I don’t know how I’ve missed this, given that it’s been in existence now for over a month now, but I have. Regular readers (and even fairly recent readers, given that I write about this topic relatively frequently) know that I’m not a big fan of the National Center for Complementary and Alternative Medicine (NCCAM). Just search this blog for “NCCAM” if you don’t believe me. I’ve explained the reasons many times, but the CliffsNotes version is that NCCAM is an enormous waste of taxpayer money, dedicated as it is to the study of modalities that are at best highly implausible and at worst break well-established laws of physics (i.e., “energy healing”). Yes, it’s true that, since the latest NCCAM director, Dr. Josephine Briggs, took over, there has been a noticeable attempt to bring more scientific rigor to NCCAM, and to some extent Dr. Briggs has succeeded. At the very least she is a legitimate scientist with an impressive pre-NCCAM track record, and I do fear who will succeed her when she moves on or retires given that there is enormous pressure from the CAM community to appoint one of their own as director.
Unfortunately, as rigorous a scientist as Dr. Briggs was in her former life, since coming to NCCAM she has gradually been assimilated into the culture of the place. Indeed, although it is good that NCCAM has backed away from studying woo like homeopathy and distance healing, the co-optation of science-based modalities such as exercise, diet, and natural products pharmacology has continued apace. Worse, the recently released five year strategic plan for NCCAM admitted that the science funded by NCCAM in the past was crap and, in essence, promised to do some real science for a change. That’s why I’ve jokingly said that we should take off and nuke NCCAM from orbit. It’s the only way to be sure. On the other hand, no doubt someone would think I seriously mean that we should nuke NCCAM. Of course, I’d never advocate that. NCCAM is located right smack dab in the middle of the NIH campus. The collateral damage would be unacceptable.
I keed. I keed. I’m not kidding, though, when I ask why NCCAM still exists.
But back to the new initiative by NCCAM that I started out the post with. I’m referring to the new NCCAM researchblog. Thus far, it seems to be basically the director’s blog, because all the posts thus far were written by Dr. Briggs, who welcomes readers to the blog in the first post:
Like all of the NIH, our mission is to conduct the highest quality biomedical research to improve the health of the Nation. NCCAM’s special charge is to bring rigorous science to the broad array of health practices that have arisen from outside of mainstream medicine. This covers a lot of tough territory! Not surprisingly the conversation about complementary and alternative health practices has often become polarized, with competing views about what makes good sense. I hope to use this blog as a place for a conversation about these challenges.
Sounds like a plan! It’s also one reason why I encourage my readers to take part in that conversation, both here and on the NCCAM blog (although you should note that the comments on the NCCAM blog are moderated) and thank Dr. Briggs for providing me with additional blogging material. In particular, I’d like to join the discussion of the word, “integrative,” which Dr. Briggs discusses in her second blog post, “Integrative” — What Is in a Word? A very good question. What is in the word “integrative”? I’ve discussed the use of this word many times before, but before we get to my blather, let’s take a look at Dr. Briggs’ blather. First, she tries to have it both ways, being a good skeptic but still accepting the CAM framing of science and language:
That seems simple enough but there are a lot of rough edges at the interface between conventional medicine on the one hand and use of complementary/alternative health approaches on the other, and “integrative” can get caught in a highly polarized debate. From one end, “integrative medicine” offers a holistic, gentle, patient-centered approach that will solve many our Nation’s most pressing health care problems. At another end, “integrative care” represents an evasive rebranding of modern equivalents of “snake oil” by practitioners who raise unrealistic hopes and promote approaches that are not sensible, supported by evidence, or proven safe.
This is the classic false equivalency. Notice how Dr. Briggs characterizes “integrative medicine” on the one hand as being all soft and fuzzy, the equivalent of mom and apple pie. Who could argue with “holistic, gentle, patient-centered” approaches? Well, actually, I can, because the word “holistic” is meaningless in this context. A good science-based primary care doctor is “holistic.” You don’t need to buy into woo to be a holistic doctor. Similarly, you don’t need to buy into woo to be patient-centered in your approach. In addition, as I’ve pointed out before, “patient-centered” is a wonderfully flexible term that can mean so many things to so many people, and the woo-meisters have certainly taken advantage of that in order to promote the idea that patient-centered care necessarily involves their favored quackery.
Now here’s the false equivalency. Dr. Briggs equates the above wonderfully Orwellian verbal prestidigitation that describes CAM (or “integrative medicine” or whatever you want to call it) as the path to holistic care with skeptics who point out that integrating quackery with real medicine makes no sense. As Mark Crislip so famously put it, “If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.”
And if you “integrate” pseudoscience with science, it does not make the science more rigorous. If you mix quackery with real medicine, you do not make the real medicine better—or even more “holistic.” Much of “integrative medicine” represents, more than anything else, a return to pre-scientific beliefs, such as vitalism, miasmas, and illnesses being caused and cured by, in essence spirits or gods or magic. After all, reiki is nothing more than a form of faith healing, and most energy medicine is nothing more than magic, the belief that if you wish for something really, really hard, you can bend the universe to do your bidding and provide you with that thing, in this case, healing.
One notes that Dr. Briggs emphasizes multiple times “nonpharmacological approaches” to pain management. No doubt this is because pain management is where placebo effects are most common, and I’ll have to keep an eye on the blog for what Dr. Briggs says. Not only am I always on the lookout for new material, but I note that she’s already produced one post on pain management. I’m not sure whether to take it on later this week or wait to see what she comes up with next. In any case, it’s clear to me that I need to add the NCCAM blog to my RSS feeds. In the meantime, I also note that in her post about the word “integrative” Dr. Briggs then asserts three “very well documented facts.” Unfortunately, none of these facts are unequivocally true—or even that particularly well documented. I’ll show you what I mean.
Here’s “fact” one:
Individuals, their health care providers, and their health care systems are all, on a large scale, incorporating various practices which have origins outside of mainstream medicine into multi-pronged treatment and health promotion approaches.
Well, yes and no. First the no. As I’ve explained many times, the evidence for this assertion is weak at best. Most surveys of CAM use include spirituality and prayer, which artificially inflates the numbers. It also includes exercise and meditation, both of which are arguably not from “outside the mainstream.” As I’ve pointed out before, when you look at the hardcore woo, such as homeopathy and the like, the numbers of people who use them are actually quite small and haven’t changed that much over the last decade. Now the yes. It is true that quackademic medicine has infiltrated medical schools and that many hospitals whose leaders should know better have embraced it.
Now here’s “fact” two:
This “integrative” trend among providers and health care systems is growing. Driving factors include perceived benefit in health or well-being, emerging evidence in at least some cases that perceived benefits of integrative are real and/or meaningful (e.g., management of chronic pain), and marketing of “integrative care” by health care providers to consumers.
OK, I’ll give her this one—partially, anyway. The reason, however, is because Dr. Briggs cleverly worded it. Note how she refers to “perceived” benefit rather than actual benefits. She’s also right that the marketing of “integrative care” plays a large role in its current popularity. As I’ve pointed out before as well, “integrative medicine” is a marketing term, not a term that describes anything real. It’s a sham. It’s also quite arguable whether in the case of the management of chronic pain the perceived benefits of “integrative care” are real or meaningful. Indeed, some “integrative” modalities touted as effective are in fact science-based treatments, such as exercise and lifestyle interventions.
This leads to “fact” three:
With few exceptions, data to guide evidence-based decision making about safety and efficacy are at best preliminary.
No, no, no, no. With few, if any exceptions, data to guide science-based decision making about CAM or “integrative medicine” are negative. They do not work, by and large. As Kimball Atwood so famously described CAM modalities:
A spectrum of implausible beliefs and claims about health and disease. These range from the untestable and absurd to the possible but not very intriguing. In all cases the enthusiasm of advocates vastly exceeds the scientific promise.
Unfortunately, Dr. Briggs remains inordinately impressed with the concept of “integrative” medicine, calling it “simple” and “pragmatic” while declaring it a “very useful construct” that “focuses on major trends in 21st century health care.” In actuality, most CAM modalities focus on major trends in 17th or 18th century health care or even earlier. They are modalities steeped in prescientific beliefs because they have their origins in a time before we understood enough about how the body works and how health and disease occur not to attribute disease and health to mystical concepts. That is the reality of what CAM “integrates” with science-based medicine.