“Integrative” medicine at Yale: A more “fluid” concept of evidence?

I realize that I’ve been very, very remiss in attending to a task that I’ve been meaning to get to since late January. There are several reasons, albeit not excuses, for why I have failed to do this task. Perhaps the most powerful impediment to my overcoming my inertia and just diving in and doing what needs to be done is that it depresses me to no end to contemplate what needs to be contemplated to complete this task. Moreover, although I have completed a great deal, I sense that I have barely even scratched the surface of what needs to be done to complete the task, which also continuously expands.

I’m talking, of course, about my long-promised update to my famous (or, depending on your point of view, infamous) Academic Woo Aggregator.

Yes, the last time my poor Woo Aggregator was updated, there was snow on the ground, given that it was late January. It didn’t take me long afterward to find out that there were some academic hospitals that had missed my loving attention and publicity, but I decided that I would wait until I had gathered several more and then do a mass update. The problem, of course, is that as several more accumulated I became more depressed at contemplating the task. Remember, before I place an institution in the Woo Aggregator, I have to delve deeply into its “integrative medicine” website and see just what “alternative” medicine it offers, as well as figure out just how credulous I think its attitude is towards unscientific medicine. Meanwhile, I dithered on whether I should start listing woo-friendly academic medical centers outside of North America in order to make the list more comprehensive. All in all, it was a recipe for inertia.

So, to my shame, I just things lapse. Weeks turned into months, and now here we are almost at Memorial Day. The weather has turned warm, and the foliage in our backyard is in bloom. I even need to cut the lawn! And still I haven’t updated the list.

Then David Colquhoun of DC’s Improbable Science posted a report of his recent visit to Yale University, where discussed a recent conference that had been held there in April entitled the 1st Annual Integrative Medicine Scientific Symposium. I had heard about this symposium around the time it occurred when I came across this post, but couldn’t find out enough about it to figure out whether it justified a new post or not. It soon slipped my mind.

And then I read Colquhoun’s account of his talk there, and, more importantly, I perused some of the nearly three hours of video from the conference that is now available on YouTube, the three parts of which I am appending to this post for those who are interested in seeing for themselves. I didn’t have time to watch all of it, but what I watched was disturbing and enough to conclude that the situation at Yale was far worse than I had imagined. Quackademic medicine was invading! Bigtime! This called for a STAT brief update to the Aggregator to add Yale to it at the very least.

Why?

David Colquhoun tells us why:

David L. Katz, MD, MPH, FACPM, FACP, is founder and director of the Integrative Medicine Center (IMC) at Griffin Hospital in Derby, Connecticut. He is also an associate professor, adjunct, of Public Health and director of the Prevention Research Center (PRC) at the Yale University School of Medicine in New Haven, Connecticut.

That sounds pretty respectable. But he is into not just good nutrition, exercise, relaxation and massage, but also utterly barmy and disproved things like homeopathy and ‘therapeutic touch’.

Homeopathy? At Yale? Say it ain’t so. Homeopathy is the one of the most utterly pseudoscientific systems of “medicine” there is, and the Director of the Integrative Medicine Service is into homeopathy? This is really, really bad. Although no mention of homeopathy appears on the poster, mentions of chiropractic manipulation, qi gong, and reiki do. Worse, after the Dean of the Yale School of Medicine embarrassed himself in the introduction by saying he’s proud of how far this nonsense has come, Dr. Katz takes the stage and demonstrates the sort of hostile attitude towards science that, if allowed to take root will be the death of scientific medicine in any meaningful form at U.S. medical schools, in a talk apparently entitled Evidence-based Medicine and CAM: How Opposites Attract (at about 11:46 into the first part). It starts out very badly, as Dr. Katz asks:

Which of these two would we be more inclined to renounce, our dedication to science or devotion to the needs of our patients? And if there’s a constant tension between, it seems to me that we are obligated to reconcile it rather than attempt to make a choice.

I wanted to vomit right there upon hearing that. Fortunately, I managed to restrain myself. In any case, Dr. Katz’s statement is a mind-numbingly obvious false dichotomy. “We” physicians are not “obligated” to “choose” either CAM or scientific medicine, nor is it incumbent upon us to somehow “reconcile” the two. Medicine is medicine. It is either effective to varying degrees, or it is not, and the scientific method is how we discover which medicines and treatments are or are not efficacious. Dr. Katz’s statement is also highly offensive to me, being nothing more than the usual “CAM” nonsense that implies that using scientific medicine alone is not enough to show adequate devotion to the needs of patients. Frankly, I was pissed off royally when I heard him say this. Dr. Katz then goes on to spout the usual CAM cliches about how we are somehow not “meeting the full needs of our patients.” Even if it is true that we in the evidence-based medicine (EBM) community are not “meeting the full needs of our patients,” his seeming implication that we must embrace pseudoscience and magical thinking to achieve that end is not. Dr. Katz even parrots the mindless alt-med cliche beloved of cranks and pseudoscientists everywhere that “absence of evidence is not evidence of absence,” in other words, the classic argument from ignorance. Yes, well there is no evidence that there is an undetectable teapot orbiting the earth either; does that mean we must accept the contention of CAM believers that there is? At one point Dr. Katz asks:

So again, the conundrum we face as we commit ourselves to what clearly is one of the prevailing mantras in American medical education, evidence-based practice, the conundrum is, what do we do when the evidence we have learned, or perhaps if we care to be more provocative, with which we have been indoctrinated, does not fully meet the needs of our patients? What do we do then?

Ah, yes. Dr. Katz apparently views EBM as “indoctrination.” Why am I not surprised? It’s yet another classic “alt-med” trope. Perhaps the most over-the-top version of this oldie moldy was a hilariously overwrought article from a couple of years ago that referred to evidence-based medicine as “microfascism.” Apparently Dr. Katz either concurs or is at least sympathetic to that view. After all, what is one of the major features of fascism (or even “microfascism”)?

Indoctrination, of course!

This likening of evidence-base medicine to “indoctrination,” not surprisingly, leads this brave maverick physician, who, true to the inflated self-image held by all too many in the CAM world, is clearly not “indoctrinated” like the rest of us sheep, to an amazing conclusion. After discussing several randomized controlled clinical trials (RCTs) that failed to find an effect attributable of CAM interventions over and above that of placebo, he says:

I think we have to look beyond the results of RCTs in order to address patient needs today, and to do that I’ve arrived at the concept of a more fluid form of evidence than many of us have imbibed from our medical educations…[Referring to a patient anecdote, Dr. Katz went on.] Now, we don’t want you on narcotics anymore than you want to be on narcotics. We initicated a course of acupuncture and over the next two to three months weaned him off narcotics. He was pain-free on acupuncture and subsequently transitioned into homeopathy. Now, I don’t care to get into a discussion of how or even whether homeopathy even works, but this guy had tried everything.

[…]

And the anecdotal evidence that homeopathy might be effective was brought up by the naturopaths. We tried it. It worked.

In other words, for Dr. Katz, anecdotal evidence trumps solid evidence from randomized clinical trials. Dr. Colquhoun describes this attitude perfectly:

This is not science. It isn’t even common sense. It is a retreat to the dark ages of medicine when a physician felt free to guess the answer. In fact it’s worse. In the old days there was no evidence to assess. Now there is a fair amount of evidence, but Dr Katz feels free to ignore it and guess anyway. He refers to teaching about evidence as ‘indoctrination’, a pretty graphic illustration of his deeply anti-scientific approach to knowledge. And he makes a joke about having diverted a $1m grant from CDC, for much needed systematic reviews, into something that fits his aims better.

Exactly.

To CAM aficionados, the problem with science- and evidence-based medicine is that it actually provides reasonably objective evidence suggesting to us as physicians what therapies do and do not work. Indeed, it doesn’t even necessarily require all RCT evidence, as long as it’s consistent evidence from well-controlled trials from multiple lines and sources of high quality evidence obtained in a scientifically valid manner. Even with all the uncertainties in EBM, though, it’s still too constraining for “integrative” physicians like Dr. Katz because the expectation of EBM is that physicians will not use therapies for which there is no compelling clinical or scientific evidence–except as a last resort and even then only when the proposed course of treatment is at the very least scientifically plausible or justifiable. It also demands of us as physicians that we honestly inform patients when we are offering them something that has little or no evidence of efficacy, telling them to the best of our knowledge what the risks are in pursuing such a therapy. Of course, these are the problems with EBM for “integrative” physicians. Virtually all of the therapies that fall under the rubric of “CAM” or “integrative” medicine fail the most basic tests of EBM. Not only are they often completely scientifically implausible (think: homeopathy or reiki), but they reliably show no efficacy in randomized clinical trials better than placebo. Moreover, if CAM practitioners honestly told patients that, then most patients would, quite correctly, tell them, “Thanks, but no thanks.” In any case, “integrating” unscientific, ineffective remedies with effective scientific medicine makes no sense, but that is what we are being asked to do by physicians like Dr. Katz: Accept the “integration” of woo with scientific medicine.

I’ve always wondered what’s driving this move to woo in academia. For a while now, I’ve maintained that it’s money. NCCAM, with its grants to study woo, no matter how implausible, and its grants designed to promote the acceptance of CAM through “education” and CAM practitioner fellowship training programs, is clearly one major force tempting institutions into this sort of pseudoscientific dreck. Dr. Colquhoun mentions the Bravewell Consortium, whose explicit goal is to fast-track integrative medicine into the mainstream and which, run by Christy Mack, is backed up by the incredible wealth of her husband John Mack. Also, Dr. Katz himself describes the economic forces that drive the movement to CAM:

For billing, whenever possible we are reimbursed by insurance, but if a patient doesn’t have insurance or if insurance doesn’t cover a procedure then there is an out of pocket expense. As far as the business structure goes, we use midlevel providers–so while I’m overseeing the clinic, a nurse practitioner does much of the hands-on care for the patients. And similarly, on the naturopathic side, Dr Ali is the director, but we also have a naturopathic resident. The hiring of a resident offers an array of benefits. To be blunt about it, doctors in training are inexpensive labor. You spend a lot less money on a naturopathic resident than you would on an experienced practitioner.

I’ve always said that it’s cash on the barrelhead for CAM, along with simple, relatively inexpensive nostrums that can be marked up at quite a profit and mid-level practitioners to administer them and little or none of that pesky insurance claims paperwork to deal with. Combine that with NCCAM support and promotion and grant support from rich benefactors like the Macks, who encourage academic medical centers to set up programs like the one at Yale by showering money on them, and in this time of tight NIH budgets, rising expenses, and ever-tightening third party payer reimbursements, it’s hard for science-based medicine to say no. Finally, most doctors, even those dedicated to science-based medicine, are simply too busy or unconcerned. Most correctly dismiss the more extreme forms of woo as ridiculous, but they do not recognize the threat to scientific medicine that the infiltration of pseudoscience into academic medicine represents. Moreover, in accepting more “plausible” forms of woo like acupuncture, they let the tip of the wedge to woo like homeopathy be driven in; the strategy of CAM advocates promoting woo in medical schools is not unlike that of creationists and their Wedge Strategy.

But what is the real significance of this infiltration? I think Dr. R. W. nailed it perfectly when he wrote that we are now entering the era of post-scientific medicine, with powerhouse medical institutions like Yale, Harvard, and Stanford leading the way. I fear that he may be exactly correct in his characterization. After many decades of work on the part of physicians dedicated to bettering the treatments we have to make medicine more and more based on science and objective evidence rather than dogma, tradition (“we’ve always treated disease X this way”), and authority, the move to “integrative” medicine is poised to reverse all that and send us headling back to the days when physicians practiced based as much on tradition, dogma, and personal preference as on any sound scientific evidence. That’s what Dr. Katz, whether he knows it or not or would ever acknowledge it or not, meant when he referred to a “more fluid concept of evidence.” That’s what he and Dr. Weill, whether they would ever realize it or admit it or not, are pushing when they advocate a “more fluid concept of evidence.”

In other words, I guess it’s back to the future. In the meantime, I need to get my tail in gear and update the Woo Aggregator for real.

YouTube videos of the Yale conference: