Posted by David Gorski on September 2, 2013 ( Comments)
I was the other day. I’ve been on vacation this week (staycation, actually, as I stayed at home and didn’t go on any trips); so you would think it would take a lot to depress me. Unfortunately, today is the last day of that vacation; so the thought of diving back into the fray trying to fund my lab. It didn’t help that I read Scott Gavura’s Thursday post how another once-proud academic medical center, the University of Toronto, is letting the Trojan horse that is “integrative medicine” into the halls of its medical school and school of pharmacy. As I frequently say, much to the annoyance of advocates of “complementary and alternative medicine” (CAM) and “integrative medicine,” what “integrative medicine” does is to “integrate” quackery with real medicine, which neither validates the quackery nor improves the real medicine. Or, as my good bud and fellow SBM blogger Mark Crislip so aptly put it:
If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.
Yes, I’ve been trying to come up with a quote that captures the essence of “integrative medicine” better than Mark’s quote. I’ve yet to succeed; so I steal his quote whenever I need to. It’s sort of the same way that I didn’t actually coin the term “quackademic medicine” to describe the infiltration of quackery into academic medicine. (Dr. R. W. Donnell did, as far as I’ve been able to ascertain.) However, I believe I’ve done more than anyone else to use and promote the term, both here and at my not-so-super-secret other blog. As I like to say say, mediocre bloggers borrow. Great bloggers steal.
Be that as it may, Scott’s post reminded me that I hadn’t looked much at quackademic medicine, at least not at the status of its infiltration into medical academia, in a while. Then I saw a review article entitled The Future of Integrative Medicine in The American Journal of Medicine by Victor S. Sierpina, MD, ABFM, ABIHM and James E. Dalen, MD, MPH. (Note that ABIHM stands for the American Board of Integrative Holistic Medicine and ABFM stands for the American Board of Family Medicine.). The article itself has no place in any self-respecting peer-reviewed medical journal, but there it is, much the same way that quackademic woo has been intermittently infiltrating the New England Journal of Medicine. The article itself is one massive apologia for integrative medicine. In fact, it’s useful to look at because it follows a script that virtually all such articles follow, with only relatively minor variations.
Not surprisingly, it starts out, as virtually all such articles start out, with the logical fallacy known as the appeal to popularity. As I just alluded to, there must be a script for these sorts of articles about CAM, in which they all must begin with a paragraph trying to demonstrate how popular CAM is, the larger the percentage of people using CAM the better, even if the author has to include prayer and spirituality (which are religion and not medicine), exercise (which is a science-based modality rebranded as somehow “alternative”), and nutrition (which is similarly not “alternative” but a science-based modality similarly “rebranded” as “alternative”; that is, as long as the claims being made for it aren’t overblown). Sierpina and Dalen’s article is no exception. They immediately cite an article from 20 years ago that claimed that one in three people used “unconventional therapies.” (I can’t help but note that 20 years ago it was still acceptable to call quackery “unconventional” rather than to refer to it as CAM or “integrative medicine.” Unfortunately, that was also about the time that that started to change in a big way.) In any case, using this logical fallacy, they strongly imply that because CAM is popular that there must be something to it. I always respond to such arguments by pointing out that nearly half of U.S. adults don’t believe in evolution. Does that mean that evolution is not a valid scientific theory? Science is not a popularity contest.
Next in the script of these articles—and I’ve read more of them than I can remember—is to extend the appeal to popularity to imply that you, as a reader, should jump on the bandwagon. The reason, if they are to be believed, that you should jump on the bandwagon is because modern medicine is too high-tech, doctors have lost touch with their roots as healers, and patients “feel lost” in our health care system. For example, Sierpina and Dalen write:
In the past several decades we have seen a sea change in the medical landscape from the solo practice, primary care country doctor to large urbanized health care systems, from high-touch, low-cost care to high-tech, specialized, expensive, sometimes impersonal health care. Some patients feel lost in our current health care system. They see specialist after specialist and receive prescription after prescription and test after test. They wonder whether their specialists speak to each other.
In the context of these historical and social changes, a field of unconventional medicine has evolved that has been known by a progression of names: holistic medicine, complementary and alternative medicine, and now integrative medicine. It is hoped that the perspectives offered by integrative medicine will eventually transform mainstream medicine by improving patient outcomes, reducing costs, improving safety, and increasing patient satisfaction.
Of course, just because modern medicine can be impersonal and confusing is not a justification for introducing quackery into medicine. I like to remind people that the primary care country doctor of 50 or 100 years ago that is so lionized as the ideal by CAM providers because of the “human touch” he provided often couldn’t do a heck of a lot other than commiserate with their patients and provide that human touch. Don’t get me wrong. That’s a critically important part of medicine that is difficult to maintain in our current healthcare environment. However, a far better solution would be to reintroduce the human element of caring and retain the efficacy of science-based medicine without introducing the mysticism, vitalism, and prescientific thinking that is at the heart of so much CAM. It’s a false dichotomy that is being argued: It’s either impersonal, mechanized medicine or it’s “integrating” quackery into medicine. CAM apologists like Sierpina and Dalen like to imply that those are the only two choices. They aren’t. There is another way that does not involve weakening the scientific foundation of medicine.
Even more off-base, the script for this sort of article always includes a claim that somehow CAM will “transform” medicine. No doubt it will, if current trends continue and quackademic medicine continues to infiltrate unchecked. Indeed, it already has. Unfortunately, that “transformation” is not for the better, given that it involves injecting mystical faith healing like reiki and healing touch, vitalistic quackery like homeopathy and traditional Chinese medicine, and cornucopias of quackery like naturopathy into modern medicine. To CAM advocates this is a good thing that will somehow “humanize” medicine. To me it is unnecessary quackery. Unfortunately, it is ascendant right now.
Next up in these articles is often the attempt to define just what “integrative medicine” is. My definition is fairly clear: Integrating quackery with real medicine. (I know, I repeat myself, but I want to drive this point home.) However, let’s see how Sierpina and Dalen try to explain how it is defined:
Integrative medicine has been defined as “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.”
This definition, quoted from the Consortium of Academic Health Centers for Integrative Medicine, is nonsense, of course. It’s complete gobbledygook that reinforces the false dichotomy that so irritates me. Once again, it is not necessary to embrace quackery in order to “reaffirm the importance of the relationship between practitioner and patient” or to “focus on the whole person.” It just isn’t. Yet that’s the false dichotomy at the heart of all these articles. Yet that is exactly the dichotomy that CAM apologists hammer advocates of SBM over the head with in an effort to paint us as uncaring and more concerned with science than with actual patients. Of course, it is because we are so concerned with patients that we reject this dichotomy and insist on science-based medicine, but that’s a message that is sometimes hard to communicate, which makes it easy for writers like Sierpina and Dalen to write things like this:
The most obvious differences between integrative and conventional medicine are its practitioners, who offer longer consultations and emphasize minimally invasive therapies, such as mind-body approaches, nutrition, prevention, and lifestyle changes, and focus on healing and wellness. In addition to conventional therapies, they may recommend alternatives, such as acupuncture, dietary supplements, and botanicals. The doctor-patient relationship emphasizes joint decision-making by the patient and the physician.
Once again, it is not necessary to abandon SBM in order to emphasize joint decision-making by the patient and the physician. As I’ve pointed out multiple times before, the days of “Dr. Kildare”-style paternalism of 60 years ago and earlier are over, and that is generally a good thing. These days, good science-based doctors emphasize joint decision-making. The reason CAM practitioners emphasize joint decision-making so much, to the point of fetishizing it, is because that’s all they have that’s of value. The rest of what they offer consists of either quackery or science-based modalities that have been rebranded as being somehow “alternative,” such as pharmacognosy (natural products pharmacology) rebranded as herbalism and supplements, nutrition, lifestyle interventions, and exercise.
Once again Sierpina and Dalen continue to hammer on the appeal to popularity by launching straight into a discussion of how many academic medical centers have integrative medicine programs, in essence gloating about how in 1999 there were only eight medical school deans who met to discuss CAM and create the Consortium of Academic Health Centers for Integrative Medicine, which ultimately had eleven members. In 2012, there were 54 medical and health professions schools belonging to the Consortium, and today, according to Sierpina and Dalen, here’s where integrative medicine stands in 2013:
There is clear evidence that integrative medicine is becoming part of current mainstream medicine. Increasing numbers of fellowships in integrative medicine are being offered in our academic health centers. In 2013, there are fellowships in integrative medicine in 13 medical schools. In 2000, the University of Arizona established a 1000-hour online fellowship that has been completed by more than 1000 physicians, nurse practitioners, and physician assistants. This online fellowship makes it possible for fellows to continue their clinical practice during their fellowship.
A 200-hour curriculum for Integrative Medicine in Residency has been developed and is now in place in 30 family practice and 2 internal medicine residencies. The curriculum includes many of the topics that are not covered in the medical school curriculum, such as nutrition, mind–body therapies, nutritional and botanical supplements, alternative therapies (eg, acupuncture, massage, and chiropractic), and lifestyle medicine. A similar curriculum for pediatric residencies is being developed. The eventual goal is to include integrative medicine skills and competencies in all residency programs.
Sadly, they say this as though it were a good thing. It’s not. Unfortunately, thanks to the University of Arizona, the efforts to “integrate” pseudoscience into science-based medicine continue apace. For example, just the other day I saw an article cum press release touting how the University of Arizona’s Pediatric Integrative Medicine in Residency recently expanded its online offerings:
UA’s Pediatric Integrative Medicine in Residency program recently expanded its online curriculum to include four other universities in the United States, making it the first national online pediatric integrative medicine program.
Still in its pilot stage, the online curriculum now includes pediatric departments at Stanford University, the University of Chicago, the University of Kansas and Eastern Virginia Medical School Children’s Hospital of the King’s Daughters. Prior to the national launch, the online pilot program was only used at UA’s College of Medicine.
The Pediatric Integrative Medicine in Residency program allows medical school graduates working on their specialization to learn a variety of methods to treat children beyond traditional medicine.
These practices range from nutritional treatment to the Chinese healing tradition of acupuncture. Pediatric residents also learn stress management and physical activity as forms of treatment for their patients.
It always makes me cringe to think about subjecting children to acupuncture, sticking needles into children for no therapeutic benefit.
In any case, as I said at the beginning of this post, now I’m depressed. On the other hand, I’m also getting recharged. I go back to work tomorrow. Not only is it time to get back into my research again and to take care of my patients again. It’s also time to dive back into the fray and promote SBM.
