What’s in a word? “Integrative” versus “alternative” medicine, again

I’ve written a lot about the language issue with respect to alternative medicine. As I like to put it (at least in shortened form), first there was quackery. Quacks did not like that name at all, and thus was born alternative medicine. And the quacks did think it good—for a while. There was a problem, however. “Alternative” medicine implied (correctly, of course) that what was being discussed was not real medicine, and the quacks could not abide that. Thus was born “complementary and alternative medicine” (CAM).

And the quacks thought this very good indeed.

Unfortunately, it was not long before the problem with the term CAM became apparent. It had the word “complementary” in it. The implication of that word, of course, is that what they were doing was still somehow not real medicine. It was complementary to real medicine, the icing on the cake, if you will. Real medicine could do without it, and having that implication in the very name that their evolving specialty had taken on was offensive to the quacks.

So they changed it.

Thus was born “integrative medicine.” This was a term that eliminated all implication that quackery such as reiki, acupuncture, naturopathy, and the rest of the pseudoscience and antiscience that made up the bulk of the “alternative” medicine in complementary and alternative medicine was somehow lesser medicine. That it is lesser medicine—or not even medicine at all in most cases—bothered the quacks not at all. It was all about marketing, and “integrative medicine” implied a meeting of equals. More importantly, it could be sold as the “best of both worlds,” which sounds great until you consider that one world consists of medicine that works and the other world consists largely of magic. Few thought of that, however, and the term “integrative medicine” had the added bonus of being so amorphous that it could “integrate” just about anything, even what might or might not have been underutilized areas of real, science-based medicine, such as nutrition, diet, and exercise.

Thus, the term “integrative medicine” not only eliminated the stigma of being “alternative” or “complementary,” but it also facilitated the rebranding of perfectly science-based areas of medicine (like the aforementioned diet and exercise) as somehow being “alternative” or somehow unique to integrative medicine. It was a masterstroke of marketing, because diet, exercise, and lifestyle interventions can actually work (that is, when they’re not distorted beyond recognition by woo, which is part of integrative medicine) and therefore lend some of their legitimacy to the serious woo that has been “integrated” with them in the specialty known as integrative medicine.

But not everyone in the world of “integrative” medicine is happy about this state of affairs. John Weeks, for instance, just wrote a post in that wretched hive of scum and quackery, The Huffington Post, entitled In Defense of ‘Alternative Medicine’. Using the recent BMJ op-ed (no, contrary to how it’s portrayed in the press, it was most definitely not a study and did not add any new knowledge to the scientific to the literature) estimating there to be a quarter of a million deaths due to medical error, Weeks tries to co-opt the word “alternative” in arguing for a bit of a return of the word to describe what he has long promoted. (Note that version of a post about this BMJ article that I’ve written) will be forthcoming It’s also a reversal of sorts, given that he was very much into promoting the term “integrative medicine” not too long ago.

Basically, Weeks co-opts the word “alternative” by conflating the use of the word with respect to medicine and with respect to the bad things he sees in medicine. Basically, it’s a variant of the sort of false dichotomy I rail against not infrequently, the dichotomy that claims that to “fix” what’s wrong with “conventional” medicine one has to embrace quackery. Here’s a taste:

No — we sought and still seek alternatives to dehumanizing, production-centered, technology-oriented, natural process-denying, bulling disregard for the value of other professions and practices that an alternative “holistic” or “whole person” or “natural” or “mind-body” approach to what ailed us.

No one could argue that there are aspects of the way medicine is practiced right now can at times be dehumanizing. However, it is entirely possible to practice “holistic” medicine without embracing the quackery of alternative medicine. Similarly, there’s a reason why science-based practitioners have such “bulling disregard for the value of” of all those “holistic” professions. It’s because most of them are rooted in pseudoscience and practice quackery (e.g., naturopathy). Respect is earned, and what earns respect among physicians is excellent patient care based on the most rigorous science.

Next up are a several demands that mix the reasonable with apologetics for quackery:

We want an alternative to an opioid strategy such as that propounded by the CDC and the Obama administration’s 1.1-billion plan that denies the value of multiple non-pharmacologic, alternative and integrative approaches.

We want an alternative that says Never Only Opioids.

We want an alternative that says never only any long-term course of a drug known to have significant adverse consequences when used chronically if other approaches might limit the need or reduce the harm.

We want an alternative that focuses on health, well-being and healing.

The Obama administration’s plan doesn’t “deny the value of multiple non-pharmacologic, alternative and integrative approaches”; it focuses on strategies that have some science behind them supporting their efficacy and safety. I also note that, through his link, Weeks tries to co-opt the American Public Health Association’s (APHA) call for “provider training programs on mental health, non-pharmacological pain treatment alternatives, substance abuse and overdose prevention.” Unfortunately, the APHA does fall for the pseudoscience behind integrative medicine by suggesting “complementary and integrative care providers.” It irritates me to no end when what should be science-based professional societies fall for the message of alternative medicine providers.

Be that as it may, here’s the language sleight-of-hand going on here. When physicians say “non-pharmacological strategies” to deal with anything, they mean exactly that: strategies that don’t involve pharmaceutical drugs. However, they also mean science-based strategies that don’t involve drugs. That implication is unstated but there. When Weeks uses the term “non-pharmacological strategies,” what he means is alternative medicine, CAM, “integrative medicine,” or whatever you want to call the various forms of quackery that “integrative medicine” integrates.

He soon makes this clear:

We want an alternative to decision processes that exclude entire licensed practitioner groups — chiropractors, acupuncturists, integrative and naturopathic doctors, holistic nurses, massage and yoga therapists — when it is clear that millions of citizens of the United States are benefiting from their services every single day. Right now. This moment. Not awaiting Big Brother’s sanction.

There! That’s Weeks’ message, his real message. He wants to let the quacks in: chiropractors, acupuncturists, integrative and naturopaths. True, massage therapy doesn’t have to be quackery (although unfortunately massage therapists are prone to injecting a lot of woo into their ministrations, particularly “energy medicine”). Neither does yoga, at least when stripped of its mystical, vitalistic components, such as Kundalini. Stripped of Kundalini, yoga becomes nothing more than a form of exercise.

To confuse things further, Weeks “integrates” some reasonable “alternatives” along with his wanting to integrate alternatives that consist of quackery. His language, of course, is full of hyperbole, but the basic message, stripped of that hyperbole, is not too hard to get on board with.:

We want an alternative to the 5 minute or 15 minute office calls that drive physicians to prescribe drugs and flat-out deny the complexity of what got people in trouble in the first place, and the time needed to learn, and to unravel and resolve the issues.

Elsewhere:

We want an alternative to a payment system that puts the workaday wizards of change agency with people’s health processes at the bottom of the totem pole or, more likely, hatchets them off altogether.

We want an alternative to an industrial approach to payment and delivery that directly drives the morbidity and mortality reflected in those ugly data from the British Medical Journal. First, do no harm.

Who likes five or fifteen minute office visits for complex patients? Not very many primary care doctors that I know. Who likes the “industrial approach” to payment and delivery? Again, not very many doctors I know, if any. Here comes the false dichotomy again, though. The implication is that if you are not in favor of “integrative medicine,” you must be in favor of five minute office visits, reimbursement that doesn’t always cover expenses, and a dehumanized health care system. It’s nonsense, of course. Fixing the system doesn’t require embracing pseudoscience.

Weeks, however, wants you to think that it does, as he cleverly drops little bombs like these in:

We want an alternative to any medical doctors or other health professionals who lack a primary respect for the roles of nutrition, self-care, mindfulness, sleep, movement, environment, community and the actual science of supporting individuals to health.

Again, no good physician lacks a respect for these things. What he does lack respect for are modalities that have no science behind them, like reiki, acupuncture, reflexology, or most of naturopathy—and rightly so. No physician doesn’t want to support patients journey to health or to help patients remain healthy. Again, supporting patients’ health does not require embracing quackery or abandoning science.

Of course, that’s not Weeks is about:

We want an alternative, as Group Health Research Institute senior investigator Dan Cherkin, PhD recently argued to a still dominant focus of resources on reductive biomedical research and practice.

Of course, Weeks (and Cherkin) argue for getting rid of that pesky “reductionistic” science because it doesn’t support the efficacy of the quackery they want to “integrate” with medicine. It’s an old story. When science doesn’t support you, you start complaining about “reductionism” and then decrease the rigor of the science by combining interventions and getting rid of controls. If “reductionistic” science shows that, for instance, acupuncture and sham acupuncture are indistinguishable, it doesn’t mean that acupuncture doesn’t work, even though the same result for a real medical intervention would mean that intervention doesn’t work. Instead, it must mean we’re harnessing the power of placebo or that “complex interactions” are helping patients. In reality, such “explanations,” such as they are, boil down to nothing more than making excuses.

Weeks concludes by characterizing the “complementary” part of CAM as a “suck-up gesture, a way to “play inside the power-centers of the juggernauts, world views, and abiding priorities that daily generate the BMJ outcomes.” Of course, we who argue for science-based medicine and against the integration of quackery into medicine knew that all along. I’ve said as much. Language is the tool used by quack apologists and quacks to integrate their quackery into medicine. Even so, oddly enough Weeks actually likes the term “complementary” more than he does “integrative”:

The reframing to “integrative” was tap-rooted in the work of medical doctors coming from the alternative and natural medicine traditions, like Andrew Weil, MD. They were beginning to engage the daunting political-economic-medical work of reforming academic medicine from the inside. Diplomacy was required. “Alternative medicine” was a bold challenge. “Integrative” was reassuring. Regular medicine is still the center. You are still in the driver’s seat. The word has been a door-opener.

Yet these integrative medical doctor change agents in their self-definition call for a relationship centered system that is inclusive of all health professionals and disciplines, focused on health and healing. Would you say this is an “alternative” to what we have today?

“Integrative” has its value. But does it capture what is needed?

Maybe it’s because I’m a doctor, but I’ve always viewed the reframing of alternative medicine to CAM to “integrative” as the most effective single use of language used by people like Andrew Weil and John Weeks to persuade physicians that they really were “integrating” the “best of both worlds” into medicine and that the pseudoscience would be left out. Of course, the pseudoscience was not left out; rather the association between modalities like diet or exercise and the pseudoscience facilitated the integration of quackery even as quacky as reiki and other “energy healing” with medicine.

Finally, of course, contrary to Weeks’ assertion, integrative medicine will not decrease medical errors. The more rigorous application of science to the process of delivering care, rather than to just the discovery of new treatments, is what will. It won’t be easy as it is, and certainly integrating quackery with medicine won’t make it any easier, despite what Weeks wants you to think.