The Integrative Oncology Scholars Program: Indoctrinating oncology professionals into pseudoscience

Three weeks ago, I wrote about a whole “Special Focus” issue of the flagship journal for integrating quackery into medicine, the Journal of Alternative and Complementary Medicine (JACM). The issue was devoted to “integrative oncology,” which I view as being devoted to “integrating” mysticism, quackery, and pseudoscience into the clinical care of cancer patients while co-opting diet, exercise, and lifestyle interventions as somehow being “integrative” or “alternative” rather than part of conventional medicine, the better to provide cover for quackery like traditional Chinese medicine, energy medicine, and the like. Because the Special Focus issue was going to be available for free until October 24, I had planned on writing a follow-up post, but somehow (as is often the case) other topics intervened. Then, over the weekend, our very own Jann Bellamy sent me a PubMed link to an article from that issue touting something called the “Integrative Oncology Scholars Program”. I had mentioned that article in my previous loving deconstruction of the JACM integrative oncology Special Focus issue, but Jann’s email jolted me, making me realize that I really should have written more about this particular aspect, particularly given that it’s being spearheaded by my alma mater, both undergraduate and medical, the University of Michigan.

The article is, as is often the case for articles like this, credited to many authors, but the first (and corresponding) author is Suzanna Zick, a naturopath who is in charge of the Integrative Family Medicine program in the Department of Family Medicine at the University of Michigan, where she’s been teaching what I consider to be misinformation and retconned history about traditional Chinese medicine and hosting homeopaths for Family Medicine Grand Rounds, all while publishing dodgy acupressure papers. I also note that the Integrative Family Medicine program at U. of M. purports to provide “advanced training in holistic medicine, anthroposophic medicine, and acupuncture”. Anthroposophic medicine, as you might recall, was first invented by Rudolf Steiner, and it is loaded with mystical nonsense. Yet my alma mater has a program in it.

How did a naturopath find a faculty position in the family medicine department of what has traditionally been a bastion of science-based medicine? I have no idea, but it’s been a source of continual embarrassment to me ever since I discovered it. After all, U. of M. is my alma mater, and I still collaborated with U. of M. faculty as recently as 2017. It also doesn’t help that Zick is a player in the Society for Integrative Oncology (SIO), having been president of the organization a couple of years ago and having had integral (if you’ll excuse the term) involvement in drafting the SIO’s dubious guidelines for the integrative oncological care of breast cancer patients, an updated version of which, alas, was recently endorsed by the American Society of Clinical Oncology (ASCO).

So let’s take a look at what Zick et al have written, “Integrative Oncology Scholars Program: A Model for Integrative Oncology Education“.

The Integrative Oncology Scholars Program: Framing the frame

Basically, the Integrative Oncology Scholars Program is all about increasing the number of oncology professionals who buy into integrative oncology. (Note that I will quote fairly liberally, because after October 24, this article will go behind a paywall.) It all begins, as is usual for articles promoting “integrative medicine”, with framing integrative medicine as very, very popular, and therefore:

Despite this high level of use, communication about complementary and integrative medicine (CIM) use between oncology providers and patients is not ideal. Over half of oncology providers do not ask about CIM use^3,4 and indicate the main reasons being a lack of knowledge about CIM approaches and not knowing what to do with the information once collected.^3,5,6 This lack of communication can leave patients and their families with many unanswered questions, can result in negative (e.g., herb–drug) interactions and toxicities,^7,8 and may prevent patients and survivors from receiving treatments that could help reduce cancer treatment side-effects and improve quality of life.⁹ Also, while the majority of CIM treatments are being delivered in the community by complementary providers, few oncology professionals and complementary providers communicate or are aware of the others’ practice. Oncology professionals rarely refer patients to complementary providers, with oncologists only referring for more information about complementary therapies 16% of the time, and nurses and social workers 13% and 36% of the time, respectively.^4,10 One possible solution to the unsatisfactory interaction around CIM for both patients and providers (conventional and complementary) is education.

Of course, I’m all for education, as long as it’s based on science rather than promotion. Oncology professionals—heck, all physicians, nurses, physicians assistants, and anyone who gives medical advice to patients for a living—should have a working knowledge of “complementary and alternative medicine” (CAM) or “integrative medicine”. There’s the rub, though. I insist upon science-based education, which demonstrates that the vast majority of CAM doesn’t work and that which does work, such as exercise, science-based dietary modifications, and the like, is almost always already part of conventional medicine. (Low carb diet and weight loss as initial interventions for type II diabetes, anyone?)

It’s all about demand, though; that is, if you believe Zick et al. She and her co-authors are only doing this in response to overwhelming provider demand:

Oncology providers have expressed a desire to be more informed and to receive more education about oncology-specific CIM.^6,11 Until recently, however, no oncology-specific CIM training has been available and the majority of educational opportunities have been designed for physicians (e.g., in the form of fellowships), despite the multidisciplinary and growing professional diversity of oncology teams.¹² In response to this educational gap, we have designed the Integrative Oncology Scholars (IOS) Program.

See? We perceived a huge need for this education in “complementary and integrative medicine” (CIM). (I wish advocates of CAM, CIM, or whatever would make up their mind on what acronym they want to use.) So what will this program consist of?

The Integrative Oncology Scholars Program: The course

Now that the authors have established the desperate “need” for this education on integrating nonsense into oncology, how do they propose to provide for this need? The answer is simple. The authors have devised a program with the following goals:

The IOS Program is funded by a National Cancer Institute R25 grant. It has the joint goals of training 100 integrative oncology (IO) leaders over 4 years and facilitating partnerships between IO leaders and complementary practitioners within their communities. Eligible participants, who are designated as IOS, include a multidisciplinary selection of physicians, physician assistants, nurses, psychologists, social workers, physical or occupational therapists, and pharmacists, who are actively engaged in clinical oncology practice. IOS instructors are experts in the field of IO and/or adult education and reflect the multidisciplinary nature of the program with professions as diverse as patient advocates to oncology clinicians. Details on course instructors, program eligibility, and how to apply are available on the IOS Program website.*

An R25 grant from the NIH is, basically, an education grant whose purpose is “to support research education activities that: (a) Complement and/or enhance the training of a workforce to meet the nation’s biomedical, behavioral and clinical research needs; (b) Enhance the diversity of the biomedical, behavioral and clinical research workforce; (c) Help recruit individuals with specific specialty or disciplinary backgrounds to research careers in biomedical, behavioral and clinical sciences; or (d) Foster a better understanding of biomedical, behavioral and clinical research and its implications.”

This particular R25 grant (R25 CA203651), entitled A short course for creating integrative oncology leaders, is, surprisingly, not a grant issued by the National Center for Complementary and Integrative Health (NCCIH), but rather from the National Cancer Institute. Not surprisingly, Suzanna Zick is the principal investigator. It’s not a huge grant, but it’s a decent chunk of change ($220,155 to $237,612 per year thus far). Its specific aims include:

1. Develop an interdisciplinary short-course in evidenced-based integrative oncology;
2. Train 100 integrative oncology leaders (25 participants per course x 4 courses = 100) via the short-course developed in aim #1;
3. Create partnerships between oncology leaders and complementary practitioners (who provide the majority of complementary oncology services) within their communities (~25 community-based complementary partners per year {one per oncology leader} for a total of 100 over 4 years)
4. Evaluate the impact of this short-course by measuring the process and the outcomes of the various educational activities over the course, and measuring the implementation and outcomes of the capstone projects initiated by participants at their home institutions after completion of the program;
5. Disseminate the findings through peer-reviewed journals, presentations at professional meetings, and through both conventional and integrative oncology networks and associations.

So, basically, the NCI has spent nearly a half million dollars (thus far) to support this educational endeavor in two years, with three more years to go in the grant. One might ask: Why wasn’t NCCIH involved? As I’ve mentioned before, unfortunately the NCI has a very large CAM program; indeed its yearly budget is nearly as large as that of the NCCIH. The program is called the Office of Cancer Complementary and Alternative Medicine, which has one of the most cringe-inducing (in context) acronyms ever: OCCAM. A decade ago, I once spoke with a representative of OCCAM at the American Association for Cancer Research (AACR) meeting, and his blather about “emperor” and “assistant” herbs was every bit as cringe inducing as the OCCAM acronym.

So basically, the Integrative Oncology Scholars Program involves two parts. First, there is an online eLearning component implemented using a Canvas website designed by Instructure, Inc., in Salt Lake City. Second, there are three in-person sessions at—groan!—the University of Michigan. You’ll just have to excuse me if I remain…skeptical…about the eLearning modules, given that an evaluation of the U. of M. Department of Family Medicine eLearning module on acupuncture shows that it teaches acupuncture and traditional Chinese medicine (TCM) with great credulity and totally buys into the retconned version of TCM originally promoted by Chairman Mao.

The article by Zick et al actually isn’t that detailed regarding the curriculum. It does list the components of what will be taught in the three in-person sessions at U. of M. Predictably, there’s a lot on natural products and “mind-body” interventions, but there are also modules on dietary interventions both science-based and dubious (e.g., ketogenic, alkaline, paleo, macrobiotic, etc.). There’s also modules on energy medicine and traditional Chinese medicine. As far as the web-based modules, there are additional modules on:

• Diet – (1) Ketogenic Diets, (2) Calorie-restricted Diets and Fasting, (3) Anti-oxidant Supplementation During Cancer Treatment, and (4) Soy and Cancer
• Whole Systems of Medicine – (1) Homeopathy, (2) Ayurveda, and (3) Naturopathy
• Unique Pharmacological Treatments – (1) Vitamin D, (2) High Dose Vitamin C, and (3) Melatonin
• Botanical Products – (1) Cannabis and Cannabinoids, and (2) Mistletoe.

Homeopathy is, of course, The One Quackery to Rule Them All. Naturopathy is basically a cornucopia of quackery, while Ayurveda and TCM are prescientific systems of medicine whose resemblance to anything science-based tends to be purely by coincidence (e.g., Artemisinin). Meanwhile, high dose vitamin C has consistently been shown to be, at best given the most generous interpretation of the existing evidence, a long run for a short slide.

In other words, what we see here is the typical “integrative medicine” approach: Co-opt some science-based diet and lifestyle modalities—such as exercise, various dietary interventions (often mixed with the more dubious, like the ketogenic diet), and mindfulness (which might be science-based)—and use them for cover for the quackery, such as homeopathy, naturopathy, high dose vitamin C, that is included with the modalities to be “integrated.”

As for the methods, besides eLearning, here’s how the in-person sessions will be organized:

As part of the TBL model we will employ a flipped classroom approach. In the flipped classroom approach scholars will read key materials, watch lectures, or complete modules before coming to class, and then engage in active educational strategies to maximize educational effectiveness during in-person class time.¹⁴ These strategies will include group discussion sessions, case studies, as well as demonstration and role-playing. Cancer patients, their families, advocates, and community-based complementary providers will be invited to be part of the curriculum to bring their experiences into the learning environment. Use of TBL and flipped classroom strategies improve short-term outcomes in health professions’ curricula,¹⁵ and out-perform traditional lecture-based continuing medical education in both short-term knowledge retention and daily practice behavior.¹⁶

So, in other words, they’re trying to be very, very effective in indoctrinating oncologists and other health care professionals into believing in integrative oncology and referring patients to integrative practitioners, including quacks like naturopaths.

Finally, let’s look at the faculty who are teaching the Integrative Oncology Scholars Program. Suzanna Zick, a naturopath, is of course the course director. Another naturopath, Heather Greenlee, will also be teaching. The first thing you’ll notice is a relative paucity of actual oncologists in the list. There’s a medical oncologist and a radiation oncologist, as well as a PA in gynecologic oncology. That’s it. There are, however, psychologists and a nurse. For instance:

Judith M. Fouladbakhsh, PhD, RN, AHN-BC, PHCNS-BC, CHTP
Dr. Judi Fouladbakhsh, Associate Professor at Oakland University, and former faculty of long standing at Wayne State University, College of Nursing, holds advanced clinical practice certifications in Community Health and Holistic Nursing, Healing Touch, Reflexology and Reiki. Dr. J has extensive experience in complementary and alternative (traditional) medicine, integrative oncology, pain management, public health and cancer nursing. Research interests include effects of yoga on breathing, mood, sleep and QOL of lung cancer patients funded by the NIH, and yoga therapy and qigong for pain management among breast cancer survivors. She also serves as faculty at the Beaumont Health System School of Yoga Therapy.

How depressing. She has apparently been faculty at my current medical school for a long time. Worse, she’s into healing touch and reiki, forms of “energy medicine” that rely on belief in the existence of a mystical magical “energy field” that healers can manipulate to healing effect. As I’ve said more times than I can remember, reiki, for instance, is nothing more than faith healing in which Eastern religious beliefs are substituted for Christian religious beliefs. Unfortunately, nonsense like reiki is available and promoted in far too many NCI-designated comprehensive cancer centers.

There’s also an acupuncture researcher:

Dr. Richard Harris, PhD
Richard Harris is an Associate Professor in the Department of Anesthesiology and the Department of Internal Medicine at the University of Michigan. He received his Ph. D. in Molecular and Cell Biology from UC Berkeley in 1997. Dr. Harris is currently investigating mechanisms of acupuncture and acupressure in the treatment of chronic pain and fatigue conditions. His recent investigations have focused on the role of brain neurotransmitters in acupuncture analgesia and chronic pain.

Teaching focus areas: Pain; acupuncture/acupressure; traditional Chinese medicine; diet, exercise, and supplements in cancer prevention, cancer treatment and survivorship; GI disturbances

I perused Dr. Harris’ PubMed publication list (note that he is not this Richard Harris). There’s surprisingly little about acupuncture there, but what is there is pretty credulous, including a publication in JACM about how acupuncture “rewires” the brain with lasting effects and an article in the quack journal Medical Acupuncture about how cellular reorganization plays a vital role in acupuncture anesthesia. In other words, it’s quackademic medicine at its purest, and much of what will be taught to these “integrative oncology scholars” will either not be science based or will be a co-opted version of science based treatments framed as “integrative or alternative.” No big surprise there.

The Integrative Oncology Scholars Program: The goal

In the end, what is the goal of the Integrative Oncology Scholars Program? Clearly, it’s to increase the number of believers in integrative oncology in key locations, particularly academic medical centers (which, truth be told, are already hotbeds of pseudoscience). The investigators even have metrics that they want to look at for their “graduates” and their program:

To evaluate the IOS Program, we will use a mixed method approach employing tools developed from the University of Michigan Integrative Faculty Scholars Program in Integrative Healthcare and modified for the IOS Program. Overall, the IOS evaluation plan is composed of three elements: (1) evaluate overall IOS Program progress, (2) monitor individual IOS advancement, and (3) evaluate the IOS Program and make adjustments for subsequent cohorts, as needed.

We will also assess IOS progress toward nine goals focused on building IO research, clinical and educational impact: (1) writing applications for IO NIH funding, (2) authorship of IO publications, (3) presenting at IO-related conferences, (4) academic appointments to a faculty (or equivalent) position, (5) gaining employment in an IO team, (6) obtaining an IO leadership position, (7) individual IO-focused research grant support from NIH or other sources, (8) leadership as an IO “resource” person, and (9) improved IO clinical skills and knowledge as measured by a self-assessment tool.

The first cohort of 25 scholars is already well into the training, too:

The first cohort of 25 IOS has been accepted and will begin the program in August, 2018. The cohort is comprised of 10 physicians from radiation, medical, and surgical oncology as well as primary care, dermatology, and palliative care; 5 advanced practice nurses; 5 social workers; three physician assistants; 1 pharmacist; and 1 physical therapist. Several of the social workers and nurses coordinate cancer survivorship programs at their institutions. IOS come from 13 states and the District of Columbia and represent 23 U.S. healthcare systems, including comprehensive cancer centers (refer to Fig. 1).

It’s interesting to me that a minority of the first cohort are physicians and an even smaller minority appear to be from oncology-related specialties. Perhaps there is hope after all. On the other hand, this is only the first year. One can expect this program, if successful, to grow and metastasize to other institutions.

Now excuse me while I go and find a paper bag to put over my head, given that it’s my alma mater that’s leading this effort.