When traditional medicine doesn’t help, does integrative medicine provide answers?

Sometimes, I think advocates of “integrative” medicine are trolling me. Of course, unlike antivaccine advocates, I realize it (usually) isn’t about me at all and they’re just writing what they believe and have (usually in the vast majority of cases) never encountered me and (usually in the vast majority of cases) aren’t considering me at all. Even so, it’s hard, when coming across an article like The Power of Integrative Medicine When All Else Fails by Emma M. Seppälä over on Psychology Today, not to think that I’m being trolled, so blatant are the alternative medicine propaganda and apologia. As if the title weren’t bad enough, check out the tag line:

When traditional medicine doesn’t help, integrative medicine provides answers.

Regular readers and commenters of this very blog can probably predict Orac’s reaction to this.

It begins, as do so many of these sorts of articles, with an anecdote, a human interest story. In this case, it’s a woman named Stacy Brindise, who, for whatever reason, was having problems with infertility. She and her husband Mike had been trying to conceive for several years and failing. They had what is called “unexplained infertility,” which usually means the man has adequate sperm count and quality, while the woman is ovulating normally. In other words, there doesn’t appear to be a medical explanation, either on the male or female side, for the infertility. Like many couples in this predicament, the Brindises underwent a steady escalation, from hormone treatments for Stacy, to monthly intrauterine insemination, which both failed.

The next step was to be in vitro fertilization (IVF), which starts at $12,000 a round and is usually not covered by medical insurance. This story was the hook, and we’re left with this:

Nothing had worked and it was time, Stacy decided, to change her approach.

“When people have a medical problem, everybody seems to jump right to drugs as the solution,” she says. “I wanted to see if improving my overall health and well-being would increase our chances of getting pregnant naturally.”

I say the story of the Brindises is the hook because the first part of it is told at the beginning, and they are not revisited until the very end of the article. Spoiler alert: We don’t learn about what happened to the Brindises until the end, but these sorts of stories (particularly if they involve infertility) are so utterly predictable that it isn’t really a spoiler at all to reveal right now that Stacy ultimately got pregnant and credits acupuncture. More on that later. First, let’s get to the propaganda between the beginning and end of the Brindises’ story:

Stacy is not alone in her gut feeling that first addressing her overall health and well-being—before investing in more invasive solutions—might be a key element in her health care. High-tech, high-cost approaches clearly have their place, and modern medicine can boast many silver-bullet solutions, but millions of Americans feel that’s not enough. They spend more than $30 billion a year out of their own pockets for alternative treatments, according to data compiled by the National Center for Complementary and Alternative Medicine. Funding for NCCAM—the U.S. government’s “lead agency for scientific research on complementary and alternative medicine”—hit $128 million in 2012, a 156% increase since its inception in 1999.

Even though this article is dated June 30, 2015, one wonders when Dr. Seppälä wrote it. As you all know, it’s no longer called NCCAM—and hasn’t been for more than six months. In December, NCCAM was reborn as the National Center for Complementary and Integrative Health (NCCIH, an acronym that doesn’t flow off the tongue as nice and easy as NCCAM did). Dr. Seppälä needs to get hip with the times. It’s no longer “complementary and alternative medicine” (CAM, another acronym that slides easily off the tongue), but “integrative medicine,” because the nasty word “alternative” has to be banished if the practice of “integrating” quackery into real medicine is to proceed apace. Of course, it remains depressing that the NCCIH budget remains in the $120-130 million range. I suppose the only good thing about the currently stagnant NIH budget is that the NCCIH budget has remained stagnant as well; on the other hand, that’s roughly $125 million that doesn’t go to real research.

In any case, now seems as good a time as any to repeat my rather clear position that NCCIH should be dissolved and its component parts absorbed back into various appropriate NIH centers and institutes. Upon its founding, the reason for its existence was to study alternative or (“unconventional”) medicine, the intent of its primary sponsor, Senator Tom Harkin, being that it “validate” such practices. We’re not just talking about unproven practices that might have some plausibility, such as supplements (which could contain pharmacologically active ingredients) or yoga (which is really just a form of exercise that has been co-opted as somehow “alternative” because it’s, you know, Asian in origin). Indeed, Sen. Harkin became most displeased with NCCAM in 2009, saying that it had “fallen short” because it had failed, as he put it, to validate any alternative medicine. Of course, it never occurred to him that perhaps the reason for this is because there was nothing there to be “validated.” Be that as it may, given that the director of NCCIH, Dr. Josephine Briggs, has promised not to emphasize the sorts of studies that were so widely derided before (such as studies of homeopathy, distant healing, and the like) and, as I like to characterize her view expressed in the 2011-2105 NCCAM strategic plan, do some real science for a change, there really is no reason for NCCIH to exist any more. Its real reason for existence was to provide scientific cover for the more outrageous forms of alternative medicine, and it has failed at that.

Not that that stops Dr. Seppälä from writing:

In 2010, 600 health care professionals assembled in Washington, D.C., for a summit on integrative medicine. It was sponsored by the Institute of Medicine, which defines integrative medicine as “health care that addresses together the mental, emotional, and physical aspects of the healing process for improving the breadth and depth of patient-centered care and promoting the nation’s health.”

The doctors who champion integrative approaches are not simply proposing “alternatives.” They advocate an updated model of health care that integrates mind and body, promotes more interaction and communication in the doctor-patient relationship, puts the patient at the center, and encourages self-care.

First off, the only thing this conference is an indication of is just how entrenched and successful advocates of “integrating” quackery into science-based medicine have been. Second, and more importantly, this is nothing more than the same old trope that you somehow have to embrace quackery in order to “put the patient at the center,” “promote more interaction and communication in the doctor-patient relationship,” and “encourage self-care.” Basically, it’s a false dichotomy that says, in order to become a more “holistic” physician and achieve these three things, you have to embrace woo, including, apparently, mind-body dualism, a concept implied by the frequent use of the term “mind-body” in various “integrative” methods. There’s nothing “updated” about this model of health care, because a good primary care doctor practicing science-based medicine should be a wholistic doctor who does all these things. There is no need to embrace unproven supplements or treatments based on mysticism and prescientific beliefs about medicine, such as acupuncture (or virtually anything other than scientifically validated natural products) from traditional Chinese medicine or “energy medicine,” such as reiki or healing touch, to achieve this. Nor is it necessary to “rebrand” perfectly science-based modalities such as diet and exercise (which is all yoga and Tai Chi, for example, are, forms of exercise) as somehow being “alternative” or “integrative” to achieve this.

Before we get back to the Brindises, though, Dr. Seppälä relates two more anecdotes. The first is a woman named Florence Strang, who is a breast cancer survivor. The treatment of her breast cancer required, as many breast cancers often do, chemotherapy and radiation and credits “mindfulness” with getting through it. Here’s the thing. There’s really nothing particularly “alternative” (back when it was CAM) or “integrative” (now that it’s part of “integrative medicine”) about mindfulness, which is in psychology an approach to reduce cognitive vulnerability to stress and emotional distress. If mindfulness turns out to be a useful psychological strategy to reduce distress, it will be validated by science. Again, it is a false dichotomy to consider it “alternative.” To paraphrase Tim Minchin, there is no such thing as alternative medicine. What do you call alternative medicine that’s been proven to work by science? Medicine! And “alternative” medicine that’s been validated by science will be naturally integrated into medicine, no need for a separate label.

Also, no need for woo-speak:

Strang’s way of coping with her cancer reflects the approach that integrative health care doctors take, according to Dr. Margaret Chesney, director of the Osher Center for Integrative Medicine at the University of California-San Francisco. Chesney emphasizes that the best way to enhance health and heal illness is often a combination of conventional medicine and healing methods that “address the person as a whole, that see where they are in their lives from the point of view of mind, body, spirit, and community.” For a patient at the Osher Center who wants to prevent heart disease, for example, the treatment plan might include an appointment with a cardiologist for appropriate testing but also a stress-management program such as yoga, meditation, or massage.

Once again, you do not need to embrace woo in order to “treat the whole patient.” Wait, you say. Yoga, meditation, and massage are not necessarily woo. I would (mostly agree). Yoga is just a form of exercise, at least when it’s stripped of its mystical practices. Massage is just something that feels good; calling it therapy medicalizes something that doesn’t really need to be medicalized. That’s a complaint that I have about much of “integrative” health practices. Modalities that once were just viewed as supportive services, things to help patients pass the time in the hospital or to take their minds off of things, either in or out of the hospital, have now become “treatments” or “therapy”; i.e., unnecessarily medicalized. I also note that the Osher Center at UCSF offers a lot more than just yoga, meditation, and massage. It offers acupuncture, traditional Chinese Medicine, and Ayurveda, among other unscientific therapies. Funny how supporters of integrative medicine tend not to mention these other things when promoting their centers.

The other anecdote is that of a veteran named Richard Low, who suffered severe post-traumatic stress disorder (PTSD) after 16 months in Iraq as an officer in the 4th Battalion of the 23rd Infantry Regiment. He learned to practice yoga, and apparently it helped him deal with his PTSD. So far, not so bad. Unfortunately, right after that Dr. Seppälä touts pure nonsense:

Shad Meshad, founder of the National Veterans Foundation, was instrumental in bringing attention to post-traumatic stress disorder before it was a clinically acknowledged diagnosis. He is internationally renowned for his work with trauma and was asked by the U.S. government to train critical-incident and trauma teams after the 9/11 attacks. Meshad uses a technique called TFT, in which a practitioner asks the patient to recall a traumatic event, then helps them tap different parts of the body known as meridian points (mostly on the face) in order to release the trauma. This practice is often coupled with breathing practices.

What is TFT, I wondered? Actually, I knew. Odd that Dr. Seppälä didn’t call the treatment what its abbreviation stands for: Thought Field Therapy. TFT is, actually, a form of “energy medicine” based on the traditional Chinese medicine concept of qi. It’s even spawned an offshoot, EFT, or emotional freedom techiques. Basically, Meshad left out a very big part of what TFT really is:

The theory behind TFT is that negative emotions cause energy blockage and if the energy is unblocked then the fears will disappear. Tapping acupressure points is thought to be the means of unblocking the energy. Allegedly, it only takes five to six minutes to elicit a cure. Dr. Callahan claims an 85% success rate. He even does cures over the phone using “Voice Technology” on infants and animals; by analyzing the voice he claims he can determine what points on the body the patient should tap for treatment.

Brandon A. Gaudiano and James D. Herbert wrote an excellent overview of TFT in Skeptical Inquirer 15 years ago:

Despite extraordinary claims to the contrary, TFT is not supported by scientific evidence. The theoretical basis of TFT is grounded in unsupported and discredited concepts including the Chinese philosophy of chi and Applied Kinesiology. Many of the practices of TFT proponents are much more consistent with pseudoscience than science. Controlled studies evaluating the efficacy of TFT will be required for the treatment to be taken seriously by the scientific community.

Nothing has changed regarding the evidence for TFT in 15 years. It’s quackery.

What article like this would be complete without an appeal to “empowering the patient? Yes, it’s there:

The power of integrative medicine doesn’t just lie in techniques. According to Dr. David Spiegel, director of the Center on Stress and Health at Stanford University, part of what’s powerful about any integrative approach is that it helps patients feel more involved, more in control and responsible for their own health care. It also allows for more time with a medical practitioner. “The average doctor,” says Spiegel, “spends seven minutes per patient and the average integrative practitioner spends 30 minutes.”

My common response to this is simple. You don’t have to embrace pseudoscience and quackery like TFT in order to “empower” the patient and make him feel “more involved, more in control and responsible for their own health care.” It’s the false dichotomy at the heart of “integrative medicine.” (More on that tomorrow, when I will discuss another annoying article of this ilk.)

After this detour through steadily increasing levels of quackery, from non-quackery (yoga) to pure quackery (TFT), Seppälä finally makes it back to the Brindises:

It was a friend of Stacy’s who helped the Brindises solve their unexplained infertility. She was a nurse in an obstetrician’s office and she told Stacy that she had met many women who had used acupuncture successfully when they were trying to get pregnant. Despite some misgivings about the little she knew about acupuncture—namely, that it involved a lot of tiny needles—Stacy booked an appointment at the Acupuncture and Chinese Medical Center in Edina, Minnesota.

“My first surprise was that the doctor spent a good hour and a half with me,” Stacy says. “She asked me detailed questions about my eating habits, stress levels, and lifestyle. She took the time to get to know all of my habits so I could make choices that were more conducive to pregnancy. Her assessing my overall well-being made me feel really comfortable and taken care of.”

The acupuncturist advised once-a-week acupuncture sessions and dietary adjustments. Five weeks later, Stacy got her second surprise: She was pregnant. Stacy and Mike welcomed a healthy baby boy into the world in November.

There is no good evidence that acupuncture has anything to do with helping infertile couples conceive or, as it’s often touted to do, improving success rates for IVF or help polycystic ovary syndrome, a common cause of female infertility. Indeed, as happy as one might be for the Brindises having managed to have a child after trying for so long, there is no good evidence that acupuncture improves fertility. (Why should it? There’s no plausible reason why it should, and science bears out that the prediction that it shouldn’t.) Ditto other alternative treatments. Yet, typically anecdotes like the Brindises are presented as slam-dunk examples of the benefits of acupuncture and other “integrative” medicine, when in fact they are examples of tooth fairy science. Acupuncture does not work.

It’s depressing to see an article such as this in Psychology Today. I had never heard of Dr. Seppälä before this; so I took a look at her profile. She is Science Director of the Center for Compassion and Altruism Research and Education at Stanford University. Oddly enough, for holding such a position, she only has three publications listed on PubMed. But she does do this:

In addition to her work at Stanford, she founded Fulfillment Daily (www.fulfillmentdaily.com (link is external)), a magazine on science-based news for a happier life. She is also a popular Psychology Today blogger and contributor to a number of press outlets such as Scientific American Mind, the Huffington Post, Mindful and Spirituality & Health magazines. She often teaches Science of Well-being workshops in university and corporate setting and is a speaker with BrightSight group.

In other words, she appears to be a self-help guru, who mostly publishes in non-peer-reviewed sources and does a lot of talks and workshops. Whatever her role is, Dr. Seppälä has credulously contributed to the spin that promotes integrative medicine as somehow the way to empower patients and provide “holistic care.” It’s a common message that is the primary driver of the growing popularity of integrative medicine. It’s not true that when traditional medicine doesn’t help, integrative medicine provides answers, nor is it necessary to embrace pseudoscience to get those answers.