endorse much of what their compatriots in the alternative medicine field do, if they bothered to research the subject. I hope I am right. (If not, integrative medicine is an even bigger problem than we thought.) Yet by incorporating alternative medicine providers and products into their practices, integrative medicine must face the fact that it is supporting alternative medicine in all its guises – the quackery, the deceit, the wasted money, the injury and death. The naturopaths employed by Cancer Treatment Centers of America come from the same system that produces the naturopath who treats Chris Wark. The chiropractors employed by CTCA come from the same schools that educated the chiropractors who misinform patients about the safety and efficacy of vaccinations. And these practitioners aren’t outliers. They are part of the mainstream. The treatments employed by Wark’s naturopath are standard naturopathic treatments. Neither the American Chiropractic Association nor the International Chiropractic Association, the two main chiropractic trade associations, endorses the CDC vaccination schedule for patients. Two chiropractic organizations actually support the notoriously anti-vaccination National Vaccine Information Center. (Or, as we prefer to call it, the National Vaccine (Mis)Information Center.)
Integrative medicine helps keep this entire alternative medicine enterprise afloat. It’s reminiscent of that saying about women (or men, depending on your perspective): “you can’t live with them but you can’t live without them.” Integrative medicine practitioners cannot endorse much of what alternative medicine practitioners do, but they can’t live without them either. Integrative medicine’s defense would no doubt be that it is actually helping patients navigate this world of snake oil, quackery and pseudoscience by vetting alternative medicine and delivering only the “best” to patients, even if it is admittedly unproven or disproven. But that doesn’t let them off the hook. That excuse is no different from an art museum admitting it buys from art thieves but defending itself by saying it buys only the best of what they have to offer. It is the same as the fashion and computer retailers who turn blind eye to the appalling conditions under which their products are manufactured.
So let’s return to the question: is integrative medicine worth it? Is it worth the collateral damage? It certainly appears to benefit a limited segment of the medical industry when employed as a marketing device or to attract funding. To my mind, that hardly outweighs the harm, especially without any demonstrated improvement in patients’ health. Perhaps integrative medicine can make the case that somehow these financial benefits outweigh the damage. A good start would be by addressing the issue at all.
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