MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Yesterday, I received a ‘LETTER FROM DR JONAS’ (the capital lettering was his) – actually, it was an email, and not a very personal one at that. Therefore I feel it might be permissible to share some of it here (you do remember Jonas, don’t you? I did mention him in a recent post: “Considering the prominence and experience of Wayne Jonas, the 1st author of this paper, such obvious transgression is more than a little disappointing – I would argue that is amounts to overt scientific misconduct.”)

Here we go:

As part of my book tour, I spent last month visiting hospitals and medical schools, talking to the doctors, nurses and students. I tell them to think of a chronically ill patient, and I ask:

“What matters most for this patient? What is the person’s lifestyle like – their nutrition, movement and sleep? How does that patient manage their stress? Does that patient have a good support system at home? What supplements does that patient take? Has your patient seen any CAM practitioners to cope with their condition? Why do they want to get well?”

Most can’t answer these questions. Providers may know the diagnosis and treatments a patient gets, but few know their primary determinants of health. They know ‘what’s the matter’, but not ‘what matters.’ …

END OF QUOTE

Let’s have a closer look at those items of which Jonas thinks they matter:

  1. What is the person’s lifestyle like – their nutrition, movement and sleep? Depending on the condition of the patient, these issues might indeed matter. And if they do, any good doctor will consider them. There is nothing new about this; it is stuff I learnt in medical school all those years ago.
  2. How does that patient manage their stress? The question supposes that all patients suffer from stress. I know it is fashionable to ‘have stress’, but not every patient suffers from it. If the patient does suffer, it goes without saying that a good doctor would consider it.
  3. Does that patient have a good support system at home? Elementary, my dear Watson! If a doctor does not know about this, (s)he has slept through medical school (where did you go to medical school Wayne, and what did you do during these 6 years?).
  4. What supplements does that patient take? That’s a good one. I suppose Jonas would ask it to see what further nonsense he might recommend. Most rational doctors would ask this question to see what (s)he must advise the patient to discontinue.
  5. Has your patient seen any CAM practitioners to cope with their condition? As above.
  6. Why do they want to get well? Most patients would assume we are pulling their leg, if we really asked this. Instead of a response, they might return a question: Why do you ask, do you think being ill is fun?

So, doctor Jonas’ questions might do well during lectures to a self-selected audience, but in reality they turn out to be a mixture of embarrassing re-discoveries from conventional medicine, platitudes and outright nonsense. “My goal is for integrative healthcare to become the standard of care…” says Jonas towards the end of his ‘LETTER’. I suppose, this explains it!

Thus Jonas’ ‘LETTER’ turns out to be yet another indication to suggest that the reality of ‘integrative medicine’ consists of little more than re-discoveries from conventional medicine, platitudes and outright nonsense.

22 Responses to The reality of ‘integrative medicine’ consists of little more than re-discoveries from conventional medicine, platitudes and outright nonsense

  • By ‘embarrassing re-discoveries from conventional medicine’ it seems you’re referring to things like attending to lifestyle factors and stress? As I’ve pointedness out here before, the Neijing (for example) detailed clear and simple lifestyle guidelines some 2000 years ago. Although they may be framed differently, a lot of the advice boils down to the kind of thing being regularly confirmed by modern research. So it could be argued that it is conventional medicine making the ‘embarrassing re-discoveries’.

    Also, although I agree good doctors should be aware of the often critical importance of these factors, they are left in an impossible situation in the current 10 minute consultation model. Once test results etc have been discussed, how often is more than lip service paid to lifestyle factors, in reality?

    • “… it could be argued that it is conventional medicine making the ‘embarrassing re-discoveries’.”
      not really, because doctors learn all this stuff at med school. it has been part of medicine since its beginning. and more recently, much of it [arguably the valuable elements of it] has become evidence-based through systematic research.

    • My doctors give me more than 10 minutes, and they absolutely ask about stress and lifestyle. More to the point, they refer to specialists if I need more advice.

  • But it’s been part of most if not all traditional medicines from the beginning too, and for much longer.

    And doctors ‘learn all this stuff in med school’! Really?! That’s an extraordinary comment.

    “There is a lack of knowledge and understanding of the basic evidence for the impact of nutrition and physical activity on health among the overwhelming majority of doctors. This has its roots in the lack of early formal training,”

    ‘Fewer than 10% [of Edinburgh Uni med students] felt adequately trained to give patients advice on physical activity and more than 90% said they would like more training on it.’

    https://www.theguardian.com/society/2016/oct/19/doctors-know-too-little-about-effects-of-nutrition-and-exercise

    ‘On average, students received 23.9 contact hours of nutrition instruction during medical school… most medical schools are not providing adequate nutrition instruction.‘

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2430660/

    • “A total of 106 surveys were returned for a response rate of 84%. Ninety-nine of the 106 schools responding required some form of nutrition education; however, only 32 schools (30%) required a separate nutrition course. On average, students received 23.9 contact hours of nutrition instruction during medical school (range: 2–70 h). Only 40 schools required the minimum 25 h recommended by the National Academy of Sciences. Most instructors (88%) expressed the need for additional nutrition instruction at their institutions.”
      the answer could be quite simple: in my case {LMU Munich}, we were taught nutrition and exercise mostly in the relevant courses such as endocrinology, cardiology, orthopaedics, etc.
      and secondly, ask medical students whether they feel they need more of any subject you can think of [with the exception of stats perhaps], they are likely say YES.
      I mainly judge this from having taught at 4 different med schools in 3 different countries [not the US] and i tell you: it is included.

      • Sir Richard Thompson, ex-president of the Royal College of Physicians, Professor Chris Oliver of Edinburgh University, Dr David Haslam, chairman of the National Obesity Forum and Dr Aseem Malhotra, a cardiologist and health campaigner all seem to strongly disagree with you.

        • in what way?
          that I was taught nutrition?
          that students habitually say they want more?
          that I have taught med students in 4 med schools?
          CAN YO BE A BIT MORE PRECISE, PLEASE?

          • I think it’s pretty obvious what my point is, but to spell it out – they disagree that there isn’t a serious need for more nutrition/lifestyle education for doctors. You make it clear you believe that ‘all this stuff’ is adequately covered – they clearly disagree.

          • you are putting words in my mouth: I don’t think it is ADEQUATELY covered. I explained it is covered and ask medical students [or professor, including myself] whether they feel they need more of any subject you can think of [with the exception of stats perhaps], they are likely say YES.

  • ‘Integrated Medicine’ is a term dreamt up by those who wanted to avoid ‘Complementary’ (which they are not, they don’t ‘complete’ any treatment) or ‘Alternative’ (which they are not, or they would be in the materia medica) epithets.

    It has then been taken up by some conventional institutions who want to scam patients they treat and students on their courses.

    Of course, they will deny this. That’s what quacks do.

    The majority of proponents and practitioners of ‘IM’ have failed (for one reason or another) to enter medicine, or having done so, have spotted a niche in the market which they are happy to take advantage of, disguised as ‘progress’.
    I join Mr Kennedy in his criticism of a ten minute consultation with only lip service paid to ‘lifestyle’ – but he is confused and conflates the difficulties of practical medical practice with aspirations to ‘heal’ and ‘do the best’ no matter what the cost (principally in time). Doctors have to prioritise and ration their services. If folks want more, funds must be found – but we don’t need anyone to market nonsense dressed up as a rational care system – nor to set up colleges of irrational medicine (IM).

    Again I draw distinction between TLC, good advice, consolation and a constructive relationship with an empathic practitioner (which might be beneficial) and the pillules, pricking, pummeling, potions and preternatural powers claimed by camists to have an effect (and which they wish to market), but for which there is no evidence of benefit beyond placebo.

  • Forgive me, but when you say ‘doctors learn all this stuff in med school’, it sounds to me as though you consider these things adequately covered. Otherwise I might expect a statement something like ‘doctors learn a bit of this stuff in med school, but not an adequate amount’. I don’t mean to put words in your mouth (although I’ve had that done to me multiple times on this blog), I’m pointing out how your comments come across (to me at least).

    • few things can be said to be taught totally ADEQUATELY at med school. there is always room for improvement – but sadly, often not the time! this is why doctors are initially supervised, need to specialise and have a professional and ethical obligation to engage in plenty of further education throughout their professional lives. quite different from alternative practitioners, I think.

      • There’s certainly plenty of room for improvement in the CAM world, no arguments there. But I would say that we also have a professional and ethical obligation to engage in plenty of further education throughout our professional lives. This emphasis has become gradually more built-in to the more established therapies for some time – although still a long way from perfect.

        But I think the point being made in the Guardian article is that there is more than just ‘room for improvement’ in these fundamental areas. As you hinted at, the huge role of diet and lifestyle in disease prevention and management is very much evidence-based now, and it seems arguable that a total overhaul in medical education is called for. I think that’s partly what Dr Jonas is saying, isn’t it?

        • i agree with you to a point – but i certainly do not agree with the notion that Jonas was trying to say this [nor that ‘integrative medicine’ is primarily aimed at this – which, of course, you did not claim].

    • If you decide that all illness has a unitary cause that can be treated with a single therapeutic approach (choose between acupuncture, homeopathy, chiropractic, reiki, prayer to a deity, reflexology, iridology.. the list goes on) you’ll probably be amused every time you meet a qualified medical specialist and ask them about something biomedical outwith their specialist field and you’re answered with a shrug of ignorance.

      The fact is that NO medical curriculum can impart all knowledge of medicine, physiology, biochemistry, anatomy, genetics, psychology and so on, even within the standard 5-year basic learning frame for UK medical students. Even specialists tend to sub-specialize within their disciplines. The march of science has made it impossible for any one person to know everything. Unless, of course, you specialize in one of the pseudo-medical specialities that attributes all disease to a single underlying cause and offers a single type of cure.

      • The march of science has made it impossible for any one person to know everything.

        Exactly. There is a reason why medical studies take so long and then still don’t even begin to cover everything. There is only so much that can fit in a *human* head (and yes, doctors are human). Multiple full heads tend to know a lot more than one full head. That’s why there is so much multisciplinary consultation.
        How different things are at the House of Quack! No need for multidisciplinary anything. After all, three empty heads don’t know anything more than a single empty head.

  • I do not know whether U.K. doctors have adequate knowledge of nutrition and fitness. If they feel it is part of the health issue presented by the patient I am sure that there are lots more of resources that the patient could be pointed to. I also feel that for most people managing their own fitness and nutrition is intellectually not too difficult although motivation might be another issue.

    I am sure though that advocating CAM is a waste of time. There is no evidence for these approaches having any efficacy beyond placebo.

    If nutrition and fitness are relevant issues in a patient they do not need addressing by pseudo medicine.

    • for most people managing their own fitness and nutrition is intellectually not too difficult

      As Dr McCoy said “I can do more for you if you just eat right and exercise regularly” (The Omega Glory, ST TOS S2E23). That was in 1968, 50 years ago, almost to the day. It was nothing remotely new even then and while guidelines may have been refined a bit since, they knew very well what “eat right” meant.

      although motivation might be another issue

      And that’s part of the tragedy, isn’t it. The secret to success used to be called “willpower”. Now, it is fashionable to call the reason for failure “not your fault”. Which is, of course, largely nonsense.

  • When scammers start clamoring about the “lack” in medical education, rational observers know what comes next: their particular tentacle of money-laundering…..wedging their gnostic-insights and parsimonious “answer” (costing plenty-o-cash money) for whatever chimerical problem the patient presents with.
    That no one can know everything doesn’t suggest a no-nothing knows something.

  • The article was not suggesting a total overhaul in British medical education is needed. Katie Petty-Saphon of the MSC says greater emphasis should be given to exercise and nutrition in the future training of doctors. The message is already out there that diet and exercise are significant factors for health. Many people find it difficult to make adjustments to their lifestyle choices. That is where the overhaul is needed. A culture shift is needed. That’s not a task for doctors, it’s a task for individuals.

    Dr. Jonas has made a very lucrative career out of CAM. He wants it to become normalised medicine in the USA. Socialised medicine is minimalistic and what there is, is vehemently opposed by corporate America. Medicine is big business in the USA. Jonas does not want to transform medicine, he wants to normalise CAM. He would, wouldn’t he?

  • “That’s not a task for doctors, it’s a task for individuals”. Bravo & exactly!
    Perhaps super-fit political leaders like Trump can serve as role models?

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