Every so often I wonder what the status is regarding the infiltration of pseudoscience into medicine. It’s something I’ve been writing about on a regular basis for nine years now, a phenomenon known as “quackademic medicine.” It’s simultaneously a depressing and energizing topic, energizing because it’s something I’m passionate about, but depressing because at times it seems like an unwinnable battle.
Times like now.
What depressed me this time was article that popped up in my feed on Medscape entitled, Do Clinicians Base CAM Recommendations to Patients on Evidence of Efficacy? Since “complementary and alternative medicine” (CAM) is, by and large, mostly made up of a collection of modalities either based on prescientific thinking and possessing little, if any, plausibility on a scientific basis, my first reaction was to note that health care practitioners do recommend CAM to some patients, meaning that the answer must be, “No,” and then to move on. However, I wanted to see what Dr. Désirée A. Lie, the author, said and to see what the reasons are for whatever answer she came up with. So I read on.
The article starts with a case study:
A 50-year-old man with a body mass index in the normal range presents to your office stating that he would like to be more active in outdoor sports, but he is unable to participate because of chronic low back pain. Vertebral disc prolapse had been excluded by earlier imaging, which was notable for mild osteoarthritis of the lumbar spine. In the past, physical therapy has been of limited help, although he continues to do back stretches daily. He spends 2-4 hours commuting by car to work each day and runs or walks 2-3 times a week, 30-40 minutes at a time.
The patient is asking for your recommendation for a complementary or alternative medicine (CAM) option that would improve his functioning and ability to participate in more vigorous physical activity. He does not wish to take anti-inflammatory agents because of reflux esophagitis.
Notice how the question is framed. The patient is asking for CAM. That puts a physician in a tough spot. The patient wants something magical to make his low back pain go away, and, unfortunately, for low back pain there is nothing magical. My first recommendation would be that the man find a way not to have to drive so much, because if there’ one thing that’s hard on a person with low back pain, it’s driving hours every day in a car. If that’s impossible, I’d ask the man if he could find a way to have better lumbar support and plenty of room. Or, I might suggest a few things but then tell the patient what he doesn’t want to hear, namely that if those interventions don’t work his desire to be more active in outdoor sports might not be feasible. Be that as it may, though, many docs would probably recommend some sort of “CAM” to this patient, although I would note that recommending more or different exercises or other lifestyle modalities represent what should be science-based medicine, not CAM. CAM has appropriated many of these modalities, such as lifestyle interventions or nutrition, as somehow being “alternative” when they are not.
Be that as it may, there are two questions in a survey form:
- Which of the following healthcare professionals is likely to recommend CAM for the patient’s low back pain?
- What modalities are healthcare professionals most likely to recommend?
The choices for the first question included physicians, nurses, and pharmacists—and, of course, “all of the above.” The choices for the second question included osteopathic or chiropractic manipulation, acupuncture, massage, and, again, “all of the above.” Disappointingly, by far the most common answer given for the second question was “all of the above” (61%), while for the first question the most common answer was “a nurse” (45%), followed by “they are all likely to recommend CAM” (40%). “All of the above” was listed as the “correct answer” for both questions, based on this explanation:
Since the 1990s, national survey data in the United States have reported a prevalence of CAM use that has risen from 1 in 3 patients to nearly one half of all patients.[1-4] A recent review of the 2007 National Health Interview Survey examined self-reported CAM use by healthcare workers (categorized as providers, such as physicians and nurses; technicians, such as sonographers and laboratory technicians; and support workers, such as nursing aides) using the National Center for Complementary and Alternative Medicine taxonomy (alternative medical systems, biologically based therapies, manipulative body therapies, mind/body therapies, and energy-healing therapies).
The authors found a higher prevalence of use in the past year among all healthcare workers compared with the general population (41% vs 30%). As well, 76% of all healthcare workers reported using at least 1 modality in the prior year. Those working in the ambulatory setting were more likely than hospital workers to use CAM. Healthcare providers (such as physicians, nurses, and pharmacists) had a 2.2 times increased odds of seeking practitioner-based CAM modalities (such as acupuncture and manipulation) and 2.7 times increased odds of self-treated CAM modalities (such as botanicals or supplements) compared with support workers.
The most common reason given for CAM use by healthcare workers was “general wellness,” and the most commonly treated condition was anxiety in this study. There was also a significant increase since 2002 in use of the following modalities by healthcare workers: acupuncture, deep breathing exercise, massage therapy, meditation, naturopathy, and yoga.
I can’t help but note that the very first sentence promulgates a common myth about CAM, namely that anywhere from one-third to one-half of patients use it; i.e, that its so popular that it should be considered mainstream. As bloggers here at SBM, such as Steve Novella, Brennen MacKenzie, and myself, have explained, this is indeed an exaggeration, but it’s a useful exaggeration, given how it feeds CAM media myths. As Steve Novella has pointed out, for instance, that, contrary to a picture of increasing CAM use, CAM use for all categories except massage are all either static or only slightly increased. More importantly, as all of us have been pointing out again and again, these CAM numbers are inflated by including items that shouldn’t necessarily be considered outside of mainstream medicine, such as massage, biofeedback, and yoga—which, let’s not forget, is merely exercise and stretching. It’s only when pseudoscientific claims are made (as is not infrequently the case for nutrition and exercise modalities like Tai Chi and yoga) that these modalities fall outside of the mainstream and become “alternative.” Also, manipulative therapy is included. As I like to say, I have little problem with chiropractic as long as chiropractors use only manipulative therapies similar to those used by physical therapists, which is science-based medicine. I only have a problem with chiropractors when they go beyond that—which, unfortunately, all too many of them do—and become what I like to call physical therapists with delusions of grandeur, claiming to be able to treat allergies, asthma, and all manner of disease not based on the spine or the musculoskeletal system. In any case, chiropractic and osteopathic manipulation together add up to around 21%, and yoga adds nearly 10% to that.
Yes, Dr. Lie fell into that trap. She also cites a study published in 2012 claiming that CAM use is more prevalent in health care workers and providers (41% compared to 30% in the last year). If you look at the study in a bit more detail, though, you’ll soon find that it has the same issues as the 2007 NHIS had, and if you look at the numbers for individual modalities (which you can, as the study’s available at PubMed Commons for free), particularly in Table 2, you’ll see that, once again, they are dominated by manipulative therapies, 21.7% reporting having used chiropractic or osteopathic manipulation. If you look at biologically based therapies, which includes any diet-based therapy, such as vegetarian diet, macrobiotic diet, Atkins diet, Pritikin diet, Ornish diet, Zone diet, South Beach diet, as well as any use of dietary supplements, you’ll notice that 68.9% report some form of self-treatment, but only 0.3% doing “practitioner-based” therapy. One wonders whether anyone who put himself on a diet to lose weight without having a practitioner supervise it would count as having used CAM by this definition. One notes a similar issue with “mind-body” therapies. While 30.8% of health care practitioners reported using them as “self-treatment,” only 0.9% reported practitioner-based use of these therapies. One notes that yoga and Tai Chi are listed as falling under this category (supplemental information); so it’s not at all surprising that one in three people might have tried yoga or Tai Chi at some time in their lives. My wife’s done yoga. My uncle used to do yoga before it was cool to do it. I’ve thought of trying it myself to get into better shape. It’s exercise, people!
The rest of the modalities listed in Table 2 show single digit percentages for everything else, such as energy therapies, which would included reiki, therapeutic touch, and various other forms of “energy healing” (1.5%), and alternative medical systems, which would include homeopathy and ayurveda (3.0% self-treatment, 2.6% practitioner-based treatment). Next, if you look at the odds ratios in Table 4, you’ll see that, disappointingly, health care providers have an odds ratio of having used CAM in the last year of 2.6 (95% confidence interval 1.7-4.2), leading the authors to conclude:
Even with these limitations, our results are suggestive of why CAM therapies are increasingly integrated into health care. There is evidence that personal use of CAM by health care workers is related to the provision of, referral for, or general openness to the integration of CAM therapies in health care practices. For example, Tracy et al. (2005) reported a strong correlation between personal use of specific CAM therapies among critical care nurses and the use of those same CAM therapies in practice. Thus, personal use of CAM by health care workers may be a principal determinant in the movement toward “integrative care”—the mainstreaming of CAM with allopathic medicine (Mann, Gaylord, and Norton 2004; Winnick 2005). In addition, in the context of recent federal health reform changes, in 2014 when the health insurance exchanges begin, states may be more ready to license practitioners of various CAM therapies and thus require insurance coverage for CAM.
In other words, more health care providers are using CAM, at least if you believe this study and Dr. Lie’s article. The implication (and apparent hope) among CAM advocates is that this means that CAM will increasingly become more tightly “integrated” with real medicine. True, we are left with the proverbial “chicken or egg” problem in that it’s not clear whether the reason health care practitioners are apparently using more CAM, however defined, is because of the propaganda promoting its use or whether CAM is becoming more “integrated” with medicine because more and more physicians are embracing it. It could well be a vicious cycle, in which increasing “mainstreaming” of CAM through its infiltration into academic medical centers and the medical school curriculum feeds greater acceptance among physicians and therefore greater usage. While it is true, if Dr. Lie’s article is correct, that CAM use is highest among nurses, followed by pharmacists, and then by physicians. It’s noted, however, that although the average of reported usage by physicians is the lowest, geographic variability in usage among physicians is the highest, ranging from only 24% of physicians in Denver having reported ever using CAM (I really didn’t see that one coming, given Colorado’s well-known predilection for embracing quackery) to 49% of physicians in Kentucky and up to 83% of primary care physicians at a medical school (it was the Morehouse School of Medicine, for anyone who’s interested).
It all makes me wonder whether medicine has reached a tipping point, if the CAM genie is out of the bottle and can’t be put back in. A while back, I wrote about how Andrew Weil was spearheading a plan for a board certification in “integrative medicine,” which I dubbed the “ultimate triumph of quackery,” because of how it was the next step in the legitimization of “integrating” quackery with scientific medicine? Even though CAM practitioners were very cool to the idea because of turf issues (namely, only physicians could have a board certification in “integrative medicine”), physicians are apparently flocking to this new certification, so much so that the first ever integrative medicine board exam has been postponed, as announced on the American Board of Physician Specialties website:
Since announced in mid-2013, interest in the new American Board of Integrative Medicine (ABOIM) has been overwhelmingly positive. An unprecedented number of applications were received by the December 1st deadline for the first exam administration, originally scheduled for May 2014, and this tremendous demand affected our projected timelines. In an effort to ensure the highest level of customer service to both current and future applicants, we have postponed the first administration of the examination until November 2014.
It’s times like these that I wonder whether the forces of pseudoscience have already won. But then I reassure myself by pointing out that, if you exclude exercise, diet, and manipulative therapies, vanishingly small numbers of physicians and other health care providers use anything that could in any way be considered “CAM.” Most physicians don’t use CAM themselves or prescribe it for their patients. From my anecdotal experience, most physicians appear dismissive of CAM. Unfortunately, they also don’t stand up for science-based medicine (or even evidence-based medicine) enough, either. Rather they are “shruggies,” whom Val Jones defined as “fairly inert,” unwilling to “argue the merits (or lack thereof) of complementary and alternative medicine (CAM) or pseudoscience in general,” because they just “aren’t all that interested in the discussion, and are somewhat puzzled by those who are.” That leaves it to us, the ones who are interested, to sway them and hold our fingers in the dike protecting SBM from the ever-pummeling waves of quackademic medicine that have been pounding against it for the last 30 years ago. Stories like these remind me that we need to do more than just hold our fingers in the dike.