Quackademic medicine marches on: George Washington University and the University of Toronto

Collingewheel

Quackery has been steadily infiltrating academic medicine for at least two decades now in the form of what was once called “complementary and alternative medicine” but is now more commonly referred to as “integrative medicine.” Of course, as I’ve written many times before, what “integrative medicine” really means is the “integration” of quackery with science- and evidence-based medicine, to the detriment of SBM. As my good bud Mark Crislip once put it, “integrating” cow pie with apple pie does not improve the apple pie. Yet that is what’s going on in medical academia these days—with a vengeance. It’s a phenomenon that I like to call quackademic medicine, something that’s fast turning medical academia into medical quackademia. It is not, as its proponents claim, the “best of both worlds.”

In fact, it was my two recent publications bemoaning the infiltration of quackademic medicine into medical academia, one in Nature Reviews Cancer and one with Steve Novella in Trends in Molecular Medicine, that got me thinking again about this phenomenon. Actually, it was more my learning of yet another step deeper into quackademia by a once well-respected academic medical institution, occurring so soon after having just published two articles bemoaning that very tendency, that served as a harsh reminder of just what we’re up against. You might remember that a few months ago I noted the infiltration of a naturopath practicing traditional Chinese medicine at the once-respected Cleveland Clinic Foundation (CCF) and then just a couple of weeks ago I was alarmed at the CCF’s seemingly one-upping itself in quackery by starting a partnership with the guru of the quackery known as “functional medicine,” Mark Hyman. This was, sadly, not surprising, given the CCF’s history of integrating cow pie with apple pie, so to speak, in its “integrative pediatrics” program.

Yes, just when I thought things can’t get worse, they do. There is also room for hope in that I also found evidence that our criticisms are at least starting to be noticed.

George Washington University does the CCF one better

From my vantage point it’s depressingly true that the CCF has gotten very, very bad indeed with respect to its promotion of medical pseudoscience. Besides its traditional Chinese medicine clinic and its Center for Functional Medicine, just take a look at its Center for Integrative Medicine, which offers chiropractic, acupuncture, and the magical faith healing that is reiki. If you really want to see how far gone the CCF is, just read its Reiki Factsheet.)

Then look at the Center for Integrative Medicine at the George Washington University Medical Center (GWCIM). Compared to the GWCIM, the CCF’s integrative medicine program looks like a bastion of science-based medicine. GWCIM’s list of services includes acupuncture (of course!), chiropractic, craniosacral therapy, infrared light therapies, glutathione infusions, Myers’ Cocktail, naturopathy (again, of course!), reiki, intravenous high dose vitamin C, and genetic profile results that include “customized interpretation of 23andme.com genetic profile results with specific accent on methylation and detoxification profiles.” It’s a truly horrifying website to contemplate, given how little of it has any resemblance to science-based medicine and how much of it includes outright quackery like reiki. Perhaps even the GWCIM is a bit embarrassed, because it can’t even provide a correct description of reiki:

Reiki describes both a harmonizing energy and a non-invasive therapy which involves the placing of hands in a sequence of locations on or near the body. It is not massage, as the hands remain stationary at each position.

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 instilling a sense of harmony and balance. Reiki can be used in conjunction with any other treatment to enhance and accelerate its effectiveness.

No, reiki is faith healing that substitutes Eastern mystical beliefs for Christian beliefs, as I like to point out any time a discussion of reiki comes up. At least the CCF describes the magic that is the channeling of “healing energy” from the “universal source” more or less correctly.

I perused what GWCIM writes about a few other modalities, and its website’s descriptions of various alternative medicine modalities are depressingly and similarly credulous. Acupuncture is described as being used for “for treatment of respiratory, digestive, urinary and reproductive systems, as well as the disorders of muscle tone, hormone production, circulation, and allergic responses” plus “pain relief, gynecological conditions and symptoms, insomnia, anxiety, and to enhance wellness.” Naturopathy is described as a “comprehensive approach to health and healing that combines modern scientific knowledge with traditional and natural forms of medicine,” with naturopaths addressing “the mental, emotional and physical aspects of an individual, and aim to treat the root causes as well as the symptoms of illness.” According to GWCIM, naturopaths are “trained as primary care doctors at accredited four-year naturopathic medical schools.” They are not. Their training is inadequate and usually consists of as little as 20 days of primary care practice during their third or fourth years of naturopathy school. Meanwhile naturopaths embrace the four humors and tend to be staunchly antivaccine with rare “sort of” exceptions. Doesn’t GWCIM know that? Or doesn’t it care? Apparently not.

Indeed, look at what GWCIM says about high dose intravenous vitamin C therapy for cancer. After citing in vitro and animal studies that are not particularly compelling and then claiming that there are “several case reports published in peer-reviewed medical journals that meet quality standards set by the National Cancer Institute” that “demonstrate that a small number of patients have responded to a high dose IV Vit-C infusion treatment after all other treatments have failed” (which is patently incorrect, as these cases are as unconvincing as Stanislaw Burzynski cases), all the while admitting that there aren’t any compelling randomized clinical trials, GWCIM writes that in practice:

Based on a vast pool of clinical experience, IV administration of high dose Vit-C has been shown to essentially have no side effects, unlike chemotherapy drugs and radiation therapy. Since IV Vit-C works just like chemotherapy and radiation therapy by releasing free radicals, there are no contraindications for their simultaneous use. In fact, Vit-C may work synergistically with chemotherapy and potentiate its effect.

However, there are some disadvantages. The course of therapy is long and intense, two to three times per week (2 hours each) and for the duration of about a year. It can cost over $20,000 for a year-long course of treatment if it is not covered by an insurance.

When evaluating new innovative cancer treatments we need to ensure that three basic requirements are met:

One: There is a clinical plausibility, i.e., credible case reports exist.

Two: There is a biological plausibility, i.e., the mechanism of action is clear.

Three: Proven clinical effectiveness, i.e., a randomized controlled trial has been conducted.

High dose IV Vit-C therapy has met the first two requirements. It is unfortunate that it would take many years before the last step can be accomplished.

We feel compelled to offer this treatment to patients when there are no other choices even though the definitive clinical evidence of its effectiveness is not yet available.

Clinical plausibility? Intravenous vitamin C might not be homeopathy-grade implausible, but it’s not particularly plausible either. As I like to say frequently, vitamin C, even if it worked, would be a really long run for a short slide, given the incredibly high concentration of ascorbate that’s ever been shown to have in vitro anticancer activity. If vitamin C were anything other than “natural,” doctors would have abandoned it a very long time ago as far more trouble than its minimal to nonexistent promise warrants. Achieving such concentrations is difficult, and it is not without side effects, contrary to GWCIM’s claims. I therefore call nonsense on number one. As for biological plausibility, the mechanism is anything but clear. It could be generation of free radicals, but there are also studies suggesting that ascorbate could interfere with chemotherapy, as the Memorial Sloan-Kettering Cancer Center integrative medicine web page acknowledges as it says that high dose vitamin C shouldn’t be used outside of a clinical trial. I call nonsense on number two. Finally, while it’s true that there hasn’t been a large randomized clinical trial for vitamin C for cancer, there has been a phase I/II clinical trial that was basically negative, as I described earlier this year. So I call nonsense on number three as well.

In other words, there is no reason for oncologists at GWCIM to “feel compelled” to offer this treatment, especially given that GWCIM admits that there is no definitive clinical evidence of its effectiveness, particularly considering that, contrary to what GWCIM claims, high dose ascorbate is not without the potential for adverse events. None of this stops GWCIM from recommending high dose vitamin C for the treatment of “a variety of infections as an adjunctive modality.” I fear that GWCIM interprets the science of alternative medicines in the same way it interprets the evidence on vitamin C as a cancer treatment: Through wishful thinking and the most positive spin possible on a body of evidence that does not support their efficacy. Oh, and you can detox, possibly get chelation therapy, and help study reiki at GWCIM, too!

See why I’m depressed? Unfortunately, I’m not done yet.

Et tu, University of Toronto?

I just received an e-mail from a reader yesterday that told the sad tale of yet another domino falling. This time, it’s the University of Toronto. As you might recall, I’ve mentioned UT before on this blog, for example, an autism quackfest held there that UT ultimately disavowed when notified of its true nature. That didn’t stop UT, unfortunately, from having a real quackfest of its own, complete with presentations from a naturopath and homeopath. Yes, the Trojan horse that is quackademic medicine has arrived big time at UT.

And now, apparently, it’s there to stay:

This is why a new academic partnership has formed among our Faculty of Medicine, the Leslie Dan Faculty of Pharmacy and The Scarborough Hospital — a long time community-affiliate of the University of Toronto. The Centre for Integrative Medicine (CIM) will focus on CAM research and education. This will be achieved through an interprofessional approach — led by the Centre’s Director, Professor Lynda Balneaves — that brings together scientists, physicians, pharmacists, nurses, CAM practitioners and others who work in the health care field. Our Faculties of Pharmacy and Medicine will support the scientific research that will ground the Centre’s evidence-based approach, while a Clinical Hub will be established at The Scarborough Hospital’s Birchmount campus to help patients manage their day-to-day health. The result will be a living laboratory that allows us to study ways to safely and effectively integrate evidence-informed CAM therapies, including traditional Chinese medicine, with conventional medical care.

On September 29, our Faculty Council approved CIM’s creation as an EDU-C and on October 17, we will celebrate the official launch of the Centre. Professor Balneaves, working with colleagues across U of T and The Scarborough Hospital, has already been overseeing the first phase of the Centre’s launch, which is focused on consulting and identifying the needs of the community. She is also laying strong foundations for the effective clinical care and research to follow. By spring 2015, the Centre will launch a series of pilot projects designed to address the clinical needs of the TSH community integrated with education and applied clinical research, and it will be ready to announce long-term plans.

“Integrating” traditional Chinese medicine quackery at a new Centre for Integrative Medicine (CIM)? Lovely. Another one bites the dust, although, to be honest, UT was well on its way to becoming a center of quackademia before it announced this.

Integrative medicine advocates strike back

Three years ago, I wrote a post in which I characterized integrative medicine as a “brand, not a specialty.” In it, I described how in the 1990s “alternative medicine” was rebranded as “complementary and alternative medicine” (CAM) and, over the last few years, has been further rebranded as “integrative medicine,” which is frequently portrayed by advocates as the “best of both worlds.” It’s not that kind of “best of both worlds,” but rather this kind, with integrative medicine “assimilating” what should be—and usually is—science-based medicine, such as nutrition, exercise, and natural products into itself and fusing it with a purpose inimical to science-based medicine.

Glenn Sabin apparently doesn’t like such arguments. And, to be fair, there could be counterarguments based on sound reasoning and evidence. Unfortunately, Sabin appears incapable of offering them. Instead, he proclaims that there are “dwindling skeptics,” using what I like to call the logical fallacy known as the bandwagon fallacy. It’s a fallacy Sabin embraces with gusto:

This phenomenon is fueled by growing patient demand and an emerging cadre of integrative-trained clinicians. Patients across the spectrum of conditions and pathologies consistently experience quality outcomes vis-à-vis these services delivered by a wide range of licensed integrative health disciplines.

I like to respond to this sort of argument thusly: You know what else and who else were enormously popular? Yep, Nazi-ism and Hitler. No, I’m not claiming that integrative medicine is in any way like Nazi-ism. It is simply a suitably and intentionally overblown comparison designed to demonstrate the ridiculousness of appeals to popularity like Sabin’s as an argument. Just because something is popular does not mean it is evidence-based or good. It might be, but it also very well might not be. To take another example, half the people in the US do not believe in evolution. Does that mean evolution is not valid science? Of course not. All an appeal to popularity means is that something is popular, and often that popularity in such appeals is exaggerated.

As happy as Sabin is about the seeming “popularity” of integrative medicine, he’s equally ticked off about criticisms that it’s nothing more than a “rebranding” of quackery:

These skeptics darkly describe a continuous ‘rebranding’ of the field: from alternative medicine, to complementary alternative medicine (CAM) to the integrative health and medicine field of today. It’s not a rebranding. It’s an evolution. Some view it more like a revolution. This is about patient-centered health creation and self-efficacy. It’s the natural progression towards greater population health.

That’s right! New Coke wasn’t a rebranding! It was an evolution! Actually, the rationale for recent proposal by that the National Center for Complementary and Alternative Medicine (NCCAM) be renamed the “National Center for Research on Complementary and Integrative Health” sure sounds like a rebranding:

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.

As I pointed out at the time, 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’ve The reason for this continual rebranding of quackery is that words have power.

Sabin is also off base when he writes:

Naysayers declare that nutrition and exercise are neither “alternative” nor “integrative”; that they’ve always been part and parcel of “plain medicine”; that integrative and lifestyle medicine physicians are “coopting conventional medicine!” The truth is that a mere fifty years ago our food was largely unadulterated, grown in fertile soil and much more nutritious. People were generally more active and doctors were teachers (”teacher” actually comes from the Latin word for doctor”). Unfortunately “the teaching” aspect is largely missing today and nutrition, exercise and psycho-social counseling play no central role in the practice of conventional medicine.

Food fifty years ago was unadulterated? What about the concerns about pollution and pesticide use back then that led, in part, to the dawn of the environmental movement and stricter laws and regulations? Wonder Bread was more nutritious? Nutrition, exercise, and psycho-social counseling play “no central role in the practice of conventional medicine”? Whatever Sabin is smoking, I’d want some were it not that I can’t inhale. If psychosocial counseling plays “no central role” in, for instance, oncology, then why is it that the American College of Surgeons Commission on Cancer’s (ACS CoC’s) requirements for cancer program certification now include standards for psychosocial distress screening, survivorship care plans including addressing patients’ psychosocial needs, risk assessment, nutrition services, and physical activity and weight loss programs? Why does the ACS CoC also require education programs regarding cancer awareness and prevention to meet the needs of the community? Why is it, as I mentioned in my NRC paper, that the standard of care for prediabetes and recently diagnosed type II diabetes includes dietary interventions and encouragement of exercise? Sabin is just plain incorrect.

I can’t help but wonder if at some level Sabin knows that we “skeptics” (or, as he calls us, “cynics”) have a point, given that he writes this about us:

Perhaps they’ll refocus their energies on the real perpetuators of medical quackery: those unprincipled charlatans who often rob their patients of life and treasure with ineffective or dangerous products, agents, interventions or ideology in lieu of proven curative and often life-saving standard of care interventions.

One wonders if he means Stanislaw Burzynski. Or perhaps he means treatments like Nicholas Gonzalez’s treatments. Probably not. He does, however, castigate us for this:

I would like to see better attention paid to the contraindications between natural and formulated pharma agents, or a deeper scientific dive into the controversy surrounding antioxidant adjuvant chemotherapy and radiation therapy, and, um, less on whether acupuncture works or if Reiki’s really helpful with reducing stress and anxiety. Clearly, if patients benefit and there are no significant safety concerns, who really cares exactly how they work? (I’m not implying that scientists should stop investigating these matters. I’m emphasizing the primacy of favorable patient outcomes.)

One wonders whether Sabin doesn’t want us paying so much attention to reiki and acupuncture because, deep in his heart, he knows almost as well as skeptics do that they are quackery based on prescientific mystical belief systems. Unfortunately, as has been pointed out in other discussions of reiki quackery at the CCF, University of Arizona, and elsewhere, acupuncture and reiki are some of the most commonly offered alternative medical modality in quackademic medicine. Notice how he also seems to be admitting that these modalities are placebo modalities, asking “ Just because some health creation programs, processes and interventions (especially those based on whole systems) do not perfectly align with the traditional random controlled, double-blinded pharma model of reductionist scientific discovery, does it cancel out the patient’s positive outcome?”

The problem is that the positive outcomes touted have not been demonstrated to be due to these modalities, and, as Steve Novella, Harriet Hall, Mark Crislip, and I have discussed repeatedly, placebo effects are subjective effects, require deception, and are simply being “rebranded” as “self-healing” and the “power of positive thinking.” It’s a narrative being sold by people like Sabin.

Finally, I can’t help but note that Sabin himself has admitted that the name “integrative medicine” is a “rebranding of CAM in an article entitled CAM Is Dead:

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”.

The bold text is Sabin’s not mine. As I pointed out at the time, Sabin basically admitted that the term “integrative medicine” is about the marketing of quackery. This is not surprising, given that Sabin is the founder of FON Therapeutics, a company that exists for this purpose:

FON is dedicated to positioning integrative health organizations for long term growth while advancing evidence-based integrative medicine as the standard of care.

A leading business development consulting firm, FON specializes in customized solutions—focused on growing patient volume, program and product sales—driven by innovative marketing, messaging and branded storytelling, all rooted in fiscally viable business models that work.

FON offers an e-book by Sabin entitled Grow Your Integrative Medicine Business by Telling Bigger Stories (wow, I wonder if Sabin knows what that sounds like) and a white paper on How to Increase Clinic Utilization of Integrative Medicine Services in 60 Days, while expressing admiration for the Cancer Treatment Centers of America as the 800-pound marketing gorilla. FON is a marketing company, offering all sorts of marketing services to integrative medical centers, pointing out the economic potential of integrative medicine as being projected to reach $50 billion annually. Indeed, in Weeks’ article on the Hyman-CCF partnership, Sabin worries:

Sabin then raised some questions about the intersection of typical functional medicine business practices with the Cleveland Clinic culture. He noted that in Hyman’s private clinic an office visit with the doctor to the Clintons can run pretty steep. It’s $1,500 for 80 minutes with Hyman. Fifty minutes with a nutritionist will set you back $240. Hyman’s clinic does not accept insurance. Hyman’s business model also includes profiting from supplement sales, from which he donates a portion for functional medicine research.

Sabin adds a further question: “How deep will Cleveland Clinic go in terms of embracing a model of comprehensive functional labs looking at biochemical milieu to inform recommendations of well-placed nutraceuticals.” Such lab work-ups can also be quite expensive for patients even as are the bags of natural medicines that are typically part of functional medicine therapeutic regimes.

Although ideology and a misguided view that to become more “holistic” one must embrace quackery seem to be driving the infiltration of quackery into medical academia, we must never forget that there is a clever and sophisticated marketing campaign behind it as well. Does anyone think that the CCF would have embraced Mark Hyman if it didn’t think he can make the hospital significant money? I doubt it, Mark Hyman’s anecdote about how he told the CCF’s Cosgrove that it “probably didn’t want him there” notwithstanding, and I bet Sabin would agree with this point at least.

As much as advocates claim that it’s not just about the money, it’s also about the money.