Alternative medicine: The bait and switch is working

For a long time, going back almost to the beginning of this blog eight and a half years ago, I’ve referred to the “bait and switch” of alternative medicine. What I mean by that is the manner in which advocates of alternative medicine—or, as they like to call it these days, “complementary and alternative medicine” (CAM) or, more recently still, “integrative medicine”—co-opt perfectly science-based modalities like diet, nutrition, and exercise as being somehow “alternative.” Alternatively, they woo-ify such science-based modalities and then claim them as CAM. Either way, they deceptively give the impression of a much greater data base supporting CAM than there really is, because they’ve leavened it with all sorts of co-opted modalities that are really unremarkably part of medicine of the sort that primary care doctors routinely give to their patients to help with hypertension, type II diabetes, and other chronic health conditions. That’s why, whenever I see an example of this sort of “bait and switch,” I’m tempted to blog about it. Sometimes, I even give in to that temptation.

This is one of those times.

I’m referring to a post from a couple of weeks ago at that wretched hive of scum and quackery, The Huffington Post, by its Senior Editor, Healthy Living. (Geez, her very title fits in with HuffPo’s tendency towards woo.) Its very title promotes the message I’m talking about, Traditional Doctors, Alternative Treatments: An Intersection? The false dichotomy begins right at the very beginning of the post:

Sometimes it can seem as though complementary/alternative treatments and traditional medicine live in two silos — never the twain shall meet, as the saying goes. We go to the doctor when we’re sick or for regular wellness checks. And we go to the yoga studio or a meditation class. Yet we don’t talk to our doctors about how one can support the other.

Let’s put it this way. Stripped of all its Eastern mystical trappings, yoga is nothing more than a system of exercise, and using exercise to treat various conditions is science-based. Be that as it may, Shocker (I love writing that name) points out that a recent study in Archives of Internal Medicine reported that 3% of people seeking “mind/body treatments,” such as yoga, meditation, tai chi, deep breathing and progressive muscle relaxation, are doing so based on a referral from a real medical provider, as opposed to fake medical providers such as naturopaths, chiropractors, or reiki masters. One thing I noticed about this study is that it’s over two years old; so I’m not sure why Shocker is making such a big deal out of it now. It’s old news. Whatever. Personally, I don’t think this study is anything to be particularly proud of. Shocker labors mightily to convince you that it is. She fails.

That doesn’t stop her from moving on to trying to represent “mind-body therapies” as representing a groundswell among physicians. The only thing she gets right, by and large, is that this is largely a patient-driven, not a physician-driven, phenomenon. It’s rather like the National Center for Complementary and Alternative Medicine (NCCAM) that way. Scientists didn’t want it. Scientists didn’t see a need for it. Politicians did, and woo-friendly politicians like Senator Tom Harkin made sure that Americans got it. Boy, did we ever get it: a Center right in the very middle of the heart of biomedical research in the U.S. dedicated at its very formation to the study and legitimization of pseudoscience and quackery.

Ironically, Shocker might have inadvertently hit on one reason for this phenomenon and one reason why physicians might be willing to refer their patients for something that is almost certain not to help them: Frustration, laziness, inability to spend enough time with a patient in counseling:

The researchers also found that the patients who were seeking out mind-body treatments at the recommendation of a medical provider were those who typically had more diagnosed conditions and used the health-care system more often. Nerurkar says one reason that may be is that providers are referring their more complex patients once other treatments have failed — and this concept may lead to future research studies about what would happen if these complementary programs were offered earlier on in the treatment process.

Not to mention a seeming new willingness to prescribe placebo medicine:

Of course, not all complementary and alternative treatments have evidence behind them, Nerurkar points out. But when the research that is out there is coupled with patients’ success stories, some providers are opening up to the possibilities. “Ultimately you just want your patients to feel better,” she says. “At the end of the day, if my patients are using these therapies and they’re feeling good, I encourage them to do it.”

In other words, I don’t care if it’s science-based or not, just as long as it gives the patient the illusion that things are better.

A better discussion of the whole issue of what to do when patients want CAM therapies can be found in Medscape, entitled What to Do When a Patient Wants ‘Alternative’ Medicine. Unfortunately, even though this article is definitely better (how could it not be better than a HuffPo article?) it nonetheless dances dangerously close to buying into the false dichotomy that suggests that alternative medicine is anywhere in the same ballpark as science-based medicine, or, as I sometimes refer to it, the fallacy of false balance. Regular readers will likely recognize one of the “experts” quoted in the article. Readers of the HuffPo article I just cited will recognize the other one as the woo-friendly doc cited in that very article, Aditi Nerurkar, MD, Assistant Medical Director at the Cheng and Tsui Center for Integrative Care at Beth Israel Deaconess Medical Center in Boston. Dr. Nerurkar, it turns out, is a true believer. She openly admits that the evidence base for CAM, in particular mind-body therapies, is very weak, but really, really believes that they are effective anyway:

At Beth Israel Deaconess, for instance, Nerurkar uses CAM techniques, such as yoga and meditation, in conjunction with standard drugs and procedures in internal medicine. That combination is now being called “integrative medicine.” But Nerurkar has good reason for keeping her enthusiasm for CAM in check. “Some of these treatments have evidence supporting them, and some don’t yet,” she admits. Nerurkar acknowledges there are still many gaps in knowledge of mind/body treatments, and they will have to be filled in with further studies, but she strongly believes those future studies will show effectiveness.

It’s all well and good to believe that a treatment will one day be validated in clinical trials. There’s nothing wrong with that. However, in that case, you have to admit that such treatments have to be considered experimental and therefore shouldn’t in general be used outside of the context of well-designed clinical trials. Would Dr. Nerurkar use an unapproved drug outside of a clinical trial? I wouldn’t, but that’s what CAM practitioners do with CAM all the time. Their philosophy seems to be just to keep using it and hope like hell that clinical trials eventually validate it. The problem is, from the standpoint of scientific plausibility, many CAM studies are incredibly implausible and therefore highly unlikely ever to be validated. However, it is that same “noise” in randomized clinical trials of treatments with low plausibility that keep a steady trickle of seemingly positive studies that are the result of chance, confounding factors that weren’t adequately controlled for, or bias.

Unfortunately, compared to 30 years ago, things have almost completely flipped. In the past, the practice of medicine was presumed to be based on science and clinical trials. Now, that standard no longer exists:

CAM became complicated for doctors in the 1980s, when the American Medical Association (AMA) was forced to abandon a simple rule: The medical profession should have nothing to do with alternative medicine. For 30 years, Section 3 of the AMA principles of medical ethics stated, “A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily associate professionally with anyone who violates this principle.”[4]

The AMA expunged this principle after it was sued for antitrust violations by chiropractor Chester A. Wilk in 1976. The AMA litigated for 14 years and ultimately lost the case.

Of course, the AMA is not the be-all and end-all of medicine. Less than 25% of physicians belong to the organization anymore the last time I checked. However, over the next 20 years, we saw the Dietary Supplement Health and Education Act (DSHEA) of 1994, the formation of NCCAM, and the infiltration of scientific medicine with pseudoscience, culminating in our current state of affairs. And here’s where the article goes astray at the end. After the criticism of CAM as unscientific, the article closes with the observation that failure to inform patients about CAM treatments could result in a malpractice suit. Only a few short years ago, I would have considered this utter nonsense, but now I’m not so sure:

Are doctors legally required to discuss CAM treatments with patients? The jury is still out on that.

Attorneys who have dealt with lawsuits involving CAM have differing opinions. Ericka L. Adler, JD, a partner in the Chicago law firm of Kamensky Rubinstein Hochman & Delott, which handles healthcare cases, says that doctors can tell patients, “I’m not familiar with these other types of products,” and leave it at that.

Others feel that the law of informed consent requires physicians to discuss CAM treatment options. “The information about potential risks, including frequent, nonserious adverse effects as well as serious complications, is crucial for patients to know. Failure to disclose availability of benefits and risks of CAM treatments could give rise to malpractice claims,” according to Edzard Ernst, MD, and Michael Cohen, JD.[10]

That is, of course, the message that CAMsters have been relentlessly parroting for the last few years, namely the claim that CAM is effective and therefore not informing patients about it is a violation of informed consent. The idea, of course, is to legitimize CAM and try to get doctors to “learn about CAM” in a credulous manner, the better to spread that credulous thinking to their patients and even refer patients to CAM practitioners. I still think it’s nonsense. Physicians shouldn’t be obligated to “inform” patients about pseudoscience other than to tell them it’s pseudoscience and quackery. Certainly, that’s what I do whenever a patient asks me about specific CAM modalities with which I’m familiar. I do not, however, bring it up myself. The patient has to do so before I will comment.

Now, the part that’s the failure is the very end, where the reporter concludes by extensively quoting Dr. Nerurkar, who basically says the same thing she said in the HuffPo article about how she thinks that patients should be referred for CAM earlier in the process. Sadly, I fear that this particular article ended up falling into the same trap of false balance. The overall impression left after reading this article is that CAM is ascendent, that there are some skeptics (including a token skeptic), but the evidence base is rising to the point that it might even be a lapse in informed consent if a physician doesn’t suggest CAM as a treatment.

Maybe woo is ascendent, after all. The bait and switch works.