One of the most effective spin techniques used by advocates of “integrative medicine” (also sometimes called “complementary and alternative medicine,” or CAM for short) to legitimize quackery has been to claim basically all non-pharmacologic, non-surgical interventions as “integrative,” “complementary,” or “alternative.” Thus, science-based interventions such as diet changes to treat and/or prevent disease, exercise, and other lifestyle alterations are portrayed as somehow so special that they need their own specialty, “integrative medicine,” even though they are simply part of medicine. I pointed this out a mere two weeks ago when I discussed the National Center for Complementary and Integrative Health (NCCIH) review of non-pharmacological treatments for pain. It was a systematic review that was essentially negative but spun as positive for some interventions and lacked some key analyses that a good systematic review includes, such as assessment of the quality of the studies included and evaluating them for bias.
Such were my thoughts over the weekend as I got into a Twitter exchange with an advocate of integrative medicine who was touting the benefits of diet as a cancer preventative and how a course in nutrition “opened her eyes.” That in and of itself wasn’t particularly annoying, although I strongly suspect that the nutrition course she took was not given by actual registered dietitians or other experts in science-based nutrition (she wouldn’t say when questioned). What was annoying is that she trotted out some tropes beloved by integrative medicine proponents, such as the claim that most doctors don’t do prevention because they get paid to treat. She was called out for it:
Oddly enough, on the same day a post from the American Society of Clinical Oncology (ASCO) came up in e-mail lists that discussed the actual evidence for the utility of diet and exercise for cancer prevention. It’s almost as though Twitter were telling me it was time for me to discuss this issue from a science-based perspective. So I will attempt to do so.
I’ve had the Monday spot on this blog for quite a long time now. While there are many advantages to posting on Monday, not the least of which is having more time to put a post together (although that is also a disadvantage because it incentivizes my taking more time than I sometimes should), one distinct disadvantage is that all the Monday holidays are mine. That leaves me a choice on, for example, Memorial Day and Labor Day every year. It’s a choice with three options: The first is: Don’t post. (Do stop laughing, please. I know it’s me.) The second is: Use a guest post. I thought about this, and there are guest posts in the pipeline, but I don’t like to use a guest post just because I’m feeling lazy. It strikes me as an abuse of being the managing editor. Finally, I could post, which is what I decided to do.
I mainly decided to do a post because late last week there was something to blog about that was pretty important and interesting, courtesy of the National Center for Complementary and Integrative Health (NCCIH), which was formerly known as the National Center for Complementary and Alternative Medicine (NCCAM). Basically, on September 1, the NCCIH published a press release, “Review Examines Clinical Trial Evidence on Complementary Approaches for Five Painful Conditions.” Elsewhere, NCCIH Lead Epidemiologist and first author of the review, Richard Nahin, PhD, MPH, bragged on the NCCIH blog, “New Review Offers Providers and Researchers Evidence-Based Information on Complementary Health Approaches for Pain.” It didn’t take long for headlines to start appearing that said things like:
I was originally going to write this post for the 4th of July, given the subject matter. However, as regular readers know, I am not unlike Dug the Dog in the movie Up, with new topics that float past me in my social media and blog reading rounds serving as the squirrel. Then I got a copy of the movie VAXXED to review last week, and before I knew it this post had been delayed two weeks. Never let it be said, though, that I don’t circle back to topics that interest med. (Wait, strike that. Sometimes, that actually does happen. It just didn’t happen this time.) This time around, I will be using documents forwarded to me by a reader as a means of revisiting a discussion that dates back to the early days of this blog, before discussing the broader problem, which is the infiltration of pseudoscientific “complementary and alternative medicine” (CAM) into VA medical centers.
The return of the revenge of “battlefield acupuncture”
Today’s topic is the Veterans Health Administration (VHA) and its embrace of pseudoscience. VA Medical Centers (VAMCs) provide care for over 8 million veterans, ranging from the dwindling number of World War II and Korean War veterans to soldiers coming home now from our wars in Iraq and Afghanistan. Although there have been problems over the years with VAMCs and the quality of care they provide, including a recent scandal over hiding veterans’ inability to get timely doctor’s appointments at VAMCs, a concerted effort to improve that quality of care over the last couple of decades has yielded fruit so that today the quality of care in VA facilities compares favorably to the private sector. Unfortunately, like the private sector, the VA is also embracing alternative medicine in the form of CAM, or, as its proponents like to call it these days, “integrative medicine,” in order to put a happy label on the “integration” of pseudoscience and quackery with conventional medicine.
Exactly one year ago tomorrow, The Bravewell Collaborative shut down, an event so momentous that few seem to have noticed. It’s been a while since we at SBM devoted much attention to Bravewell, although, at one time, its doings were a regular feature of SBM posts.
For those of you not familiar with Bravewell, a brief history. The main mover and shaker behind The Bravewell Collaborative was Christy Mack, wife of former Morgan Stanley head John Mack and a financier of sorts in her own right. She and the widow of another Morgan Stanley bigwig, Susan Karches, neither of whom had any particular expertise in finance, managed to get about $220 million in bailout funds from the Federal Reserve, a boondoggle recounted in Matt Taibbi’s 2011 hilarious Rolling Stone article, “The Real Housewives of Wall St.” Ms. Mack had established the Bravewell Collaborative a few years earlier, with her own contributions and that of other philanthropists, as a private operating foundation, a further opportunity to benefit from government largesse in the form of tax deductions.
Here’s Bravewell’s definition of “integrative medicine”:
Integrative medicine is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person’s health. Employing a personalized strategy that considers the patient’s unique conditions, needs and circumstances, integrative medicine uses the most appropriate interventions from an array of scientific disciplines to heal illness and disease and help people regain and maintain optimal health.
The National Consortium for Credentialing of Health & Wellness Coaches (NCCHWC) and the National Board of Medical Examiners (NBME) signed an agreement last month for the launch of a national certification for individual health and wellness coaches in the U.S. According to a joint press release, the agreement is a landmark in the efforts of a dedicated group of individuals who have been working for years to establish professional practice and educational standards for health and wellness coaching.
What is “health and wellness coaching?” According to NCCHWC’s website:
Health and Wellness Coaches partner with clients seeking self-directed, lasting changes, aligned with their values, which promote health and wellness and, thereby, enhance well-being. In the course of their work health and wellness coaches display unconditional positive regard for their clients and a belief in their capacity for change, and honoring that each client is an expert on his or her life, while ensuring that all interactions are respectful and non-judgmental.
“Complementary and alternative medicine” (CAM), now more frequently referred to as “integrative medicine” by its proponents, consists of a hodge-podge of largely unrelated treatments that range from seemingly reasonable (e.g., diet and exercise) to pure quackery (e.g., acupuncture, reiki and other “energy medicine”) that CAM proponents are trying furiously to “integrate” as coequals into science-based medicine. They do this because they have fallen under the sway of an ideology that posits a false dichotomy: To practice true “holistic” and “preventative” medicine, physicians and other health care professionals must embrace the pre-scientific, pseudoscientific, or anti-scientific ideas about medicine that underlie much of the “alternative medicine” being “integrated.”
Unfortunately, they’ve been largely successful over the last 25 years or so. From my perspective, the strategy that has been the most effective in mainstreaming quack practices as part of “integrative medicine” has been what I like to call the “rebranding” of practices that could and should be part of standard, science-based medicine. I’m referring, of course, to nutrition and dietary interventions, as well as lifestyle interventions, specifically exercise. To the extent that standard medicine might have undervalued such interventions over the past few decades, we practitioners of science-based medicine might be said, to some extent at least, to have brought this on ourselves. On the other hand, it is not as though doctors haven’t been advising our patients to quit smoking and moderate their drinking and to lose weight through altering their diet and exercising more for many decades. We do this because we know it works. For instance, when some naturopathic quack touts “curing” type II diabetes with a vegan diet plus exercise, we know that can work because we know that losing weight can normalize blood sugar values in many cases of type II diabetes. Heck, the Endocrine Society itself even says so, declaring “lifestyle optimization” as “essential for all patients with diabetes” and recommending that all patients with type II diabetes “strive to attain and maintain an optimal weight through a primarily plant-based diet high in polyunsaturated and monounsaturated fatty acids, with limited intake of saturated fatty acids and avoidance of trans fats,” that they lose weight through physical activity, and get enough rest. A vegan diet just takes that dietary advice to an unnecessary extreme, and any supplements recommended are almost always unnecessary.
It turns out that the use of certain forms of CAM makes it less likely that breast cancer patients will receive the chemotherapy they need.
So-called “alternative” medicine is made up of a hodge-podge of health care practices and treatments based on beliefs that are unscientific, pre-scientific, and pseudoscientific. These modalities include practices as diverse as homeopathy, traditional Chinese medicine, reflexology, reiki and other forms of “energy medicine” based on vitalism, chiropractic, and naturopathy, and that’s a short list of the quackery that falls under the rubric of the term “alternative medicine.” Unfortunately, this unscientific, pre-scientific, and pseudoscientific hodge-podge of treatments rooted in nonsense is rapidly being “integrated” into real medicine, thanks to an unfortunately influential movement in medicine whose members have been seduced into thinking that there might be something to them and view “integrating” them into medicine as means of practicing more “holistic” and “humanistic” medicine. This “integration” started out by being called “complementary and alternative medicine” (CAM) but now among believers the preferred term is usually “integrative medicine,” largely because it eliminates the word “alternative,” which implies (correctly) that the modality is not real medicine, and “complementary,” which implies a subsidiary status, a status of being nice to have but not essential.
Particularly harmful is the hostility towards conventional medicine that often strongly correlates with use of alternative medicine. Indeed, some people even choose to rely on alternative medicine instead of real medicine to treat cancer. Unsurprisingly, the results of such a decision are generally not very good. Actually, they are almost always terrible. Very, very terrible indeed. Not surprisingly, the use of alternative medicine is associated with bad outcomes. Cancer patients who might have survived die because of it. It’s not as though it hasn’t been studied either, although the main studies I’m aware of tend to look at the bad outcomes in patients who choose alternative medicine. There is another question, and it’s one that a new study published in JAMA Oncology last week seeks to answer. It’s a study that briefly made the news, producing headlines like:
I’ve written a lot about the language issue with respect to alternative medicine. As I like to put it (at least in shortened form), first there was quackery. Quacks did not like that name at all, and thus was born alternative medicine. And the quacks did think it good—for a while. There was a problem, however. “Alternative” medicine implied (correctly, of course) that what was being discussed was not real medicine, and the quacks could not abide that. Thus was born “complementary and alternative medicine” (CAM).
And the quacks thought this very good indeed.
Unfortunately, it was not long before the problem with the term CAM became apparent. It had the word “complementary” in it. The implication of that word, of course, is that what they were doing was still somehow not real medicine. It was complementary to real medicine, the icing on the cake, if you will. Real medicine could do without it, and having that implication in the very name that their evolving specialty had taken on was offensive to the quacks.
So they changed it.
NOTE: Anyone who has seen several derogatory articles about me on the web and is curious about what the real story is, please read this and this.
SB277, which eliminates nonmedical exemptions to school vaccine mandates in California, is a very good law, but it’s not perfect. Unfortunately, one provision allows the issuance of medical exemptions based on the say-so of doctors using antivaccine misinformation and pseudoscience.
I realize that it’s a cliché to say so, but some clichés are true. Time really does fly. It’s hard to believe that a year ago California—and, by proxy, the rest of the country—was in the throes of a major political war over the bill SB277. SB277, you will recall, was a bill introduced into the California Assembly in the wake of the Disneyland Measles outbreak in early 2015 that eliminated non-medical exemptions to school vaccine mandates beginning with the 2016-2017 school year. Ultimately, SB277 passed and was signed into law by Governor Jerry Brown last July. It was an uncommon victory for science and public health, and already appears to be having a positive effect on vaccine uptake in kindergarten children.
Unfortunately but not unexpectedly, to say that the proposal and passage of SB277 into law drove the antivaccine movement into even greater fits of crazy in response is to put it mildly. It became a common trope on antivaccine websites and blogs to see SB277 compared to fascism, in particular the Holocaust. Robert F. Kennedy, Jr. and “Dr. Bob” Sears explicitly compared SB277 to the Holocaust. Truly, the Godwin was strong in the antivaccine movement. One particularly offensive meme that went around at the time consisted of antivaccinationists suggesting that SB277 was a major step in the direction of requiring unvaccinated children to wear a badge or armband to identify themselves, the way that the Nazis required Jews to wear badges or armbands with a yellow Star of David on them. One, Heather Barajas, even went so far as to be photographed with her children wearing such an “unvaccinated” badge and juxtapose that photo with photos of Jews from the Third Reich wearing yellow Stars of David.
The Integrative Medicine Wheel
“Integrative medicine” (IM) is an ideological movement within medicine driven in large part by those whose livelihoods depend on its continued existence. This includes both those with positions in academic medicine and individual practitioners who use the IM brand to attract patients.
Despite IM and its antecedents (alternative, complementary, alternative and complementary, complementary and integrative) having been around for about a quarter century, we still do not have a working definition of integrative medicine or have any idea whether it positively affects patient outcomes. And, despite the lip service given to IM being evidence-based, or “evidence-informed” or incorporating “appropriate” services into conventional medicine, there does not seem to be any standard for determining which modalities are appropriate for inclusion. We can infer, however, that evidence of effectiveness is not a criterion, as reiki, cranial sacral “therapy”, and homeopathy are standard fare.
In fact, the prospect for actually improving patient outcomes by importing CAM treatments (such as acupuncture) into medical practice would seem to be decreasing over time, as more and more fail to hold up under the scrutiny of well-designed and conducted clinical trials. Perhaps the dearth of evidence for “alternative” treatments is the impetus behind the importation of conventional modalities, such as nutrition and exercise, into the IM fold, treatments that were never viewed as CAM when the whole enterprise started. It has also led to special pleading demanding that research standards be loosened, most recently by the NCCIH, its director’s promise to ensure “rigorous science” notwithstanding.
There is no standard delivery model for integrative medicine or, importantly, an agreed-upon role for the various practitioners who bring the “integrative” to integrative medicine, such as chiropractors, naturopaths and acupuncturists. For example, should they be allowed to practice independently or should the medical doctor have final say on patient care? And, if they differ in their proposed diagnoses and treatments, how are those issues to be resolved? (more…)