I thought I’d take a brief break from COVID-19 blogging just for today in order to return to a frequent topic from before the pandemic: so-called “integrative” medicine (with a dash of “functional medicine”). You remember “integrative medicine” and “functional medicine,” don’t you? I used to write about them a lot before the pandemic, particularly in the context of what I like to call “quackademic medicine,” in which rank pseudoscience and quackery like naturopathy (which, remember, always includes homeopathy) have insinuated themselves into academic medical centers as though they had the same level of scientific support behind them as even conventional medicine modalities with the weakest scientific support. Three years ago, my co-blogger at my not-so-super-secret other blog wrote a post about how “integrative medicine” is attracting so many bad apples with its “integration” of quackery with medicine that even prominent integrative docs like Dr. Melinda Ring noticed and recently felt compelled to write a defense of their newly created specialty, blaming a “lack of training” for the bad apples. Unfortunately, as Jann Bellamy noted at the time, that was not the problem. The rejection of science-based medicine and “integration” of quackery into “integrative medicine” were. It turns out that Dr. Ring noticed this article recently and wrote a post for KevinMD entitled, I’m called anti-science. I’m just an early adopter.
Before I address Dr. Ring’s post directly, I always like to point out that I can’t say that I coined the term “quackademic medicine” (although I really wish I had!), but it describes the embrace of integrative and functional medicine quackery at institutions like UC-Irvine (which embraced homeopathy and got a $200 million gift to transform its medical school into a bastion of quackery), the Cleveland Clinic (which has embraced functional medicine and traditional Chinese medicine, while producing at least one antivaccine faculty member), Thomas Jefferson University (which now has a truly quacky department of integrative medicine), UC-San Diego (which numbers Deepak Chopra as faculty and does dubious research with him), and many more too numerous to list here. Then there’s the National Center for Complementary and Integrative Health (NCCIH), formerly known as the National Center for Complementary and Alternative Medicine (NCCAM), whose motto seems to be “let’s try some real science for a change!” and whose leadership was taken over by a believer in acupuncture who’s published all sorts of dubious research to “prove” a biological mechanism by which it “works.” Why do I mention this? Dr. Ring is faculty at Northwestern University. She practices there, and is therefore part of what I like to refer to as “quackademic medicine,” as a clinical associate professor and the director of the Osher Center for Integrative Medicine at Northwestern. Here’s her short intro video, of the sort found on a lot of university websites in which faculty give a one or two minute talk on what they do:
Right away you see the usual “integrative” claptrap about “mind-body” practices and taking care of the “whole patient,” along with the importance of the “patient’s story.” The latter two out of three of these are, of course, nothing more than conventional medicine rebranded as somehow being “holistic” and “integrative.” As I like to say, a good primary care doctor is a “holistic” doctor, and the only thing that “integrative” medicine integrates into medicine is pseudoscience. Integrative medicine is, in reality, a brand, not a specialty, and it’s a specialty that its own practitioners can’t even seem to define very well. Functional medicine is a subdiscipline (I cringe to use that term) of integrative medicine and basically consists of ordering a whole bunch of useless tests and then correcting every conceivable lab abnormality (usually with copious supplements), whether it’s clinically helpful to do so or not, coupled with the usual integrative “rebranding” of lifestyle interventions like sleep, exercise, and diet as somehow being “functional” and “integrative.” Sadly, there are academic medical centers—I’m looking at you, Cleveland Clinic—that have made considerable press (and attracted a lot of patients) for this nonsense. Unsurprisingly, quacks like naturopaths and chiropractors love functional medicine.
So what does Dr. Ring have to say? She’s not very happy with Jann Bellamy:
As an integrative/functional medicine physician, I’ve been criticized, like many of my colleagues in the field, for being “anti-science.” In the past five years, many of us within the field have perceived increased and biased scrutiny by the ACCME, the organization tasked with accrediting continuing medical education providers. But in the wake of COVID-19, where pharmaceutical interventions were being used in patient care based purely on hypothetical mechanisms of action, the question should be asked: Where is the line between an “early adopter” and “unscientific”?
Normally, this would be an interesting scientific and medical question. For example, having lived through the laparoscopic surgery revolution in the 1990s, when laparoscopic cholecystectomy rapidly replaced the “old-fashioned” method of removing the gallbladder using good old-fashioned surgical steel to make an incision in the right upper quadrant of the abdomen, despite little evidence that it was better (at least initially), I’ve thought about this question a lot, but not in quite the way that Dr. Ring appears to. Basically, as long ago as 2008, I was wondering what happens when popularity outpaces science in surgery. Here’s a little taste:
One thing I can tell you is that the reason laparoscopic cholecystectomy so rapidly supplanted open cholecystectomy in the early 1990s was not because rigorous studies showed it to be superior. What had happened is that surgeons and hospitals had seen a marketing opportunity and run with it. Ads for laparoscopic cholecystectomy proliferated. Older surgeons, who had not been trained in laparoscopic cholecystectomy, rushed to sign up for courses to learn how to do this procedure and had to be proctored through the “learning curve” of the case, which for experienced surgeons was estimated to be 25 cases. They had to. Cholecystectomy was (and is) “bread and butter” surgery for general surgeons, a large component of their case mix. Patients needing gallbladder surgery were going elsewhere, to surgeons who knew how to do the latest and (presumably) best operation.
While it was true that one almost didn’t need a study to see that patients undergoing laparoscopic cholecystectomy suffered less postoperative pain and went back to work or activities of daily living much faster. What wasn’t known was the complication rate. One of the most feared complications of any gallbladder or biliary tract surgery is an inadvertent injury to the common bile duct, the tube into which the gallbladder and the biliary tree from the liver empties, which leads to the duodenum, into which bile made by the liver is deposited. Such injuries didn’t always show up right away and typically manifest themselves as a stricture causing obstruction to bile flow that, if not noticed in a timely fashion and allowed to become chronic, could lead to liver damage and cirrhosis.
I don’t want to dwell on this example and only bring it up to point out that being an “early adopter” in medicine is not necessarily a good thing. In this example, early adopters turned out to be (mostly) prescient in that the upsides of laparoscopic cholecystectomy were deemed to outweigh the downside of a slightly higher risk of common bile duct injury, at least once a new generation of surgeons had been trained to minimize the complication. During the “early adoption” phase in the 1990s, the risk was much higher. I also bring it up to contrast it to a counterexample, bone marrow transplantation for advanced breast cancer, which was all the rage in the 1990s based on early adoption justified by relatively weak evidence and ultimately found to be no better (and possibly more harmful) than conventional treatment. Early adoption is a two-edged sword. If you guess right as an early adopter, you are prescient and a pioneer in laparoscopic surgery. If you guess wrong, you can end up like the advocates of bone marrow transplantation for breast cancer. Of course, both of these examples are of medicine that had a scientifically plausible rationale. In the case of huge swaths of functional medicine, there is no such rationale, with the same being true for the vast majority of what is called integrative medicine as well.
But, according to Dr. Ring, integrative and functional medicine is the future, baby:
In 1962, social scientist Everett Rogers published the classic text Diffusion of Innovations describing how new ideas — which are initially seen as uncertain or even risky — spread. In his framework, he defined five groups by their enthusiasm to embrace novel concepts:
- Innovators are venturesome, not afraid to fail, and often creators of new concepts.
- Early adopters are opinion leaders, often in leadership roles, who embrace change opportunities.
- Early majority are deliberate in their decisions, just ahead of average when accepting new ideas.
- Late majority tend to be skeptical of change to the status quo, and will wait for standard guidelines to guide their practice.
- Laggards are bound by tradition and very conservative.
These categories have been applied to all aspects of modern culture, including the health care industry.
Pharmaceutical companies, device manufacturers, and technology suppliers utilize diffusion theory to sell their products, with the promise of better outcomes, lower costs, and greater revenue. However, the actual translation of research to the bedside typically has a long lag time, and innovations are disseminated broadly at a slow pace.
Note the assumption on Dr. Ring’s part: She’s not a quack. Oh, no! She’s an “early adopter” of functional and integrative medicine! Of course, the assumption behind her being able to view herself as a brave pioneer rather than your run-of-the-mill quack bandwagon jumper that must be that functional and integrative medicine are the future and will be validated by science, rather than repudiated and cast off as pseudoscience. She clearly views herself as being more like a laparoscopic surgeon than as an oncologist who did bone marrow transplants for breast cancer. However, as much as I like to point to the example of bone marrow transplants for breast cancer as an example of a failed hypothesis, at least it was a treatment that had some level of biological plausibility compared to so much of “integrative medicine,” which, as you might recall, embraces magical thinking like naturopathy, sometimes homeopathy, acupuncture and traditional Chinese medicine, chiropractic, and so much more quackery as modalities worth “integrating” into medicine.
Nor, contrary to Dr. Ring’s self-image, is her early adoption like that of telemedicine:
In some areas of medicine, early adoption is applauded. Consider telemedicine: Pre-pandemic the vast majority of clinicians, systems, and insurance companies were slow to incorporate telehealth. However, with the pressure of the pandemic, the pivot happened at a very accelerated pace, increasing from 0.3 percent of clinician visits in 2019 to 23.6 percent in 2020. Noteworthy in this was high patient and provider satisfaction, possible decreases in health care delivery cost, and increased access for patients in remote locations. I know in my own integrative consult practice, patients rave about the convenience- and we are all thrilled that Illinois is moving to extend telemedicine coverage.
Telemedicine, of course, is not a medical treatment (such as an antihypertensive drug) or a discipline of medicine. It is method of delivering healthcare, not a treatment itself. Used properly, telehealth is a means of delivering science-based care to patients without actually requiring them to come to see a physician in her office face-to-face, and, as Dr. Ring notes, its adoption was accelerated greatly by the COVID-19 pandemic. Early adopters of telehealth were not adopting quackery to “integrate” into their practices. They were looking for ways to bring science-based medicine to more people more conveniently.
Not that that stops Dr. Ring from urging her fellow “integrative” physicians to claim the “early adopter” mantle:
I’d like to propose a shift in how integrative medicine is perceived by those trained in Western biomedicine. A reframing that the majority of health professionals in the relatively newer fields of integrative and functional medicine, especially those operating within the context of academic health centers, are not “quacks” or “unscientific.” Rather, consider that these clinicians are innovators and early adopters who are choosing to use new concepts to help patients, rather than wait out the gap between availability and incorporation into published guidelines by medical societies.
She then goes on to try to portray integrative medicine as really, truly scientific:
Examples of “alternative” medical approaches that have become mainstream abound. Biofeedback was considered an esoteric practice when it came onto the medical scene in the 1960s. Now it’s offered in physical therapy clinics, medical centers, and hospitals, and rated as efficacious or probably efficacious for a wide range of conditions. Acupuncture, which came to public awareness in the U.S. in the 1970s (and still called by some a pseudoscience by some skeptics), is recommended in guidelines from government health institutions, national health system recommendations, and medical specialty groups. And natural products such as omega-3 fatty acids and L-methylfolate are now available as FDA-approved prescriptions for specific conditions, while others are included in guidelines, such as peppermint in the 2021 American College of Gastroenterology guidelines for IBS. Each year sees increasing numbers of research studies published in traditional, integrative, and basic science journals, and the NIH-NCCIH (National Center for Complementary and Integrative Health) 2021-5 strategic plan aims to increase the integrative research workforce and its impact on individuals, communities, and populations.
I reject this framing of course. For one thing, no matter how much acupuncture advocates have managed to dupe various groups writing guidelines for medical treatment into recommending acupuncture despite its origins in prescientific beliefs about the body, acupuncture is still quackery. Even the way that acupuncture made it to the US in the 1970s was as part of a calculated effort by Mao Zedong to export the concepts of traditional Chinese medicine that dated back 20 years before that. It never ceases to amuse me how little the adherents of acupuncture and TCM in the “West” know of how the Chinese government retconned the true history of TCM and acupuncture and continues to do so to this day to promote TCM, even to the point of punishing those who criticize TCM as unscientific, conning the World Health Organization to “integrate” TCM diagnoses in to the most widely used classification of diseases and diagnoses in the world, and forcing its people to use TCM to treat COVID-19. As for the rest, if a supplement is shown to have a medically beneficial effect for a disease or condition, it ceases to be “alternative” or “integrative” medicine and becomes just “medicine.”
If you “integrate” naturopathy, for example, into your practice, you are an “early adopter” of quackery, which, I would argue is not the sort of early adopter that medicine needs. You are not an “innovator” if you are an “early adopter” of prescientific medicine like acupuncture into your practice.
Dr. Ring concludes by “suggesting that our more strictly biomedical colleagues consider a shift in their perspective of the integrative field from that of ‘charlatans’ to ‘early adopters,’ and collaborate in helping patients reach their goals.” I respond by arguing that the word “charlatan” describes physicians who embrace such practices just fine and asking why KevinMD is giving a platform to this defense of “integrating” functional and integrative pseudoscience into medicine.