No, it is not okay to give patients a treatment with no proved medical benefits

Et tu, Scientific American?

A few of you seem to know what will catch my attention and push my buttons, because over the past couple of days a few of you sent me an article published in Scientific America by an internal medicine resident named Allison Bond entitled Sometimes It’s Okay to Give Patients a Treatment with No Proved Medical Benefits. Yes, a title like that is akin to waving the proverbial cape in front of a bull. Of course, I doubt that Bond herself came up with that title; editors usually come up with such titles. Still, the title is a fairly accurate summation of what is being argued in Bond’s article. Unfortunately, it’s a profoundly misguided argument.

The article begins with a sad tale, but one that is unfortunately not that uncommon: a young woman in her 20s with a very severe chronic disease that had “ravaged her body, giving her the appearance of a woman 30 years her senior.” A grim picture is painted:

As a first-year resident physician, I was caring for her in the intensive care unit during her fourth hospitalization in just a few months. She had life-threatening liver disease and signs of a serious infection, and when she first was admitted, she was tearful and shivering, writhing in pain and clutching her mother’s hand. Her body’s own defense mechanisms had destroyed her liver, which in turn had seriously hampered her immune system. It unfortunately wasn’t surprising, then, that we found numerous infections in her liver and lungs. Once these pockets of fluid were drained, and after she had received antibiotics and pain medicine, she became more comfortable and more stable.

I remember caring for equally ill (or even sicker) patients with stories just as tragic and who were suffering. It’s a hard lesson that we as physicians learn in our first couple of years of residency, because being a resident is categorically different from being a medical student. Medical students do help to care for patients on the service, but they are nowhere near primarily responsible for them. When you’re a resident, suddenly you’re responsible for everything. You become involved in a way that you couldn’t be before, while at the same time you are responsible for more patients than you ever have been before. Patients like this woman are hard because for the first time they challenge you in a way you’ve never been challenged before: You find that you can’t do nearly as much as you might have thought to relieve her suffering, and you went into medical school in the first place, at least in major part, to relieve suffering. It’s easy to understand how young doctors might be tempted to “try anything.”

So Bond witnessed this:

One morning after rounds, I glanced over at Ms. W’s room and saw an unfamiliar woman walk in and pull the curtain closed at the room’s entrance. The visitor was a reiki practitioner who had come at Ms. W’s request. In reiki, the practitioner uses his or her hands to transfer so-called vibrational energy to the recipient in an effort to promote healing or increase well-being. It hasn’t been shown to be an effective treatment for any condition, and numerous medical organizations—including the American Cancer Society and the National Center for Complementary and Integrative Health—recommend against reiki as a primary treatment for illnesses such as cancer. My patient was sick frequently enough to be well known to many services at the hospital, including the one that provides reiki to patients who desire it.

Reiki? As I’ve discussed many times before, reiki is nothing more than faith healing that substitutes Eastern mystical beliefs for Christian beliefs. For those who don’t know enough about reiki to see the analogy, I’ll briefly repeat it. Reiki involves a reiki master channeling what is described as “energy” (that, of course, can’t be detected) from what reiki masters call the “universal source” through the reiki master and into the patient for healing effect. Now, to make the analogy to faith healing crystal clear: Substitute the words “faith healer” for “reiki master,” “god” for “universal source,” and “power” for “energy,” and you have a faith healer channeling the healing power of god into the patient. There really is no difference in concept, and it really is that simple. On the other hand, reiki does provide “innovations” over run-of-the=mill faith healing. For instance, reiki masters claim to be able to heal at a distance and even to be able to send the reiki energy backwards and forwards in time. (One wonders if The Doctor does reiki, or if maybe reiki energy is what powers the TARDIS.) Most faith healers that I’m aware of won’t go quite that far.

I also noted another thing. Note that Bond describes the service that provides reiki. In other words, her hospital provides it. She happens to be a resident at Boston University; so I did a quick trip over to the Boston University Medical Campus website and looked for its offerings in “complementary and alternative medicine” (CAM), now more frequently called “integrative medicine” because it integrates quackery with real medicine. At BU, oddly enough, the CAM program is referred to as the Program for Integrative Medicine and Health Care Disparities. What health disparities have to do with integrative medicine, I have no idea. Perhaps BU is trying to bring quackery to the poor and underserved. Interestingly, although there’s lots of reference to acupuncture, massage, and the like, but no mention of reiki, although reiki is briefly mentioned in this brochure. It’s almost as though BU doesn’t want to advertise too much that it offers Eastern mystical faith healing (reiki) to its patients.

So what’s the problem? What’s the harm? For example, Bond seems to understand that the benefits of yoga and tai chi have nothing to do with their mystical underpinnings and everything to do with the fact that they are simply forms of gentle exercise, and physical activity and exercise are almost universally beneficial. Like so many who have drunk the Kool Aid of “integrative medicine,” she also goes to great lengths to differentiate “integrative” medicine to “alternative medicine,” using (of course) the example of a patient with cancer who had eschewed effective treatment “in favor of receiving injections of a caustic chemical the patient thought was more ‘natural.'” The results were predictable:

Predictably, these injections did not shrink his cancer. Worst of all, repeat imaging showed that the cancer had become widely metastatic. The patient had lost precious time that would have been crucial to halting the spread of his cancer, and now his prognosis was much worse.

Yes, this is the sort of thing I’ve railed about for over a decade now, ever since this blog was first started. No one is arguing that physicians should support the use of ineffective alternative medicine in place of real medicine. The problem, of course, is that a lot of those bogus treatments are the same treatments that are now being “integrated” into real medicine. So if it’s not OK to use pseudoscientific treatments in place of effective, science-based treatments, why is it acceptable to “integrate” such treatments with real medicine?

Bond tries this tack in making her argument:

Yet not all alternative therapies have proven benefits, and in many cases, high-quality scientific data are sparse. Reiki, for example, is widely considered pseudoscience in the medical and scientific communities. One study found reiki improved mood and quality of life among patients receiving chemotherapy for breast cancer – but so did simply being assigned a companion with whom to spend time. In other words, perhaps it is not reiki’s purported “energy exchange” that is beneficial, but rather the sense of companionship and support stemming from spending time with another person.

Interestingly, some patients who use alternative therapies freely acknowledge that the benefits of such practices may arise simply from the respite or companionship they provide. Ms. H, for example, was a patient of mine who suffered from severe pain as a result of advanced breast cancer. When I asked her why she enjoyed receiving acupuncture, she shrugged, saying she enjoyed the company and found that lying still during the hourlong session provided a refreshing period of rest.

This is, of course, a seductive argument. If it’s really just companionship and the interaction with an empathetic fellow human being that is responsible for the perceived “benefits” of modalities like reiki and acupuncture, then there is no rationale for reiki and acupuncture, particularly the latter, which involves sticking needles into human flesh and therefore has real risks, albeit small. Why not just eliminate the mysticism and pseudoscience and provide companions and counselors, who will spend time with the patient and lend support and a sympathetic ear? This is a role that used to be filled by volunteers, chaplains, and the like. Indeed, because reiki is basically a form of religion, I’ve also frequently said that I have no problem with reiki masters coming into the hospital to give comfort to patients. What I object to is treating reiki masters like actual medical practitioners and having the hospital offer reiki as another medical service. It is not. Reiki masters are much more akin to chaplains and should be treated the same way as priests, rabbis, reverends, and other religious figures who are allowed into the hospital as chaplains to tend to patients’ religious beliefs. Unfortunately, by offering reiki as a “medical” service, hospitals are putting their imprimatur on it and representing it as what it is not (medicine) rather than what it is (religion/spirituality).

There is a false dichotomy here that Bond, whether she realizes it or not, seems to buy into. “Integrative” medicine advocates will argue that what their specialty provides is the “human touch” and “holistic care,” as though they somehow care for the “whole patient” and science-based medicine does not. Medicine does not have to embrace quackery to provide that “human touch” that made patients like Mrs. W and Mrs. H feel better and helped them to get through their hospitalizations. It is not necessary to stick needles into the skin, as acupuncturists do, or to make symbols with one’s hands over the patient and play act channeling “healing energy” into them, as reiki masters do, to tend to the psychosocial needs of patients.

The problem is that we do not choose to do so. We do not value the human touch, which is why simply talking to patients and spending time with them are services that are not generally not paid for, unless they are psychiatric or counseling services for specific purposes. That’s why the “human touch” is left mostly to chaplains, volunteers, family and friends, and, haphazardly, to hospital staff who are so inclined when they have a couple of minutes between running around to do their numerous duties. Indeed, one can look at reiki and much of “integrative medicine” as a stealth method to sneak in human interaction in the form of billable services that do nothing. The problem, of course, is that this strategy “integrates” pseudoscience with medicine and that these treatments (e.g., acupuncture) are not without risks and adverse effects. Worse, representing such quackery as real medicine subverts the informed consent process, as physicians and quacks tell patients that, for example, reiki will do things that it cannot do. In essence, “integrating” quackery into science-based medicine as a means of providing the human interaction lacking in current medicine involves deceiving patients, lying to them, even.

There has to be a better way that doesn’t involve tarting up the human interaction with ritualistic pseudo-“treatments” based on mysticism and pseudoscience sold as medicine. Unfortunately, doctors in training, like Dr. Bond, have been inculcated since the 1990s with a world view that somehow “integrating” quackery with real medicine represents the “best of both worlds” and that pseudoscience like acupuncture actually works. How we reverse this pernicious attitude, which has been around long enough to have become ossified in the curricula of medical schools across the country will be the challenge for the next generation of physicians, those in high school and college now.

ADDENDUM: Steve Novella has commented as well.