MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Two of the top US general medical journals have just published articles which somehow smell of the promotion of quackery. A relatively long comment on alternative medicine, entitled THE FUTURE OF INTEGRATIVE MEDICINE appeared in THE AMERICAN JOURNAL OF MEDICINE and another one entitled PERSPECTIVES ON COMPLEMENTARY AND ALTERNATIVE MEDICINE RESEARCH in THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. As this sort of thing does not happen that often, it is perhaps worth having a closer look at these publications. The JAMA-article has already been analysed skilfully by Orac, so I will not criticise it further. In the following text, the passages which are in italics are direct quotes from the AJM-article, while the interceptions in normal print are my comments on it.

…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. These are NOT synonyms, and there are many more names which have been forgotten, e.g. fringe, unorthodox, natural 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. Am I the only one to feel this sentence is a platitude?

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.” There is, in fact, no accepted definition; the most remarkable bit in this one is perhaps the term “informed by evidence” which, as we will see shortly, is by no means the same as “evidence-based”, the accepted term and principle in medicine.

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. Come again! Is that supposed to mean that conventional doctors do not employ “minimally invasive therapies or prevention or nutrition etc.”? In addition to conventional therapies, they may recommend alternatives, such as acupuncture, dietary supplements, and botanicals. BINGO! The difference between integrative and conventional physicians is quite simply that the former put an emphasis on unproven treatments; evidence my foot! This is just quackery by a different name. The doctor-patient relationship emphasizes joint decision-making by the patient and the physician. Yes, that may be true, but it does so in any type of good health care. To imply that the doctor-patient relationship and joint decision-making is an invention of integrative medicine is utter nonsense. 

More and more patients seek integrative medicine practitioners. By 2007, approximately 40% of adult Americans and 12% of children were using some form of alternative therapies compared with 33% in 1991.

The number of US hospitals offering integrative therapies, such as acupuncture, massage therapy, therapeutic touch, and guided imagery, has increased from 8% in 1998 to 42% in 2010.Many academic cancer centers offer these integrative practices as part of a full spectrum of care. Other hospitals offer programs in integrative women’s health, cardiology, and pain management. But why? I think the authors forgot to mention that the main reason here is to make money.

Despite the increasing number of patients seeking alternative therapies, until recently, many of these skills were not routinely offered in medical schools or graduate medical education. Yet they are critical competencies and essential to stemming the tide of chronic diseases threatening to overwhelm both our health care and our financial systems. Essential? Really? Most alternative therapies are, in fact, unproven or disproven! Further, conventional medical journals rarely contained articles about alternative therapies until 1998 when the Journal of the American Medical Association and its affiliated journals published more than 60 articles on the theme of complementary and alternative medicine.

The National Institutes of Health established an office in 1994 and a National Center for Complementary and Alternative Medicine in 1998. Because many alternative therapies date back thousands of years, their efficacy has not been tested in randomized clinical trials. The reasons for the lack of research may be complex but they have very little to do with the long history of the modalities in question. The National Center for Complementary and Alternative Medicine provides the funds to conduct appropriate trials of these therapies. The NCCAM- funded studies have been criticised over and over again and most scientists find them not at all “appropriate”. They also have funded education research and programs in both conventional medical nursing schools and complementary and alternative medicine professional schools. Outcomes of these studies are being published in the conventional medical literature. Not exactly true! Much of it is published in journals of alternative medicine. Also, the authors forgot to mention that none of the studies of NCCAM have ever convincingly shown an alternative treatment to work.

Integrative medicine began to have an impact on medical education when 8 medical school deans met in 1999 to discuss complementary and alternative medicine. This meeting led to the establishment of the Consortium of Academic Health Centers for Integrative Medicine, composed initially of 11 academic centers. By 2012, this group had grown to 54 medical and health profession schools in the United States, Canada, and Mexico that have established integrative medicine programs. The consortium’s first international research conference on integrative medicine was held in 2006, with subsequent research conferences being held in 2009 and 2012. Three conferences? Big deal! I have hosted 14 research conferences in Exeter in as many years. I think, the authors are here blowing up a mouse to look like an elephant.

Multiple academic integrative medicine programs across the country have been supported by National Institutes of Health funding and private contributions, including the Bravewell Collaborative that was founded in 2002 by a group of philanthropists. The goal of the Bravewell Collaborative is “to transform the culture of healthcare by advancing the adoption of Integrative Medicine.” It foremost was an organisation of apologists of alternative medicine and quackery. A high water mark also occurred in 2009 when the Institute of Medicine held a Summit on Integrative Medicine led by Dr Ralph Snyderman. 

There is clear evidence that integrative medicine is becoming part of current mainstream medicine. Really? I would like to see it. 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. I see, this is supposed to be the evidence?

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. It is not true that conventional medical schools do not teach about nutrition, psychology etc. Not all might, however, teach overt quackery. A similar curriculum for pediatric residencies is being developed. The eventual goal is to include integrative medicine skills and competencies in all residency programs.

Conclusions 

Integrative medicine now has a broad presence in medical education, having evolved because of public demand, student and resident interest, increased research, institutional support, and novel educational programs. Now on the horizon is a more pluralistic, pragmatic approach to medicine that is patient-centered, that offers the broadest range of potential therapies, and that advocates not only the holistic treatment of disease but also prevention, health, and wellness.

Is it not an insult to conventional medicine to imply it is not pluralistic, pragmatic, patient-centred, that it does not offer a broad range of therapies, holism and prevention? This article displays much of what is wrong with the mind-set of the apologists of alternative medicine. The more I think about it, the more I feel that it is a bonanza of fallacies, follies and attempts to white-wash quackery. But I would be interested in how my readers see it.

28 Responses to Have the top US journals taken to promoting quackery?

  • Guy Chapman says:

    I refer the hon. gentleman to my earlier comment: http://www.chapmancentral.co.uk/blahg/2012/08/my-holistic-healer/

    The core of this claim is that that medicine can only be “holistic” by abandoning the standards of evidence that have dragged it out of the mediaeval practices of bloodletting and purging and into the 21st Century with its rapidly increasing human life expectancy.

    Anybody who is that convinced of the benefit of pre-scientific doctrines is welcome to live in a mud hut somewhere and forego them. I predict a short but eventful life. There are not two ways of knowing or two kinds of knowledge. There is only science, the rest is bullshit.

    • Irene says:

      I can’t improve on that Mr. Chapman. Well said. I would only add that if one lives in a village in a mud hut, one will have access to long and personalize, consultations, accompanied by myriad ritual healing, with the resident medicine-person. Funny how most who live in such circumstances flock to an actual medical clinic whenever one is opened by a government or charity. I admit that many will continue to see the local quack even after being cured by the clinic staff–such is apparently human nature. Sigh.

  • Former sceptic says:

    Believe it or not, acupuncture has been used by the U.S. military for decades:

    - Auricular acupuncture: a brief introduction for military providers: http://www.ncbi.nlm.nih.gov/pubmed/23929047

    - Doctors Use Acupuncture as Newest Battlefield Tool: http://www.defense.gov/News/NewsArticle.aspx?ID=62053

    Why would the world’s most powerful and most technologically advanced military want to use alternative medicine if its really just pseudoscience based on nothing but placebo and quackery?

    • Edzard says:

      are you not the victim of one of the most classical fallacies of them all? it’s called appeal to authority.
      the US military also took UFOs seriously for a while!!!

      • Former sceptic says:

        I beg to differ. Military personnel are offered acupuncture when they have “not responded well to Western medicine” (quoting from the article from my above post), and not because they are forced to.

        Aside from conspiracy theories, I have never heard of the U.S. military getting involved with UFOS. Why would the U.S. military, the National Health Institute, the UK’s National Health Service, the World Health Organization, the two US journals you’ve mentioned in this post, etc, why are all of them so desperate to promote alternative medicine? And why is the public so eager to embrace pseudoscience based on quackery?

        Why would these scientific journals promote quackery if it doesn’t work?

    • Alan Henness says:

      Appeals to personal incredulity are rarely, if ever, convincing.

      The UK military (and others) used the rather obviously fake bomb detectors.

      Why would one of the world’s most powerful and most technologically advanced military want to use these bomb detectors if it’s really just pseudoscience based on nothing but ideomotor effects?

      • Gianteye says:

        Guhh. My browser got the ick before I was able to actually type that thing out in full.

        Sufficed to say, lots of smart people, capable scientists, and large organizations have believed in quackery and hokum over the years even in times when it was well known that the practices they were espousing were junk. I feel there’s a crucial difference (which believers are keen to gloss over) between decisions that are made on the best evidence people had to hand (though more evidence would have told a different story as in the case of Tamiflu) and decisions that are based on poor evidence and hearsay.

        I sincerely don’t believe that the army knows something the medical world at large doesn’t about acupuncture. The results are in. If it has any effect specifically due to the process and the theory behind pressure points and aligning mysterious bodily energies, it’s failed to show its powers are any stronger than the power of suggestion and the placebo effect.

        Why would the army like those treatments? Because the people propping the programs up would really, really like a cheap effective means of treating a host of difficult illnesses from PTSD to chronic pain. People, who aren’t trained to look at scientific data, support military acupuncture programs because, from a glossy and biased look at the evidence, they feel it’s too good not to be true. They are actively hoping it works just like parents are praying simple fish oil supplements will cure their childrens’ complex social disorders.

        • Edzard says:

          THANK YOU
          here are just a few reasons which spring into my mind why the army might employ useless treatments:
          1) because they are desperate
          2) because they have not the very best doctors/medical scientists
          3) because they are under political pressure to do so
          4) because they are short-sighted and want to save money
          5) because they feel it looks good

    • Irene says:

      Because they are not trained in the scientific method and don’t bother to look at the actual evidence–which clearly demonstrates that acupuncture is nothing more than an elaborate placebo.

      Bloodletting was very popular in its day. The Argument from Popularity is a logical fallacy.

  • Armando Brito de Sá says:

    Being a GP I am deeply embarrassed seeing family medicine departments embarking in the teaching and promotion of quackery. There may be some plausible explanations for that behaviour, though. Family medicine constantly deals with vague illness as opposed, for instance, physicians in ICUs. Internal medicine and pediatrics following the same path is to be expected, since these specialties deal with primary care in the US. Integrative medicine, or whatever quack designation someone cares to invent, is indeed appealing: it provides the feeling of something different being done to ill patients with no serious disease; may mark a difference towards those “insensitive and cold hospital physicians”, a classical us/them divide cleverly exploited by those trying to gain from that divide; it may keep the patient amused while the illness goes away (Voltaire dixit, more or less); and finally can bring some extra income, since insurance companies pay for nonsense (by consumer pressure and demand, they will say).

    Summing it up, it is a very personal blend of scientific ignorance, poor training in communication skills, will to please, desire to do good, ilnesses hard to deal with, demanding patients, lower than average income, wanting to make a difference.

    Dark times ahead, I’m afraid. The fighting against entropy goes on.

    • Irene says:

      I agree completely, and have also given this problem (the human need for something beyond the brief appointment, exam, diagnosis, rx, “have a nice day” medical appointment) some thought. GP’s (and internists, pediatricians, and other generalists) need to invest in organizing support staff (the nurse practitioner has done this to some extent) who can simply spend time and sympathise with patients without offering quackery. Dietitians, physical therapists, mental health counselors, social workers, and others should be filling the niche currently filled by the quacks. Perhaps there is a way to bring some kind of “spirituality” to this idea (not for me, certainly, but the majority are believers and seem to crave this) so that people feel their “whole” person is being considered.

      The people I have known (and there are MANY) who dabble or totally indulge in CAM consistently bemoan that their doctors are “arrogant” (seems to me they mistake expertise for arrogance), unfeeling, too “skeptical” and “think they know everything” or “don’t listen to me”. For myself, I have experienced being repeatedly cut off while answering questions asked by the doctor. I attribute this to my tendency to ramble, but others may not. There also seems to be an increased disrespect for expertise and science in general (other than its application to technological innovation), that seems to run parallel to the meme of “don’t trust the government”. Most of the alties I encounter are very wedded to any number of conspiracy theories as well–regardless of where they are on the political spectrum.

    • Former sceptic says:

      There are certainly a number of general practitioners of medicine who recommend unnecessary procedures all too often, but this occurs everywhere in clinical practice.

      If conventional medicine fails, I dont see why alternative medicine shouldn’t be used. For example, when a patient suffers from severe, recurring episodes of depression, it certainly makes sense to switch to mindful meditation especially in cases where drugs such as SSRIs do not help

      • Alan Henness says:

        Former sceptic said:

        There are certainly a number of general practitioners of medicine who recommend unnecessary procedures all too often, but this occurs everywhere in clinical practice.

        Quite possibly, but irrelevant to the promotion of quackery.

        If conventional medicine fails, I dont see why alternative medicine shouldn’t be used.

        I’m sure you don’t. However, many are concerned that patients are given the best available treatments; the ones with the best evidence to substantiate them. Alternative treatments, by definition, are not backed by good evidence, therefore it would be unethical to think of them as simply some ‘alternative’ to conventional medicine and unethical to let a patient think they might be effective.

        For example, when a patient suffers from severe, recurring episodes of depression, it certainly makes sense to switch to mindful meditation especially in cases where drugs such as SSRIs do not help

        It would only make sense (and be ethical) if there was good evidence that meditation was effective, and if there was, it would not be ‘alternative’. The patient should be given the best available treatments, not the ones only backed by wishful thinking.

  • J. R. says:

    My husband has been seeing “alternative practitioners” for about a year and a half. Even the esteemed University of Kansas Medical Center has an “Integrative Medicine” department. He has spent thousands and thousands of dollars on their treatments, dozens of supplements, countless lab tests, and an untold number of “therapies”. He started going to KU Integrative Med for several reasons: fatigue, erectile dysfunction, diabetes, overweight, and most of all, a seriously failing memory. Today, a year and a half later, he is fatigued, overweight (though he has lost about 8 pounds), his ED is much, much worse, he still has diabetes…in fact it’s worse, and he literally cannot remember something that he is told 10 minutes later. I’m not talking about wondering where his glasses or keys are….I’m talking about asking me three times in five minutes where we are getting ready to go. It breaks my heart. He thinks these people are going to help him. Discussing it is not an option. He refuses to believe anything negative about “integrative medicine”.

Leave a Reply

Your email address will not be published. Required fields are marked *


+ one = 8

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

Categories