Articles

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.

The power of language in CAM

That we at the Science-Based Medicine blog aren’t exactly fans of NCCAM is not exactly a secret. So confident am I of this contention that I daresay that I speak for us all at SBM when I point out that NCCAM is a source of research funding that has been dedicated to pointless studies of quackery, “rebranding” science-based modalities, such as diet and exercise, as somehow being CAM, and “educational” grants clearly designed to promote CAM. After all, several of us have at various times called for its dismantling, with its potentially useful components (for example, the study of natural products pharmacology currently disguised as studying herbal medicines and supplements, to be absorbed back into various Institutes and Centers of the NIH more appropriate to study them.

A couple of years ago, in response to Dr. Briggs’ discussing the same matter, albeit without the discussion of a potential name change, I asked a simple question with respect to NCCAM: What’s in a word? In fact, I asked that question in response to the very first blog post that Dr. Briggs wrote, in which she welcomed readers to the new NCCAM researchblog and, more importantly (and tellingly), her second post “Integrative — What’s in a Word?” At the time, I thought it was a very good question, albeit not in the way that Dr. Briggs intended. The reason was that advocates of so-called “complementary and alternative medicine” (CAM), despite having been the ones to have coined the term in order to soften the negative connotation of the word “alternative” applied to medicine, are no longer happy with the term “CAM.” Indeed, government entities being government entities and tending to move slowly, I’m only surprised that it took NCCAM so long to want to change its name to be more in line with the new, hipper thinking (if you can call it that) that says that there’s nothing “alternative” in CAM. If we’re to believe CAM advocates, CAM involves it’s “integrating” only the good stuff from CAM, the stuff that allegedly can be proven scientifically. Never mind that much of it is what Dr. Crislip called type 1 CAM: pure fantasy, which might be useful if CAM practitioners could admit that the only studies such modalities are useful for is to demonstrate the noise inherent in the clinical trial process and to measure placebo effects, which have, not surprisingly, been “rebranded” as “powerful mind-body effects.”

So let’s take a look at Dr. Briggs’ justification for this proposed name change. In it, you will see the misuse of language, the clever verbal prestidigitation, that underlies so much of CAM. I don’t think that Dr. Briggs’ is doing this intentionally, but, after six years at the helm of NCCAM, she seems to have imbibed deeply of the culture of CAM and its chosen word use that it’s now second nature to her:

Today, I’m asking for your input regarding the name of our Center. In the 16 years since NCCAM was established, we have funded more than 3,800 research projects examining the safety, efficacy, and use of a very wide array of interventions and practices with origins outside mainstream medicine. At the same time, large population-based surveys have reinforced the fact that the use of true alternative medicine—that is, the use of unproven practices in place of treatments we know to be safe and effective—that that is rare. Also during this time, the field of research has progressed, and a much more defined set of research opportunities has emerged. We see the growth of integrative health care within communities across the US, including hospitals, hospices, and military health facilities. With these changes in the research and practice landscape, we believe that our current name no longer accurately reflects our Congressional mandate, which is, in part, to study the integration of these practices as a complement to conventional care.

We also recognize that our current name is not explicit about our research mission, and that it may be misconstrued as advocacy or promotion of unproven practices.

And so, we are proposing that the name of our Center be changed to “NATIONAL CENTER FOR RESEARCH ON COMPLEMENTARY AND INTEGRATIVE HEALTH.” The goal of this change is to better align the Center’s name with the evolution in health care and our research focus, and thus best address our Congressional mandate.

I don’t know whether Dr. Briggs knows it or not, but this is the very same rationale that’s been used since time immemorial (or at least over the last 30 years or so that has seen the rise of CAM and quackademic medicine) every time a name change for “alternative” medicine has been proposed. As I once put it in far more detail three years ago, once upon a time—maybe three decades ago—there was quackery. Physicians, actually caring about prior plausibility based on basic science considerations, intuitively “grokking” Bayesian thinking without necessarily having had any formal training in it, recognized that modalities such as homeopathy, reflexology, and various “energy healing” methodologies were based on a combination of prescientific vitalism, magical thinking, and/or science that was incorrect, distorted, misunderstood, or misrepresented. Physicians weren’t afraid to call a quackery quackery, quacks quacks, and charlatans charlatans. The first step for advocates to change this perception clearly involved language.

Arguably, the first ill-fated attempt to change the language landscape of quackery was to start referring to it as “alternative medicine,” medicine that was (and still is) medicine that does not fit into the current scientific paradigm, a term used to describe medical practices not supported by science and evidence, and were used instead of effective therapies. As Dr. Crislip reminded us just last Friday, there is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. “Alternative medicine” was not a rubric that could long stand, at least not in a form that would ever gain credibility in mainstream medicine.

Thus was born, around 20 or 25 years ago, the term “complementary and alternative medicine” (CAM). The arguments used for the name change were virtually identical to those that Dr. Briggs is using in favor of her name change: Almost no one uses alternative medicine instead of science-based medicine, thus making it not “alternative.” That’s the very reason why the word “complementary” was added to the term “alternative medicine” in the first place. Alternative medicine would “complement” conventional medicine, not replace it! As before, CAM was (and is) medicine that does not fit into the current scientific paradigm, including treatments that are not supported by evidence and are ineffective and/or potentially harmful. The difference? As the name implied, CAM therapies are used in addition to rather than instead of real medicine. Over a relatively brief period of time, the name change had its intended effect. No longer did many physicians automatically view modalities that were once considered quackery, later considered “alternative,” and now considered “CAM” as quackery, and those that still did were dismissed as close-minded, stubborn, and dogmatic, relics who were trying to swim against the coming wave of wonderful CAM magic.

Into this world, with this then-new nomenclature in ascendance, the precursor office to NCCAM, the Office of Alternative Medicine (OAM), was reborn as a full center, the National Center for Complementary and Alternative Medicine, with an abbreviation almost as pithy as “CAM,” namely NCCAM. That name has endured for 16 years. Ironically, the name has endured as CAM has moved on. The reason CAM has moved on, with the word “CAM” increasingly being shunned by its former advocates, is simple. The word “alternative” is still there. The very name of CAM still implies that its treatment modalities will forever be considered not quite right, not quite in the mainstream, not quite “real” medicine. At the very least, the word “complementary” implies that CAM is not the real medicine, that it only “complements” real medicine. Medicine was the cake, and their wares were just the icing. That this is simultaneously both a correct and incorrect perception—most CAM is not real medicine, but it also “complements” nothing—is irrelevant to CAM advocates. They believe; so they want a name that eliminates that inference. They craved respect. They wanted to be co-equals with physicians and science- and evidence-based medicine.

Thus was born the term “integrative medicine.” The term “integrative medicine” (IM) served their purpose perfectly. No longer were CAM/IM treatments merely “complementary” to real medicine. Now they were “integrating” their treatments with those of science- and evidence-based medicine! The implication, the very, very, very intentional implication, was that alternative medicine was co-equal to science- and evidence-based medicine, an equal partner in the “integrating.”

As I said before, I’m only surprised that it took the NCCAM Advisory Board and Dr. Briggs so long to decide that a name change is in order for NCCAM.

Polishing the turd to a high gloss

Of course, the appeal to “integrative” health and denial that anyone uses CAM instead of real medicine are not the only arguments that Dr. Briggs uses. She also uses the logical fallacy known as argumentum ad populum, the appeal to popularity, which argues in essence that because something it popular there must be something to it. In this case, in addition to the claim that CAM is not “alternative,” Dr. Briggs is arguing that the popularity of CAM justifies the name change, in which “we see the growth of integrative health care within communities across the US, including hospitals, hospices, and military health facilities.” Even if true (and, unfortunately, the infiltration of quackademic medicine into both medical academia and community hospitals like so much kudzu is a fact), how that justifies a name change, I don’t know, but apparently to Dr. Briggs it does.

The other point that Dr. Briggs makes that caught my attention was her statement that “the field of research has progressed, and a much more defined set of research opportunities has emerged.” When I heard her utter that phrase, I started thinking. What on earth was she talking about? NCCAM has a hard time even defining what “CAM” is, which makes me wonder how the definition of its mission will change when the term “CAM” is no longer even part of its name. First, let’s look at NCCAM’s definition of CAM:

Defining CAM is difficult, because the field is very broad and constantly changing. NCCAM defines CAM as a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. Conventional medicine (also called Western or allopathic medicine) is medicine as practiced by holders of M.D. (medical doctor) and D.O. (doctor of osteopathic medicine) degrees and by allied health professionals, such as physical therapists, psychologists, and registered nurses. The boundaries between CAM and conventional medicine are not absolute, and specific CAM practices may, over time, become widely accepted.

“Complementary medicine” refers to use of CAM together with conventional medicine, such as using acupuncture in addition to usual care to help lessen pain.

Can any of you tell from this what practices would and would not be CAM? I can’t, other than that by this standard certain things that are considered CAM shouldn’t be, such as diet and exercise, as well as herbal medicine, the latter of which is, as I’ve repeated more times than I can remember, nothing more than the old and respected branch of pharmacology known as pharmacognosy, or natural products pharmacology. NCCAM further divides CAM into these five categories:

  1. Alternative medical systems: Complete systems outside of mainstream medicine based on concepts that vary widely depending on the whole medical system. Includes: Homeopathy, traditional Chinese medicine, Ayurvedic medicine, Native American medicine, naturopathy.
  2. Mind-body interventions: Influencing physiology through influencing the mind. Includes: Meditation, yoga, guided imagery, deep breathing exercises, progressive relaxation, and tai chi.
  3. Biologically-based treatments: Use of substances found in nature, including diet. Includes: Herbal medicines, dietary supplements, probiotics, nutrition and diet manipulation.
  4. Manipulative and body-based methods: Manipulation of musculoskeletal structures to affect physiology. Includes: Osteopathy, chiropractic, craniosacral therapy, massage therapy.
  5. Energy therapies: Manipulation of “life energy” fields, sometimes called “biofields.” Includes: Therapeutic touch, reflexology, rolfing, reiki, acupuncture, qi gong.

Lifestyle interventions, such as exercise, clearly fall under “mind-body” while diet and natural products clearly fall under biologically based therapies. Yet all of these can be and, when not infused with CAM magic, are science-based. There is no need for a separate “complementary,” “alternative,” or “integrative” category to account for them. Doing so does nothing other than ghettoize these modalities by making them seem less than respectable because they’ve become associated with pseudoscience. Of course, one thing I noticed while doing the web research for this post is that it’s actually hard to find a table of CAM subtypes on the actual NCCAM website, although lists and tables are common elsewhere. The most recent CAM Basics brochure from NCCAM lists only natural products, mind and body medicine, and manipulative and body-based practices, while relegating energy therapies and alternative medical systems to “other.”

To be honest, I fail to see what Dr. Briggs means when she says that “a much more defined set of research opportunities has emerged.” The snarky skeptic in me can’t help but wonder whether this “much more defined set of research opportunities” came about as NCCAM was so continually embarrassed over the years because of its funding of studies into what can only be described as magic and mysticism, such as homeopathy, reiki, therapeutic touch, and distance healing that under Dr. Briggs’ leadership the most blatant of these have been (mostly) discarded. As I put it when discussing the recent five-year strategic plan for NCCAM for 2011 through 2015, this amounts to saying, “Let’s do some real science for a change!” In other words, let’s concentrate on modalities like diet, pharmacognosy (excuse me, herbal medicine and supplements), and exercise, where we might actually find something, rather than on type 1 CAM like energy medicine, which even CAM practitioners at some level seem to recognize as pure fantasy and magical thinking. Of course, if that’s what NCCAM does, then the need for NCCAM disappears, because there is nothing inherent in any of these things that requires a separate center or institute within the NIH to study it. NCCAM was created through Senator Tom Harkin’s (D-IA) efforts to study magic like energy medicine, not mundane, science-based interventions that have been “rebranded.”

Finally, Dr. Briggs claims that the proposed name change is necessary because NCCAM’s current name “may be misconstrued as advocacy or promotion of unproven practices.” The problem is that there is nothing “misconstrued” here. NCCAM has promoted unproven practices, particularly through educational grants to teach CAM, the teaching of which is almost always done not in a science-based fashion but in a credulous fashion that assumes CAM works. Indeed, it was an NCCAM grant that funded the initial effort to “integrate” such credulous CAM education into the standard medical school curriculum at Georgetown and other medical schools, even up to encouraging the partnering of real medical schools with schools of naturopathy.

No doubt this “rebranding” of NCCAM is intended as the first step in developing its next five-year strategic plan for 2016 to 2020. After all, the current NCCAM five year plan has only a year and a half left to go.

So what should we call NCCAM, anyway?

I was half-tempted to make this post about proposing names for NCCAM that would be better than the proposed new name National Center for Research on Complementary and Integrative Health. While the proposed name is a perfect example of the move away from acknowledging anything “alternative” or less-than-evidence-based about CAM, it does not describe what NCCAM really is about, whether its director and the officials who run it will acknowledge it or not. Observing some discussions where this has come up, I’ve seen proposed names such as the National Center for Research on Supplements, Complementary and Alternative Medicines (SCAMs), the National Center for Research on Tooth Fairy Medicine (I like this one), National Center for Research on Snake Oil and Science Denial, National Center for Unprovable Therapies, and National Center for More Research is Needed (I would suggest a slight alteration to this one to National Center for More Research Is Always Needed). Personally, I like Harriet Hall’s suggestion, seen on the HealthFraud mailing list, of Center for Studying Things Scientists Wouldn’t Otherwise Bother Studying. I don’t mind if you try to outdo these suggestions in the comments, but let’s not do just that. NCCAM, unfortunately, isn’t going anywhere any time soon, so I urge all SBM readers to head on over to the link for public comments regarding the proposed name change and submit your thoughts to Dr. Briggs. Feel free to cite this post. Remember, you only have until June 6.

The bottom line, however, is that it really doesn’t matter that much what NCCAM is called. Sure, removing “alternative” and adding “integrative” somewhere in the name might make it less offensive to its stakeholders, the alternative medicine practitioners whose purpose it serves, and more palatable for a different reason to science-based physicians, but unless the underlying mission and structure are changed radically, it’ll just be putting lipstick on a pig or polishing a turd, or whatever metaphor you like for trying to make something that is fundamentally flawed beyond easy redemption seem attractive.

Speaking of polishing a turd, Adam Savage and Jamie Hyneman once demonstrated on their most excellent television show MythBusters that it is indeed possible to polish a turd to a high gloss. However, doing so takes a lot of work:

Basically, polishing a turd requires breaking the turd down into a slurry, completely remolding it into a sphere, and letting it dry, followed by many hours of constant buffing. The current leadership of NCCAM appears not to want to go that far, which, if we carry the metaphor a bit further, would involve actually breaking NCCAM down to the proverbial slurry and reforming it, something that is highly unlikely to happen. Until the day that NCCAM is either completely rethought on a basis of science informed by prior plausibility that would eliminate completely the magic or dismantled, there’s nothing to do except polish the turd to a brighter sheen and hope no one notices the smell.

Posted in: Clinical Trials, Medical Academia, Politics and Regulation

Leave a Comment (138) ↓