On the evolution of quackery

Once upon a time, there was quackery. It was the term used to refer to medical practices that were not supported by evidence and were ineffective and potentially harmful. Physicians understood that modalities such as homeopathy, reflexology, and various “energy healing” (i.e., faith healing) methodologies were based either on prescientific vitalism, magical thinking, and/or on science that was at best incorrect or grossly distorted. More importantly, they weren’t afraid to say so.

Quacks did not think this good.

Then, sometime a few decades ago, supporters of quackery decided that they would never get anywhere selling their products, outside of a small minority of people, if they allowed practitioners of evidence-based medicine to define their favorite quackery as being…well, quackery. As a consequence, “quackery” somehow morphed into “alternative medicine.” Alternative medicine was (and, when the term is used, still is) medicine that does not fit into the current scientific paradigm, a term used to describe medical practices that were not supported by evidence, were ineffective and potentially harmful, and were used instead of effective therapies. Physicians understood that modalities such as homeopathy, reflexology and various “energy healing” (i.e., faith healing) methodologies were based either on prescientific vitalism, magical thinking, and/or on science that was at best incorrect or grossly distorted. More importantly, they weren’t afraid to say so.

Practitioners of alternative medicine did not think this good, either.

That’s why, sometime lost in the mists of time (back in the 1990s), alternative medicine practitioners (i.e., quacks) decided that they would never get anywhere selling their products, outside of a small minority of people, if they themselves defined their own products as being outside the mainstream of medicine by calling them alternative. Thus was born “complementary and alternative medicine,” which had the nice, pithy abbreviation of “CAM.” CAM was (and is) medicine that does not fit into the current scientific paradigm, including treatments that are not supported by evidence, are ineffective and/or potentially harmful, and are used in addition to real medicine. Over time, the name change had its intended effect. No longer did most physicians automatically view modalities that were once considered quackery, later considered “alternative,” and now considered “CAM” as quackery. Modalities such as homeopathy, reiki, various energy healing methods, and even reflexology were no longer dismissed. Somehow, despite several of them (especially homeopathy and the various energy healing modalities) violating known laws of physics and requiring that our understanding of physics be not just wrong, but spectacularly wrong, for them to work, somehow methodolatrists preaching “evidence-based medicine,” valuing randomized, double-blind, placebo-controlled trials above all else even when physics, chemistry, and common sense should tell them that a treatment (such as homeopathy) cannot work, allowed the noise and occasional false positive clinical trial to convince them that there might be something to these modalities. Also, by using their former quackery in addition (i.e., as complementary) to real medicine, CAM practitioners (mostly) neutered the biggest complaint about alternative medicine, namely the concern that patients forego effective therapy in order to pursue alternative medicine. The stage was set for the widespread adoption of CAM by medical schools.

And CAM practitioners did declare that this was indeed good–but not good enough.

That’s why CAM practitioners, even though they had made huge inroads introducing quackademic medicine into medical schools and academic medical centers, bolstered by the influence of the National Center for Complementary and Alternative Medicine (NCCAM) and the Bravewell Collaborative, an organization founded by Christy Mack, the wife of a wealthy investment banker, for the express purpose of promoting the study and use of CAM in medical academia, decided that even this was not good enough. A new term was needed. Thus was born in recent years a new term. CAM practitioners (formerly alternative medicine practitioners, formerly quacks) hit upon the perfect term for their treatments. It is a term so media-friendly, so seemingly reasonable that it is a wonder that no one had thought of it before.

“Integrative medicine.”

Yes, no longer were CAM practitioners content to have their favorite quackery be “complementary” to real medicine. After all, “complementary” implied a subsidiary position. Medicine was the cake, and their wares were just the icing. That wasn’t good enough. They craved respect. They wanted to be co-equals with physicians and science- and evidence-based medicine. The term “integrative medicine” (IM) served their purpose perfectly. No longer were their treatments merely “complementary,” they were “integrating” their treatments with those of science- and evidence-based medicine! The implication, the very, very intentional implication, was that alternative medicine was co-equal to EBM, an equal partner in the “integrating.”

And to IM practitioners, it was very good indeed, so much so that they are proclaiming that CAM is dead:

Over the past 25 years, practitioners integrating the best of Western, Eastern and other evidence-based models of medicine into their practices have endured a series of catch-all titles that describe their model of care. Not long ago, all medicine not tacking closely to conventional allopathic care was termed “alternative”. Then about 15 years ago the term complementary and alternative medicine (CAM) began to seep into the medical vernacular. NIH’s National Center for Cancer and Alternative Medicine (NCCAM) became a full-fledged center in 1991. Although most of the major hospitals and cancer centers did not introduce their integrative centers until a decade later, NCCAM’s “CAM” acronym stuck, and had an influence on new private clinics and centers across the country.

I’ll say one thing about the guy who wrote this, Glenn Sabin. He doesn’t know the history of NCCAM. In 1991, NCCAM was indeed born, except that it was not a full-fledged center. Rather, thanks to woo-friendly Senator Tom Harkin (D-IA) and $2 million of discretionary funding, NCCAM started its life as the Office of Unconventional Medicine, which was soon renamed the Office of Alternative Medicine (OAM). It was not until October 1998 that NCCAM received its current name and was elevated to a full center. Mostly, this was a big “screw you” from Tom Harkin to the then director of the NIH, Harold Varmus, who, responding to objections to the OAM from the scientific academic community, moved to place the OAM under tighter NIH control. The result? Tom Harkin introduced and passed legislation that elevated the OAM to an independent center within the NIH. Soon after, appropriations skyrocketed to over $100 million a year. NCCAM’s current budget hovers in the $125 million range.

One wonders what else Sabin gets wrong.

Whatever he might get wrong or right on a factual basis, Sabin does reveal the mindset of promoters of non-science-based medical treatments in the very next paragraph:

Today several integrative centers across the country still contain the words CAM in their name. This is both confusing to health consumers and damaging for these centers’ brand. Most clinics and centers launched during the last decade have evolved with their branding to include today’s more appropriate terminology of “integrative medicine”, “integrative services” or “integrative therapies”.

(Bold not mine.)

I will give Sabin credit. Whether he realizes it or not, he’s basically just admitted that the move to rename CAM as IM is all about the marketing of quackery. Yes, I know that he would never, ever admit that’s what he just did. After all, he liberally sprinkles his post with terms like “evidence-based integrative medicine,” which makes me wonder why IM aficionados haven’t renamed IM to “EBIM.” Perhaps that’s coming later.

But I digress.

Getting back on track, I note that Mr. Sabin does a wonderful job of expressing the confusion at the heart of so-called “evidence-based integrative medicine,” almost certainly without realizing that he is doing so. See if you can figure out what I mean before I explain it:

Alternative medicine is often pushed in lieu of proven conventional care. Alternative medicine does not have an adequate science base behind it and is not practiced in clinics within an academic setting. Integrative medicine integrates proven therapies into conventional medicine. True, not all methods of mindfulness-based stress reduction techniques like, say, Reiki have a solid evidence base behind it, but in this case, many clinicians that offer services like Reiki do so because their clinical observations tell them that it helps many of their patients relax and may lessen the need of certain pain meds.

So, let me get this straight. IM is better than “alternative medicine” because alternative medicine is “often pushed in lieu of proven conventional care” while in contrast (allegedly) IM “integrates proven therapies into conventional medicine.” Then, right after that, Sabin admits that “not all” IM methods have a solid evidence based behind them but that clinicians use them because of anecdotal observations. Here’s a hint: Anecdotal observations are not the same thing as being “proven.” Far from it! Anecdotal observations can be profoundly misleading, thanks to well-known phenomenon that confound “clinical observations,” such as regression to the mean, confirmation bias, and placebo responses. That’s why “conventional” medical researchers long ago realized that well-designed clinical trials, preferably randomized and well-controlled, are necessary to minimize these biases and to correct for placebo responses. Mr. Sabin comes across as profoundly confused about the science in that he doesn’t seem to realize that the vast majority of “alternative medicine” modalities that he wants to see “integrated” with conventional medicine are not “proven” by any stretch of the imagination. “Evidence-based.” You keep using that word, Mr. Sabin. I do not think it means what you think it means.

Not that any of this stops Sabin from proclaiming, even as he tries to misrepresent CAM as “personalized” medicine when it is anything but:

CAM is dead. The evolution of evidence-based, personalized integrative medicine, and its implementation in clinic, lives on.

Of course, CAM is dead. CAM advocates themselves killed it because they sensed a better marketing opportunity if they could come up with a term that didn’t have the connotation that their treatments were inferior to those of conventional medicine. The killing of CAM was deliberate and calculated, but it is not complete yet. Rather, it is ongoing. But don’t worry. Marketers like Glenn Sabin will make sure that before too long the corpse is well and truly dead, cold, and buried. In its place is rising the zombie that is “integrative medicine.”