Quite to my surprise, apparently I’ve become fairly well known as a critic of so-called “integrative medicine,” that which used to be called “complementary and alternative medicine” (CAM) but whose name was changed because its practitioners didn’t want to be “complementary” to anything. Rather they wanted their woo to be co-equal with science-based medicine (SBM). Before that, what is now “integrative medicine” after having been CAM was known as “alternative medicine.” (The wag in me can’t resist further pointing out that before that it was mostly known as quackery.) As I like to say, the only thing “integrative” medicine adds to SBM is pseudoscience. I do my several blog posts per week, most here, at least one a week at my not-so-super-secret other blog, and people actually read the brain droppings I want to throw out into the ether. After over a decade, I still have to pinch myself, but even with my tendency towards extreme (for the Internet) logorrhea, I still have a readership.
One of the questions that keeps recurring over the years is: Why? Why are patients drawn to unscientific medicine. Make no mistake, the whole point of “integrative medicine” is to integrate medicine that has not yet been validated by science (or has even been disproven by science) with real, science-based medicine, although advocates of “integrative medicine” are very good at convincing themselves that they are just as science-based in their practice as any of us. Not surprisingly, they become very unhappy with me when I argue otherwise.
A couple of weeks ago, Scott Gavura mentioned how quackademic medicine has ppretty much completely overrun his alma mater, the University of Toronto. He was not alone. Joe “Dr. Joe” Schwarcz, a professor of chemistry at McGill University and director of McGill’s Office for Science & Society, which is dedicated to demystifying science for the public, was also harshly critical of the dean of the Leslie Dan Faculty of Pharmacy at the University of Toronto for running a clinical trial of homeopathy for attention deficit hyperactivity disorder (ADHD), criticism that led to Heather Boon, the dean and PI of the study, to fire back. I don’t want to discuss exactly what happened here, given that Dr. Joe’s article, a post by Dr. Gavura, and another post by a certain “friend” of the blog all discuss those issues in detail.
Rather, I want to use a post by Dr. Mario Elia as a jumping off point. The post, entitled The lure of “integrative medicine”, begins thusly:
It has been fascinatingly frustrating over the past couple of weeks to see faculty and students at the University of Toronto defending “alternative” and “integrative” and “holistic” medicine with all of their might. They are portraying this entire issue as an “us vs. them” debate, as if anyone opposed to the idea of integrative medicine is also blind to new ideas, opposed to non-prescription treatments, and has no interest in patient satisfaction. Nope, we actually care about all of those things. And we care about the patient’s pocketbook and about the scientific method.
This is another example of the false dichotomy of CAM (or integrative medicine, or whatever you want to call it) that I’ve lamented so often, albeit in different terms. Usually, I point out that being a “holistic” physician does not require the embrace of pseudoscience. After all, that is a key implication often made by proponents of integrative medicine, namely that you have to embrace pseudoscience like acupuncture, homeopathy, naturopathy, and the like in order to be a truly “holistic” physician and take care of the “whole” patient. Obviously, they don’t put it in those terms, but that’s the bottom line in many of their contentions about the usefulness of integrative medicine. Opponents of integrative medicine are often painted as believing in “scientism,” of not caring about the whole patient, and the like. As Dr. Elia points out, we’re also frequently painted, either by implication or by assertion, as not caring about non-pharmacological treatments of various conditions and of not caring about anything that science doesn’t understand very well.
Now here’s where Dr. Elia nails it. He describes a patient encounter with one of his patients who has hypothyroidism. This patient also regularly saw a naturopath, who offered her a boatload of the usual things that naturopaths offer, such as supplements and herbal medicines. (As an aside, I’d like to mention here how I frequently laugh at how practitioners of SBM are accused of “pill pushing” and of only wanting to give patients a prescription for a medication that will help them when so often naturopaths and other alternative practitioners want to push supplements and herbs as the cure for what ails their patients. The difference, of course, is that as a physician I can’t sell the pharmaceutical drugs that I presribe to my patients. Naturopaths and alternative practitioners can sell their patients the very supplements that they prescribe. But I digress.) In any case, after Dr. Elia found out what supplements his patient was on and trying to explain to her as gently as he could that there was no evidence that any of these supplements did anything for her hypothyroidism, this is what happened next:
I paused and asked her “What exactly about how you feel do you wish were different?”. She said she wanted to have more energy and be less stressed and angry. I asked how she feels when she leaves the naturopath. Fantastic, she said. After a fascinating discussion with her and her husband, I learned that my patient is quite religious, and has been frustrated for the past decade that she hasn’t found anyone locally who shares her sense of spirituality. Until she met this naturopath, as they have very in-depth discussions about her faith. I explained to her that the benefit she is seeing from the naturopath is from a sense of camaraderie, and not any diets or supplements or treatments she is offering. I told her that she can feel free to continue seeing the naturopath, as long as she realizes she is essentially paying for companionship. The pricey supplements and herbs are just along for the ride, and are unproven in terms of safety and efficacy. An expensive placebo while the companionship provides all of the benefit.
As I said, I think Dr. Elia nailed it here. Remember all those studies over the years that I’ve discussed about, for instance, acupuncture, in which the provider-patient interaction was as important—or more so—than any nonspecific effects of the acupuncture (e.g., this one)? This is the distillation of what “integrative medicine” really is, for the most part.
But what’s in it for the integrative practitioner? I suspect it’s reclaiming something that has been lost over the last couple of decades, the physician-patient interaction. As the financial pressures of practicing medicine have grown and patient face time has declined, it’s understandable that some physicians would like to reclaim “the way it was,” whether it ever really was that way or not. There exists in the collective consciousness a concept of the physician along the lines of Dr. Marcus Welby and Dr. James Kildare, kindly, benign figures whose influence and good intent were unquestioned by patients. Doctors also long for a perceived time when the will of the physician was generally unquestioned, and patients did what they were told.
I’ve frequently referred to this apparent view of the role of the physician in the physician-patient interaction by proponents of “integrative medicine” as that of the shaman. Indeed, no authority less than “America’s doctor” himself (or, as I like to call him, “America’s quack”), Dr. Mehmet Oz, has said just this, as I pointed out two years ago, citing an article about him by Michael Specter:
“I would take us all back a thousand years, when our ancestors lived in small villages and there was always a healer in that village—and his job wasn’t to give you heart surgery or medication but to help find a safe place for conversation.”
Oz went on, “Western medicine has a firm belief that studying human beings is like studying bacteria in petri dishes. Doctors do not want questions from their patients; it’s easier to tell them what to do than to listen to what they say. But people are on a serpentine path through life, and that is the way it is supposed to be. All I am trying to do is put a couple of road signs out there. I sit on that set every day, and that is what I am focussing on. The road signs.”
It’s that role, that some doctors crave (and understandably so), that of the healer. Unfortunately, to attain such a role, all too many of them have embraced pseudoscience to the point of advocating “integrating” it into medicine. As I’ve pointed out before, throughout most of human history, that was the role of the physician/healer. It took many hundreds of years, which stretched into thousands of years, before it was fully accepted that medicine should be based on science. Arguably, it wasn’t until just over a century ago, with the advent of the Flexner Report, that medicine, in the U.S. at least, was placed on a firmly scientific basis. Indeed, what we now know as randomized controlled clinical trials did not see their debut, much less become the basis of determining which treatments worked and which did not, until the 1940s. Although physicians have been trying to base their craft on science for hundreds of years, it’s really only been in the last century or so that they’ve succeeded.
Yet still some would like to go back to the way it was. They yearn for the days when doctors were “healers” and shamans, the way medicine was for hundreds and hundreds of years before science intruded. Indeed, I’ve lost track of how many times I’ve taken notice of rhetoric from practitioners of “integrative” medicine that basically says just this, usually with the implication that to attain that hallowed role of healer requires the embrace of various pseudoscientific—or perhaps I should say prescientific—treatments. And it works, too! Dr. Elia illustrates this with a question:
Can you imagine if physicians used the same predatory techniques that these alternative practitioners do? A patient comes in with viral pharyngitis, and I tell them it will resolve on its own, not to worry. It resolves on its own within 48 hours. Or….I could offer them some special herbal concoction, and voila! The herbs cured the sore throat in just 48 hours! Amazing! Dr. Elia is the hero! Patients need to realize the humility that physicians show in allowing the concept of tincture of time to run its course without creating a false sense of a cure through bogus practices. I am bound by evidence and science, not by pricey cures and by the ego-boosting of “curing” illnesses. The public would truly be amazed at the proportion of my day spent simply ruling out serious disease and providing reassurance, allowing time to take its course. Not as sexy as being a hero, but it’s the only ethical way to practice.
Of course, that’s the problem with “integrative” medicine. Basically, it is based on using interventions that either haven’t been shown to work or have been shown not to work and then taking credit for what would happen anyway even if the practitioner did nothing. Now, don’t get me wrong. Practitioners of SBM are sometimes guilty of this as well, but SBM isn’t built on the very model of placebo effects and regression to the mean. Integrative medicine is. SBM is all about producing real therapeutic effects. Integrative medicine doesn’t much care if there’s a specific effect. After all, any specialty that embraces naturopathy, traditional Chinese medicine, homeopathy, and even “energy healing” can’t be too concerned with verifiable science, its protestations otherwise notwithstanding. As I’ve said before many times, the “central dogma” of alternative medicine/CAM/integrative medicine is that wishing makes it so.
“Integrative health practitioners” often point to patient satisfaction as a rationale for their existence and for funding, which is completely insufficient as a measuring stick for appropriateness in health care. We know that simply having an individual listen to your concerns and show empathy will improve outcomes, regardless of the form it takes. So take Reiki, and craniosacral, and therapeutic touch, and any mind-body energy life-force practices, and call them what they truly are. Relaxing companionship. Then let’s have a discussion about whether public funds should be directed towards that end. And let’s tell private-paying patients that they are paying for companionship and relaxation. But don’t try and explain these techniques via unproven scientific principles as a means to give them legitimacy. Perhaps many of these practitioners can work to develop self-directed education programs for patients to help those improve their own stress. Less lucrative, but far more patient-centred.
I’m not going to hold my breath waiting for this to happen.