Are more physicians really prescribing CAM?

I and others have often written about how “complementary and alternative medicine” (CAM) and “integrative medicine” (IM) represent a “bait and switch.” The basic concept is that CAM/IM has co-opted several ostensibly science-based modalities, such as diet, exercise, relaxation, and the like. These are used as the bait by representing them as being somehow “alternative” and outside of the mainstream of medicine. The switch occurs when CAM/IM advocates use the known efficacy of modalities like this to argue that other woo works. They do this through a “big tent” policy, where diet, exercise, and the like are put in the same CAM/IM big tent with reiki, homeopathy, acupuncture and other traditional Chinese medicine, energy healing, and many others.

One of my favorite examples of this bait and switch technique is the concept of herbal medicine. There’s no doubt that herbs and plants can be medicine because many of them contain medicinal compounds that have pharmacological activity. The differences between herbs and pharmaceutical are potency, purity, and consistency. Basically, herbal medicine represents unpurified natural product that can have widely varying amounts of active ingredient from lot to lot; pharmaceuticals, on the other hand, contain the active ingredient in pure form with its purity and potency stable from lot to lot, allowing for more reliable treatment. As with diet and exercise, for herbal medicine the fact that there are pharmacologically active compounds in many herbs and plants is the “bait,” which gives it plausibility. The switch comes with the philosophy that tends to cloak herbal medicine, concepts including that because it’s natural it must be better, that somehow there is “synergy” between the various compounds in an herbal remedy (something that is almost never actually the case), and even a touch of vitalism, wherein “living” plants are better than those cold, sterile, pharmaceutical company-manufactured pills. Then herbal medicines are lumped in with the other parts of the bait, such as diet and exercise, because they can be science-based. Of course, science-based medicine has used herbal medicines as the basis for medicine for a long time. There’s even a scientific branch of pharmacology devoted to the study of natural products as drugs: pharmacognosy. Bait and switch indeed.

The latest in a long line of CAM/IM bait and switch appeared earlier this week in the form of another study that got a fair amount of media play. For example, there’s this news report:

More than a third of Americans use some form of complementary and alternative medicine (CAM) and that number continues to rise attributed mostly to increases in the use of mind-body therapies (MBT) like yoga, meditation and deep breathing exercises.

Prior research suggests that MBT, while used by millions of patients, is still on the fringe of mainstream medical care in America. New research suggests that attitudes are changing.

In a study from Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School, researchers found that one in 30 Americans using MBT has been referred by a medical provider.

Notice the classic bait and switch, which is reinforced in another news report:

In 2007, 38 percent of Americans used complementary and alternative medicine (referred to by researchers as CAM). Mind-body therapies, which include things like yoga and tai chi, are a type of CAM. Use of CAM in the United States has increased since 2002, with mind-body therapies comprising 75 percent of the rise, the researchers say.

According to the study itself, “mind-body therapies” (MBTs) were defined quite broadly and included yoga, tai chi, qi gong, meditation, guided imagery, progressive muscle relaxation, and deep-breathing exercises. Why tai chi, yoga, and qi gong should fall under the rubric of a category known as “mind-body” therapy, I don’t know; they’re all basically forms of physical activity and exercise. As for guided imagery, relaxation, and deep-breathing, I suppose these could be called MBTs, but in reality the whole term “mind-body therapy” is more a marketing buzz word that sounds all nice, fuzzy, and “holistic,” rather than any sort of useful descriptive term. It’s a wastebasket into which is thrown any therapy that involves some combination of relaxation, thinking, or gentle exercise that can be infused with some form of “spirituality” or gentle woo. There’s no reason why relaxation or deep breathing therapies can’t be science-based or why they should be considered “alternative.” The same is true for exercises like yoga, tai chi, or qi gong. The switch comes in when yoga, tai chi, and qi gong assert various “spiritual” and vitalistic aspects, such as the existence of what is in essence a magical, mystical life energy (the qi in qi gong, for example).

Also, it should be pointed out that this study that sparked all these news stories a few days ago is not really a full study at all. It’s a “research letter,” the shortest form of research. It consists of exactly one table of data that looks at correlations between the use of physician-prescribed and self-prescribed MBTs based on data from the 2007 National Health Interview Survey (NHIS). Despite my dislike for the bait and switch inherent in the study, I’ll admit that there were a few interesting findings. For instance, the authors found that the use of physician-prescribed MBTs (P-MBT) was correlated with greater health care use and illness:

Respondents with more chronic conditions, quantified by a Charlson score of 4 or higher and composing 11.3% of all P-MBT users, were more likely to use P-MBT. Of our 16 comorbid conditions, only chronic obstructive pulmonary disease [COPD] and anxiety were associated with P-MBT use. Greater health care use was associated with a greater use of P-MBT. We observed a “dose-response” relationship with the number of office visits and the use of P-MBT: as the number of office visits increased over a 12-month period, so did the likelihood of using P-MBT. Use of P-MBT was associated with an encounter with a mental health professional over the past 12 months. Finally, respondents with heavy alcohol use were less likely to use P-MBT.

Although a lot of this is much ado about nothing (note how there were only correlations between two conditions and P-MBT use, one of which was a psychiatric disorder), there are at least a couple of observations worth considering. First, it seems that doctors with chronically ill patients are more willing to refer for MBT. This points to a commonly noted problem with our health care system in which we have a tendency not to do nearly as well with patients with chronic diseases as we do with more acute illnesses. Many of these common illnesses and conditions, such as hypertension, type II diabetes, and COPD are associated with lifestyle and can be mitigated by lifestyle interventions, such as diet, exercise, and smoking cessation. To the extent that CAM/IM can blur the line between science-based and woo-based lifestyle interventions, such as calling a form of exercise and concentration “qi gong” and branding it as somehow being “alternative,” it wins. The science-based modalities co-opted by the CAM/IM label serve as a propaganda tool that makes CAM/IM look like a bigger phenomenon than it is and as “wedge” strategy to slip in the real woo behind it.

Another aspect of the study is that it promotes the same sort of framing that Dr. Oz promotes on his show when he paints CAM/IM as the wave of the future and paints physicians who don’t get on the bandwagon as “holdouts” against the inevitable. The study is being presented in a similar manner, as in this report, which states:

Prior research suggests that MBT, while used by millions of patients, is still on the fringe of mainstream medical care in America. New research suggests that attitudes are changing.

That’s right, you skeptics out there, you’re all holdouts!

Except that perhaps you’re not. The real number was that only 3% of respondents had used MBTs because a physician had referred them. Because we have no number to compare this to, we have no idea whether or not this represents an increase, a decrease, or no change. Lacking that, we’re left with CAM apologists marveling at how huge the number is:

“There’s good evidence to support using mind-body therapies clinically,” said lead author Aditi Nerurkar, MD, Integrative Medicine Fellow, Harvard Medical School and BIDMC. “Still, we didn’t expect to see provider referral rates that were quite so high.”

And drawing exactly the wrong conclusion from their data:

“What we learned suggests that providers are referring their patients for mind-body therapies as a last resort once conventional therapeutic options have failed,” Nerurkar said. “It makes us wonder whether referring patients for these therapies earlier in the treatment process could lead to less use of the health care system, and possibly, better outcomes for these patients,” she said.

Or maybe it means that there is a dedicated cadre of a small percentage of doctors out there who do a lot of referring of their patients for woo-ish modalities, and the vast majority are science-based and don’t refer their patients for modalities that are unproven.

Or maybe it’s just background noise, a not-unexpected low background rate of referrals, whether due to desperation or repeated patient requests to the point where the clinician refers them just to get them off his or her back.

Or maybe it means that “conventional” doctors need to think more critically and resist the temptation to buy into the CAM/IM marketing machine and recommend “alternative” therapies as a last resort.

I rather suspect that it might well be all three or other explanations that I haven’t thought of. The data presented in this study neither support nor refute the CAMsters’ claim that it’s all because CAM/IM is becoming more “mainstream” and popular, but they sure are doing their best to use this study as an argumentum ad populum to make it seem as though it is.