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.