I fought the woo, and the woo won? Or: Gotta have more woo in my medical school, revisited

Over the last couple of days, I’ve discussed “complementary and alternative medicine” (CAM) in terms of a meme upon which evolutionary forces are acting to select certain forms of woo over others in academia. Although, in my usual inimitable fashion, I probably carried the concept one step too far, in the end I concluded that the relationship between CAM and academic medical centers is probably best characterized as parasitic rather than symbiotic.

After I finished that post, I started thinking (always a dangerous thing). Regular readers know that I’ve sometimes raised a bit of a ruckus by being very critical of certain academic medical centers for embracing non-evidence-based modalities of varying degrees of dubiousness in their scientific plausibility. As I’ve said before, I tend to suspect that it’s usually done more as a marketing tool more than out of genuine scientific interest; in other words, because patients want it, regardless of whether there is any evidence to support it. (And let’s not forget that most CAM therapies are not reimbursed by insurance, meaning that it’s cash on the barrelhead.) Still, even if we take the physicians supporting these programs at their word when they say the reason for CAM in academic medical centers is to teach it critically and scientifically and to subject it to the scientific method, in practice with few exceptions that does not appear to be what happens. If it did, I wouldn’t have a problem with the CAM curriculum in these medical schools (indeed, I would strongly support them). Unfortunately, many of these schools also offer these modalities before there’s any good evidence that they work, in essence putting the cart before the horse. Also, over time such programs tend to be taken over by true believers. Meanwhile, academic physicians who care about evidence-based medicine view CAM in their medical centers as either a harmless diversion, as not worthy of their consideration, or as something that’s become so entrenched that it’s not worth making the necessary waves and paying the price to fight it.

But how entrenched has CAM become in academic medicine in the U.S.?

That was the question I had. So I set out to get an estimate by looking for centers of “integrative medicine” (one buzzword for using woo alongside evidence-based medicine) or CAM centers. It didn’t take me long to find at least 39 different such centers that offer and/or teach CAM. Indeed, I’m sure that the list that I am about to present to you is nowhere near complete, given that it includes only CAM or “integrative medicine” centers that are easily locatable through web searches and given that I didn’t wade too deeply into Google to find every last one. With those qualifications, here is the list that I came up with:

1. The Cleveland Clinic
2. The Richard and Hinda Rosenthal Center for Complementary and Alternative Medicine, Columbia University
3. Cornell University Center for Complementary and Integrative Medicine
4. The Continuum Center for Health and Healing, Albert Einstein College of Medicine of Yeshiva University
5. Duke Integrative Medicine
6. Henry Ford Health System (medical school affiliations: Wayne State University and Michigan State University)
7. Georgetown University Medical Center (discussed here)
8. Harvard Medical School Osher Institute, Division for Research and Education in Complementary and Integrative Medicine
9. Jefferson-Myrna Brind Center of Integrative Medicine, Thomas Jefferson University
10. Mayo Clinic Complementary and Integrative Medicine Program
11. Northwestern Memorial Physicians Group Center for Integrative Medicine (Northwestern University)
12. Integrative Medicine Program, Beaumont Hospitals (primary teaching affiliation now with Oakland University; other medical school affiliations with the University of Michigan and Wayne State University)
13. The Ohio State University Center for Integrative Medicine
14. Oregon Center for Complementary and Alternative Medicine in Neurologic Disorders, Oregon Health and Science University (Also, the OHSU Center for Women’s Health Integrative Medicine Program)
15. Scripps Center for Integrative Medicine
16. Stanford Center for Integrative Medicine
17. Complementary & Alternative Research and Education Program, University of Alberta (pediatrics, yet!)
18. University of Arizona Program in Integrative Medicine
19. Susan Samueli Center for Integrative Medicine, University of California, Irvine
20. University of California at Los Angeles Collaborative Centers for Integrative Medicine
21. Osher Center for Integrative Medicine, University of California, San Francisco
22. University of Colorado
23. University of Connecticut Health Center (where a “debate” about homeopathy was recently held)
24. University of Maryland Center for Integrative Medicine
25. University of Massachusetts Medical School Center for Mindfulness
26. Institute for Complementary & Alternative Medicine, University of Medicine and Dentistry of New Jersey (UMDNJ-ICAM)
27. University of Michigan Medical School
28. University of Minnesota Center for Spirituality and Healing (PZ hates this one.)
29. University of New Mexico School of Medicine, Section of Integrative Medicine
30. Program on Integrative Medicine, University of North Carolina
31. PENNCAM, University of Pennsylvania
32. Center for Integrative Medicine, University of Pittsburgh Medical Center
33. University of Texas Medical Branch Complementary & Alternative Medicine Project
34. University of Texas M. D. Anderson Cancer Center Integrative Medicine Program
35. University of Washington School of Medicine Integrative Health Program
36. University of Wisconsin Integrative Medicine
37. Vanderbilt Center for Integrative Health
38. Wake Forest Baptist Medical Center Program for Holistic and Integrative Medicine
39. Center for Integrative Medicine at the George Washington University Medical Center

Of course, sheer numbers of programs matter little. What really matters is what is being offered to patients and/or taught to students, residents, and fellows through these programs. So I did a little perusing. The first thing that became immediately apparent is that nearly all of the centers or programs above either offer to patients or teach all or most of the following CAM modalities:

1. Acupuncture
2. Guided imagery
3. Massage therapy
4. Nutritional counseling
5. Tai Chi
6. Yoga

The inclusion of these modalities as first choices in “centers of integrative medicine” is not surprising, as there is some evidence to support some of them. Indeed, some of them (guided imagery and nutrition, for example) are not necessarily even “alternative” but really should be considered part of “conventional” medical therapies. Moreover, among CAM therapies, although I find it weak and unconvincing, there is some evidence that acupuncture might do…well, something. And, of course, massage therapy, outside of the possibility that it might have a therapeutic effect in certain conditions, at the very minimum feels very good, while Tai chi and yoga can be viewed as low impact exercise, and are probably at the very least not harmful. Finally, who can argue with nutritional counseling? And why is nutritional counseling considered “complementary,” “alternative,” or “integrative,” anyway? Nutrition is a part of conventional medicine, whether alternative medicine mavens believe it or not. Of course, it depends upon what exactly patients are being told. If they’re being told that megadoses of this supplement or that will treat cancer, then that’s what I call “alternative” nutrition, rather than good, old-fashioned, boring, evidence-based nutrition. Overall, though, among CAM therapies, the above subset appears to include modalities chosen because they are the least bizarre and the most “safe” for consumption by academic physicians.

To go a step further and find out how much serious woo there is in academic medical centers, I decided to identify which centers, if any, either offered to patients or taught uncritically two of the wooiest of woo-ey CAM modalities. Yes, I’m talking about either homeopathy (which is nothing more than a highly ritualized placebo in which a “remedy” is, as homeopaths will now admit, diluted to the point where there is not a single active molecule left) or reiki therapy (which postulates that a reiki master can somehow manipulate the flows of qi, or the life energy of the patient for therapeutic effect). Note that therapeutic touch, “healing touch,” and a variety of other “energy-based” healing modalities are very similar to reiki in that they postulate that there is some sort of “life force” that the healer can manipulate for therapeutic intent. Neither of these treatment modalities are supported by science. For example, for homeopathy to work, much of what we know about physics, chemistry, and biology would have to be wildly wrong, and no one has ever been able to detect, much less demonstrate that anyone can manipulate, this life energy (qi) that is at the heart of reiki. I therefore chose these two modalities, which are probably the least scientifically plausible and the most common among serious woo, as a weathervane of sorts, to see which way the wind was blowing with respect to seriously non-evidence-based mystical fluff finding its way into medical schools as serious treatment options.

The results were disturbing, to say the least, particularly what some of these ostensibly “academic” centers wrote about these modalities on their websites. Here are the medical centers that offer and/or teach reiki or some other form of “energy medicine,” along with what the each program’s web page says about it, if anything:

1. Cleveland Clinic: “Reiki is a method of energy-based healing involving the laying on of hands by the practitioner, promoting a deep sense of relaxation for the client. Reiki can help patients access their abilities to promote their own healing in body, mind and spirit.”
2. Albert Einstein College of Medicine: “I use Reiki in addition to other healing practices to help my patients activate their innate capacity for self-healing. By promoting a relaxed and peaceful state, stress is decreased, immune function is enhanced and the body has a greater ability to heal. As a practitioner I also benefit from this work; through centering myself I feel both calm and energized.” Aurora Ocampo, MS, RN, CS
3. Duke University: Reiki is a spiritual healing practice that helps restore emotional, mental, physical, and spiritual balance. “Rei” means universal or highest and “Ki” means subtle energy. Practitioners learn to channel primordial chi (or Tao), which may be thought of as universal consciousness. Essentially, both practitioner and client enter a space of meditation so that spiritual, mental, emotional, and physical healing is facilitated…The practitioner lays hands on several different places on the body for several minutes at a time as the individual lies fully clothed on a massage table. People typically feel very relaxed and peaceful during a treatment, and sometimes fall asleep. After a one of two day class from a reiki master, individuals can begin to practice reiki on themselves and others. This is recommended for people with chronic illness or chronic stress so that daily practice is possible to create more peace and support the ability of the physical body to heal itself.”
4. Beaumont Hospitals: Energy balancing is a complementary method that focuses on promoting health and well being and decreasing responses to stress, anxiety and pain. During these relaxing, non-invasive techniques, the practitioner very gently places her hands in a series of positions on what are believed to be the energy centers/pathways of the body. Contemporary research in this area show some of common responses to treatment include: induced relaxation and calmness; reduction in stress and pain; promotion of wound healing.”
5. Scripps Center for Integrative Medicine: “In use at Scripps since 1993, Healing Touch is an energy-based, non-invasive treatment that restores and balances energy to help decrease pain and relieve associated anxiety. Healing Touch is performed by registered nurses who recognize, manipulate and balance the electromagnetic fields surrounding the human body, thereby promoting healing and the well-being of body, mind and spirit. Healing Touch is often used as an adjunct to surgery and other medical procedures to assist in pain reduction, relaxation and healing.
6. University of Connecticut Health Center
7. University of Maryland
8. UMDNJ: “Reiki is the natural healing energy that flows through the hands of the Reiki channel in a powerful and concentrated form. Reiki functions on all levels of a person’s being and adjusts itself according to the needs of the recipient, helping them to take responsibility for their life and to make changes in attitude and/or lifestyle to promote a happier and healthier life.” (At least they say that electromagnetic therapy is not scientifically unproven.)
9. University of North Carolina-Chapel Hill
10. University of Texas M.D. Anderson Cancer Center
11. University of Wisconsin
12. George Washington University: “The purpose of Reiki is to promote the client’s own natural healing process by providing deep relaxation, abatement of signs or symptoms of distress, or a sense of harmony or balance. Reiki can be used in conjunction with any other treatment to enhance and accelerate its effectiveness.”

This is by no means a complete list. For one thing, several of the sites don’t list the actual modalities that are offered. Instead, they describe their programs using vague generalities about offering multiple CAM modalities or about “integrative consultations.” For another thing, I didn’t exhaustively peruse each website, although I do note that in my surfing not a skeptical word was found. (The slight hope that maybe I missed a skeptical take on “energy” healing methods is the only hope I have right now.)

Next, here are the medical centers that offer and/or teach homeopathy, along with what they say about it on their websites (that is, if they say anything at all):

1. Thomas Jefferson University: “Homeopathic medicines are intended to stimulate the body’s own healing abilities. Homeopathy utilizes a wide range of mostly naturally occurring substances such as plants and minerals. These medicines are prepared through a specific process of stepwise dilution. Many homeopathic medicines contain only an infinitesimal amount of original substance. Although the mechanism by which these “ultradilutions” can work is unexplained, studies have been published in medical journals showing homeopathic medicines may provide clinical benefit.”
2. University of Connecticut Health Center
3. University of Maryland
4. UMDNJ It doesn’t appear that UMDNJ actually offers homeopathy, at least not as far as I can tell, but this is what its website says about it: “Samuel Hahnemann, a German physician conceived the practice of homeopathic medicine, in the late eighteenth century. It was developed in response to the horrific medical practices of the time and is based on the Law of Similars, or ” like cures like”. It embodies the idea that large doses of a substance cause a symptom, and very small doses of that same substance can cure it. Hahnemann and colleagues gathered volumes of descriptions of the symptoms caused by the ingestion of various plants, minerals, animal products, and other substances. When a patient came into the clinic with a series of complaints, these texts were consulted, and the preparation that caused the most similar response was given to the patient. These books, called Homeopathic Pharmacopoeia, are the basis of modern homeopathic therapy. The focus of homeopathy is on the symptoms. Symptoms are seen as attempts by the body to restore health…It works slowly and is thought to have a number of systematic benefits. Homeopathic medicine is very individualized. Treatment is based on the person’s response to the disease, so the actual cause of the disease is not a focus. Remedies are very dilute substances, which are prepared through a process of potentization, which involves repeatedly diluting with either water or alcohol and shaking a remedy (perhaps 100 times). Some solutions are diluted as low as (10)-30 or (10)-20,000. Various homeopathic medicines have been incorporated into modern conventional medical practice. Nitroglycerin was first used as a medicine by a homeopath. Digitalis and gold salts are other examples.”
5. University of North Carolina-Chapel Hill
6. University of Washington School of Medicine: “When dilutions greater than 24x or 12c are prepared, basic chemistry holds that it is unlikely than even a single molecule of the original substance is still present in the remedy, leading many to question how such a therapy could work. Homeopathic theory explains that the vigorous shaking or succusions leave an imprint of the substance being diluted, and that it is this imprint which can stimulate healing in the body, stimulating the body’s own healing responses.”

Now, you may say that it’s not so bad that I found five, maybe six at the most, medical schools or academic medical centers that offer homeopathy to patients and/or teach it to trainees. Personally, I found it truly depressing that even a single medical school offers homeopathy uncritically. Weep, advocates of evidence-based medicine!

As far as miscellaneous CAM modalities go, while perusing all these website, I noticed that there are even a couple of centers offering the quackery known as reflexology, including the University of Maryland and the University of Pittsburgh, the latter of which advocates it for migraines, hypertension, fibromyalgia, and menstrual cramps, among other things. One (the University of Wisconsin) even makes a totally unsupportable statement about CAM for cancer: “Integrative medicine gives patients resources for choosing therapies that help prevent cancer or prevent a recurrence,” where preventing a recurrence is something that CAM cannot do. At least there’s no good scientific evidence that it can. One other (Thomas Jefferson University) even touts anthroposophically Extended Medicine:

Anthroposophically Extended Medicine (AEM) is a Western system of natural medicine that treats the whole person and not just the disease or symptoms. AEM views the human being as far more than a physical machine: Therapy seeks to harmonize the relationship of body, mind and spirit. Anthroposophic medicines include herbal and homeopathic preparations; their aim is to support and guide the natural healing processes within each patient.

Anthroposophy? Rudolf Steiner’s brand of woo? Say it ain’t so! That’s the same philosophy that’s behind the woo of “biodynamic farming.”

Sadly, that’s not all. I found the University of Maryland offering craniosacral therapy, while UCSF offers spinal manipulation. Meanwhile, the Susan Samueli Center for Integrative Medicine at UC Irvine claims to be able to treat depression, hypertension, leukopenia, schizophrenia, allergies, diabetes, and cornucopia of other conditions.

After looking over these websites, I came to the conclusion that the vast majority of these university hospital-based CAM programs appear not to apply a critical, scientific view to CAM modalities. Rather, the impression I get is that the faculty in most of these programs are probably believers. They have, for the most part, drunk deeply of the Kool Aid. Frustratingly, on most sites, I found very few indications of any serious scientific examination of whether these CAM therapies actually work (i.e., provide more of an effect than a placebo for real disease or pathology). Indeed, instead of first asking, “Do these therapies work?” these programs seem to be assuming that they do work and then asking either “How do these therapies work? or “How can we combine these therapies with conventional therapies?” To reiterate, that’s putting the cart before the horse. Unless these therapies have solid evidence to support them, medical schools should not be offering them outside of the context of a clinical trial. Even the Harvard Medical School Osher Institute, which comes the closest to saying the right things about the need to rigorously investigate whether any of these therapies have therapeutic benefit, can’t resist prefacing its discussion with this:

Integrative Medicine involves the integration of conventional medical and evidence-based complementary therapies. It also highlights the importance of patient participation and the patient-practitioner relationship. In 1997, Americans made an estimated 600 million office visits to providers of complementary therapies and spent roughly $30 billion out of pocket on complementary care. The budget for the National Institutes of Health to support research in this area has roughly doubled every two years since 1993, and currently exceeds $200 million annually. In addition, private support has allowed researchers and physicians to gather preliminary data and explore new avenues of scientific research.

It takes every bit of self-control for the cynic in me not to translate this as: “In other words, people spend a lot of money on this stuff, and we want our piece of the action.” (Oh, wait, my self-control failed.) Fortunately, Harvard seems to exaggerate how much the NIH through NCCAM spends every year. Unfortunately, the real amount is in the range of $121 million, unless I’m unaware of another $80 million or so that the government spends on CAM through sources other than the NIH. Whatever the true figure is, it represents your tax dollars hard at work promoting woo at the same time Medicare is slashing reimbursements for lymphoma treatments shown in well-designed clinical trials to be effective.

Going through this exercise has left me feeling not only tired from the effort (damn it when the blogging frenzy takes over) but profoundly depressed. Two days ago, a commenter characterized CAM as a “living fossil” that’s being pushed aside by scientific medicine. After perusing these 39 websites, I’m starting to feel like the fossil.

To help everyone see why, I encourage readers to peruse the 39 websites listed above, find the most outrageous examples of academic medical centers supporting nonsense, and then post them in the comments.

NOTE: I’ve updated this list and will now maintain the list of medical schools offering CAM to patients at my new Academic Woo Aggregator. Periodically, I will post about new entries to the Woo Aggregator and link back to the updated list.