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Integrative medicine as infiltrative pseudoscience: Pushback against quackery

For a quarter of a century, quackery and pseudoscience have been integrated into medicine through the construct of “integrative medicine” and into academic medicine in the form of quackademic medicine. Unfortunately, there has been little pushback. That’s why it’s good to see a recent article in The Surgeon decrying this phenomenon. We need more of this.

There are times when the seemingly inexorable advance of pseudoscience into medicine in the form of “integrative medicine” gets me down, that further criticism and resistance are pointless. After all, when billionaire couple can dump $200 million on a medical school like the University of California, Irvine, as Susan and Henry Samueli did last September in order to transform the medical school and many of the university’s health professions schools by funding the “integration” of pseudoscience and quackery (like homeopathy) into medicine and teach medical students nonsense in order to promote this “integration” in the next generation of physicians, it’s easy to feel so utterly outgunned as advocates of quackery accuse science-based medicine advocates of having “blood on our hands” for daring to criticize the brave new world of medicine. When what were once bastions of science-based medicine embrace magic like energy healing and faith healing like reiki, it’s easy to get depressed, throw up one’s hands, and just give up. After all, it’s not as though there are a lot of us trying our best to push back against the flood of irrationality and magical thinking being “integrated” into medicine, and rarely is there a discouraging word in the peer-reviewed medical literature about “complementary and alternative medicine” (CAM) or “integrative medicine” or whatever you want to call it. Indeed, when Steve Novella and I published an article criticizing clinical trials of highly improbable or virtually impossible treatments (like homeopathy) and I published a scathing perspective article on integrative oncology in a high impact journal, I counted them as major wins. Both were published over three years ago.

So it was a breath of fresh air to encounter an article in The Surgeon by Ben Li, Thomas L. Forbes, and John Byrne, all at the Division of Vascular Surgery at the University of Toronto, entitled Integrative medicine or infiltrative pseudoscience? it was a breath of fresh air and a shot in the arm telling those of us still fighting the good fight that we are not alone. It’s particularly gratifying to see such an article coming from the University of Toronto. The reason, of course, is that there have been grave lapses in science-based medicine there, such as an utterly credulous class in alternative medicine, a new integrative medicine center, complete with a traditional Chinese medicine clinic (just like the Cleveland Clinic!), an autism quackfest, and the unfortunate support for pseudoscience by The SickKids Foundation.

This article takes no prisoners, almost like one of my posts or articles. That doesn’t mean that I don’t have a few minor nits to pick with the authors, but I view this more as constructive criticism for fellow skeptics. For instance:

Complementary and alternative medicine (CAM) describes health care approaches developed outside of evidence-based medicine. Alternative medicine is used in place of evidence-based medicine, whereas complementary medicine is used in conjunction with evidence-based medicine. Most people use CAM along with conventional medicine, but some choose to forego evidence-based care.6 Terms such as integrative and functional medicine are increasingly used to depict a “holistic” approach to medicine, but they are similar to CAM and are not supported by scientific evidence. These practices include visits to naturopathic, homeopathic, and chiropractic clinicians, herbal remedies, acupuncture, meditation, yoga, and tai chi. Data from the 2007 National Health Interview Survey showed that 40% of U.S. residents use 1 or more CAM health practices,8 spending about $34 billion per year out of pocket.

They were doing so well until that last sentence, which lacks the qualification that must always be made whenever citing CAM advocates’ claims that 40%, 50%, or even more of Americans use some form of CAM. If you drill down into the numbers in a bit more detail, it doesn’t take a long time to realize that “hard-core” CAM modalities (homeopathy, naturopathy, energy healing, Ayurveda, traditional Chinese medicine) are used by relatively few Americans, with most modalities used by less than 5%, and that CAM use appeared in 2007 not to be increasing significantly. Also, the way advocates get to 40% CAM use is by lumping vitamins and dietary supplements in as CAM, a definition by which, for a time, I would have been classified as a CAM user. Massage and chiropractic are also popular. I’ve also discussed other studies where “spirituality” or prayer are considered “CAM.” By that definition, the vast majority of Americans would be considered CAM users. None of this is to say that there isn’t a problem; it’s just that CAM use might not be growing the way the narrative goes. On the other hand, there is evidence that CAM use is growing among Millennials. My point is that, yes, CAM use is probably increasing, but almost certainly not as much as CAM advocates want you to believe, because they want to keep using the “bandwagon” gambit or appeals to popularity to sell CAM.

Here’s where I give the authors serious props:

Many of the factors that are driving CAM use are misconceptions held by the public. For example, preventive medicine, which focuses on factors such as diet, lifestyle, and stress management are all encompassed in evidence-based medicine. Health care professionals who practice evidence-based medicine regularly provide preventive medicine to patients as first-line therapy based on recommendations by clinical practice guidelines. The CAM community often misappropriates preventive medicine as their own and presents conventional medicine as solely focused on prescribing drugs. This message polarizes health care into conventional pharmaceutical medicine versus preventative CAM therapy, misinforming the public and skewing their perception about evidence-based medicine.

Yes, yes, yes! How many times have I made this very point over the last 13 years? I really have no idea, but it is a major pet peeve of mine how successfully CAM and “integrative medicine” practitioners have successfully co-opted “prevention” as being within their bailiwick and denigrated SBM as paying insufficient attention to these concerns. What are vaccines but the ultimate prevention of infectious disease? Rare has the doctor visit been (at least the routine ones not focused on a new complaint) where I haven’t been urged to lose weight, eat healthier, exercise more, and get adequate sleep. The authors probably couldn’t say it, but I can. I suspect that the reason why integrative medicine co-opted diet, exercise, and lifestyle interventions as its own is because these modalities work for a lot of conditions. There is science behind them, unlike all the quackery associated with integrative medicine, such as naturopathy, acupuncture and traditional Chinese medicine, and the like. The science-based prevention modalities are lumped in with the quackery to provide seeming plausibility to the entire enterprise of CAM.

Then there’s this:

Furthermore, CAM therapies have not been shown to be more effective than evidence-based therapies at alleviating symptoms such as chronic pain. Evidence-based medications also do not cause more side effects than CAM therapies. Patients tend to believe that treatments that sound “natural” are better for them than those that do not, such as drugs, which are often associated with “non-natural, chemical-based” compounds. This naturalistic fallacy is dangerous because CAM therapies, such as herbal remedies, can cause significant harm to patients, while evidence-based medications have been thoroughly tested to ensure an acceptable safety profile.

Exactly. Herbal medicines that might work do so because they contain chemicals that function as drugs, and drugs have side effects. Even acupuncture is not entirely safe.

The authors even do a brief case study of CAM (or, as I like to call it, quackademic medicine) at the Cleveland Clinic. Given that I just discussed what happened to Dr. Daniel Neides, the former director of the Cleveland Clinic’s Wellness Institute who wrote an antivaccine screed and ultimately ended up being fired from all of his leadership positions. I pointed out that his antivaccine views should not be a surprise, given all the other pseudoscience that the Cleveland Clinic had embraced. I also noted how Dr. Toby Cosgrove, CEO of the Cleveland Clinic, self-righteously denied that the Clinic could ever, ever have antivaccine views there, seemingly not realizing how the pseudoscience of much of CAM and integrative medicine, particularly functional medicine embraced by the Clinic when it hired Mark Hyman, leads straight to antivaccine views.

Let’s see how the authors handle this:

The Centre for Functional Medicine (CFM) was created through the Cleveland Clinic’s partnership with the Institute for Functional Medicine. The U.S. Federal Trade Commission found that the Institute for Functional Medicine’s founder, Jeffrey Bland, created several corporations that made false and exaggerated claims about their health services, leading to a $45,000 civil penalty. Furthermore, the founder of the CFM, Dr. Mark Hyman, co-authored an anti-vaccination book. Despite being founded by leaders with beliefs that can cause harm to patients, the CFM saw nearly 5300 appointments and had a waiting list of over 1100 individuals since its opening in 2014. In 2016, the Cleveland Clinic stated that the CFM will receive funding to double in size. As a result of the strong media promotion of CFM, patients are unaware of the potential harms and lack of therapeutic effectiveness that come with receiving care from a centre that holds strong nonevidence- based beliefs about medicine.

Very good. In fact, I usually don’t even mention Jeffrey Bland when I discuss functional medicine. Rather, I discuss what utter quackery it is and how unfortunately popular Mark Hyman’s Center for Functional Medicine there is. The authors also note Cosgrove’s disingenuous denial:

Following the retracted column, the CEO of the Cleveland Clinic, Dr. Toby Cosgrove, reaffirmed the Cleveland Clinic’s commitment to CAM by stating that “some approaches may be considered unconventional, but most acupuncture, yoga, Chinese herbal medicine, guided imagery and relaxation techniques have scientific backing.” This is a misguided statement because although some single studies have demonstrated positive results with these CAM therapies, systematic reviews of the evidence have demonstrated that there is insufficient evidence to demonstrate clinically relevant benefit for acupuncture and Chinese herbal medicine. Yoga carries with it the benefits of exercise, while guided imagery and relaxation techniques improve stress management. These effects are shown by the evidence and these techniques are routinely recommended to patients by health care professionals for specific indications. However, the CAM community often misappropriates these techniques as their own and make claims about their effectiveness that go beyond the evidence.

That, of course, would be the understatement of the year! Of course, the CAM community appropriates pretty much any non-surgical, non-pharmacological, non-technology-based treatments as their own. As alternative medicine evolved into CAM, which then evolved into “integrative” medicine, these modalities were absorbed, along with all the magical thinking behind all the prescientific and mystical treatments that are also part of integrative medicine.

The conclusion is something we should all be behind:

Improving health care requires an increasing focus on medicine that has been scientifically tested to be safe and effective. Reducing the rigour of evidence in medicine will not improve the health of our population. Health care professionals must understand how deep CAM runs in their institutions and ensure that they not only continue to provide the best, evidence-based care for their patients, but also to advocate against the practice of non-evidence-based medicine. Practitioners and institutions should respond to the public demand for more holistic care, but do so in a way that is evidence-based. Governments also need to improve regulation of CAM products and services, following the examples of successful policy changes in Australia and England. CAM should follow the same efficacy and safety regulatory standards as conventional medicine.

Again, this is what I’ve been saying all along. Medicine should be based on the best science. Equally importantly, there should be no double standards. The same standard of evidence should apply, regardless of what the medicine is. As the cliche goes, alternative medicine that is scientifically demonstrated to work ceases to be “alternative” and becomes just “medicine.”

This is the sort of thing we need from physicians: Actual pushback in the peer-reviewed medical literature against the integration of pseudoscience and quackery with medicine. I would have used a somewhat different title, though. I wouldn’t have called it “infiltrative pseudoscience,” although that’s pretty good. I’d have called it infiltrative quackery and magic.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

22 replies on “Integrative medicine as infiltrative pseudoscience: Pushback against quackery”

“…where I haven’t been urged to lose weight, eat healthier, exercise more, and get adequate sleep.The authors probably couldn’t say it, but I can. I suspect that the reason why integrative medicine co-opted diet, exercise, and lifestyle interventions as its own is because these modalities work for a lot of conditions.”

It is unfortunate that they have high-jacked these modalities and now claim this to be a point of difference with conventional healthcare. They use this strategy very effectively and at a time it prompted me to come up with some sort of comparison that hopefully most people would understand. So I came up with comparing the CAM industry, and their modus operandi, with Al Capone who provided free soup kitchens to the poor during the great depression years. It did wonders for his PR and the public even called him ‘nice guy Capone’. The similarities between Capone’s empire and the CAM industry is however rather striking
goo.gl/KawMPR

I think a large part of the problem is that diet, exercise, and sleep are hard problems. We haven’t really solved them, especially if you have to live a modern life. Second, these things are behaviors, and humans have been influencing behavior with rituals and spells for millions of years. And third, the symptoms of sleep deprivation, bad diet, and inactivity are changeable–it’s in the definition.
All that makes these particular interventions seem a lot more magical than they are.

Worse, these crackpots then try to claim that modern medicine “doesn’t know anything” about diet and nutrition, but alt med has all the answers.

Being that they are all from the U of Toronto, I would have been far more impressed if they had concentrated on the Quackery in Canada instead of the USA. Is Canada’s Quackery prevalence the same or better or worse then the USA’s? How does it differ province by province? I realize they are publishing in an American journal, but you would think a comparative study between our nations would be as beneficial as re-hashing what is being said over and over again. But as you say, at least they are fighting against the tide of imbecility.

Has anybody done a substantially similar study in Canada as a whole, let alone province to province? Small number statistics are likely to be an issue in Atlantic Canada. I can understand them quoting an existing survey, especially one taken in the same country that the journal is published in.

Absolutely, the comparison between Canada and the US should be done, but before it can be done, we need to have a source of Canadian data. Which would mean applying for funding and getting IRB clearance, if the data are not already in hand.

https://www.fraserinstitute.org/studies/complementary-and-alternative-medicine-use-and-public-attitudes-1997-2006-and-2016

Here is a recent study, it is by the conservative minded Fraser Institute, fyi. I haven’t read the whole thing but it has a breakdown of use, ranging from massage (very popular) to acupuncture and other things like herbals etc.

I found an old Health Canada website that listed Philip Waddington as the Director General of the Natural Health Products directorate and also noted that he is a “trained naturopathic physician”. He was DG until 2008, helping to define a new regulatory framework, lord help us.

You say: “The same standard of evidence should apply, regardless of what the medicine is.” Are you advocating for science-based medicine or for evidence-based medicine? For me, there can’t be any standard of evidence for homeopathy. What is infiltrating medicine is money and conflict of interest. The problem with CAM is that it goes too far and one could conclude that with enough money, you can publish evidence for whatever you want, and this can kill the goose that laid the golden eggs.

Orac writes,

This is the sort of thing we need from physicians: Actual pushback in the peer-reviewed medical literature against the integration of pseudoscience and quackery with medicine.

MJD say,

In my opinion, physicians can embrace integrative medicine as part of the healing experience.

For example, in 2017 a friend had a hip and knee replaced at the Mayo Clinic and thereafter visited an American Indian Reservation to learn about healing from an American Indian medicine man.

The cultural remedies (i.e., pseudoscience) seemed to lift her spirits.

It’s good medicine when physicians support integrated medicine that “does no harm”.

Great stuff. The irony is that several of these people when encountered online claim we should focus on prevention – except vaccines – and seem to think diet is a magic cure for all.

That’s not to discount the importance of a healthy diet.

“That’s not to discount the importance of a healthy diet.”

Or just eating less.

An NFL coach who’s in the news today (his wife apparently scrubbed his Wikipedia page of references to violence complaints against him) claims to have lost 138 pounds through “clean eating”.

http://sports.mynorthwest.com/9994/seahawks-tom-cable-gives-the-skinny-on-his-weight-loss/?

Based on those before-and-after photos, if he lost 138 pounds, I’m the Queen of Romania*.

*be still, my subjects.

I experienced a tremendous amount of pain in my left foot. I saw 3 different podiatrists. They all said that the cause was from an injury suffered as a child. I endured Years of painful ‘prosthetic inserts’, kind of like braces, very uncomfortable. And they did Not improve the condition of my foot at all. They were wrong. That’s correct, your science based standard of evidence, one size fits all modality Failed. At least their incorrect diagnoses/treatment is Uniform. Because that’s all they can do, regurgitate the ‘standard’ care, Even when it doesn’t work!
Fast forward 10 years, still w/ chronic foot pain. I went to Dr. of TCM. Within minutes of meeting me, He asked Why i was crooked on the left side. He listened to what medical Drs diagnosed. He pondered. He put a great deal of pressure on pelvic area. Yes, it hurt. Instantly, All the left sided pain I had endured was GoNe! The pain had Nothing to do w/ my foot at all, the cause was a pressure point in my pelvis! I walked out of there straight and pain free.
I had debilitating migraines. Randomly recurrent, caused me to have to miss work. Medical Drs prescribed pain killers, did nothing to actually help eliminate the pain, just mask it. This was the ‘treatment’ I endured for a few years. Finally, I made an appointment with a Dr. of Osteopathy. I’d had a migraine for 3 days, I desperately wanted it gone. I told him that I wasnt leaving his office unti he ‘fixed’ it! He chiropractically adjusted my neck & back, recommended follow up w/ chiropractor. Left his office pain free & relieved that day. I was treated for 6 weeks chiropractically to correct issues that caused my migraines. As a direct result of that, I no longer have migraines & I don’t have to be drugged up to function.
So, Yeah. In my experience (which I’m sure you’ll dismiss as anecdotal), A.M.A. Drs failed me.Repeatedly. TCM and chiropractic care WORK!! I don’t need some pompous ‘Drs’ peer reviewed opinion. I experienced it. That is my proof!

I’m sorry you were misdiagnosed.
If your TCM doctor prescribed you a treatment made from an endangered pangolin, would you take it?

“He put a great deal of pressure on pelvic area. Yes, it hurt. Instantly, All the left sided pain I had endured was GoNe!”

And if someone whacks your bare toes with a mallet, you won’t notice your migraine headache at all.

Physical/manipulative treatments are part of acceptable ( to some ) mainstream medicine administered by a variety of practitioners of varying skills and knowledge and by poorly trained quacks. Mennell and Cyriax were medically qualified enough to practice for years at St Thomases Hospital in London, UK. This is not to accept quack hypotheses about manipulative effects and their mechanisms, particularly on the spine, but it is quite possible and likely that Mary Brown did benefit as she has written from the treatment she received. It is not necessarily a psychosomatic or placebo effect at work although clearly this could be the case. It would be more prudent to reserve judgement rather than ridicule until such time, if ever, properly conducted clinical trials become available to ascertain the credibility of different manipulative techniques and their effects.
Consider, that the causes of scurvy were unknown but there were rumors around that lime juice or the juice of pine needles prevented and cured it. Would the sailors or long besieged defenders of a walled city be sensible to try out the rumors and partake of the ‘food’, if it was available or wait for further evidence? Many thousands of merchant seamen and their captains waited and died for their lack of belief in the rumors in addition of some good, if not full-proof, evidence available to the Royal Navy, obtained from Captain Lind. I simplify for brevity.

And I’d be interested in what you think of the American College of Lifestyle Medicine and Dr David Katz. https://www.lifestylemedicine.org/

I know Doctors have been saying for years – “diet, exercise, sleep” in some form or other. We didn’t pay much attention to you. But how important do you really think those things are? I think it is ludicrous that we advertise prescription meds on TV etc. We (our whole society – whatever part Doctors play in that you can say for yourselves) has become dependent on popping a pill of some kind or other to get a quick fix.

Mark, is this question directed at me or Orac? Although in the main the criticisms of the mountain of quackery that masquerades as efficacious therapies under the guise of CAM or whatever is absolutely justified there is some imbalance in the view that ‘alternative ‘ practitioners have appropriated the preventative medical advise involving lifestyle changes related to diet, exercise and relaxation. As an example, based on the work of John Yudkin ( book ‘Sweet, White and Deadly) and the ‘Food Reform Movement’ in the USA many of these alternative practitioners ( in the UK at least) were advising sensible changes to the eating habits of their patients, such as eat less refined food, that is now mainstream common knowledge, given from primary school to old age.
When Yudkin first set out his ideas on the harmful effects of over consumption of refined sucrose he was often ridiculed by fellow nutritionists and medics. This was back in the 1960s. I remember well visiting my girl friend in Edinburgh and visiting her brilliant brother and other medical students at the Medical school and when I tried to introduce them to Yudkin’s work was laughed at by all the students around me, because all the emphasis in their lectures was on the harmful effects of different dietary fats in the aetiology of the escalating incidence of CHD.

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