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

integrated medicine

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Yesterday, it was announced that the new German health secretary will be Dr. Karl Lauterbach. This seems a most reasonable choice (when did the UK last have a physician in that post?), and I certainly wish him the best of luck in his new position.

Lauterbach studied medicine at the RWTH Aachen University, University of Texas at San Antonio and University of Düsseldorf, where he graduated. From 1989 to 1992, he studied health policy and management as well as epidemiology at the Harvard School of Public Health in Boston, graduating with a Doctor of Science in 1992. From 1992 to 1993, he held a fellowship at the Harvard Medical School.

From 1998 until 2005, Lauterbach served as the director of the Institute of Health Economics and Clinical Epidemiology (IGKE) at the University of Cologne. He was appointed adjunct professor at the Harvard School of Public Health in 2008. He was a member of the Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen (the council of experts advising the federal government on developments in the German healthcare system) from 1999 until he was elected to the Bundestag in September 2005.

But why does his appointment put the German defenders of homeopathy in a panic? The reason is simple: Lauterbach has in the past repeatedly argued against the reimbursement of homeopathy in Germany. This is, for instance, what DER SPIEGEL wrote in 2019 (my translation):

SPD parliamentary group vice-chairman Karl Lauterbach wants to prohibit public health insurance companies from reimbursing the costs of homeopathy. “We have to talk about this in the coalition,” he told the “Tagesspiegel”. Health insurance companies in Germany are not obliged to cover the costs of homeopathic treatments. However, they can pay for it voluntarily.

Voluntary benefits by health insurers must also be economically and medically reasonable, Lauterbach argues, referring to a similar push in France. According to the French Supreme Health Authority (HAS), the funds do not have sufficient scientific effect. The Ministry of Health had previously commissioned the HAS with the examination. It is considered likely that the French government will soon abolish the coverage of costs.

“In the spirit of reason and education as well as patient protection, it is also wrong in Germany for insurance companies to pay for homeopathy for marketing reasons,” Lauterbach wrote on Twitter in reaction to the decision in France. His demand is not new. Lauterbach had already spoken out in 2010 for a ban on the assumption of costs.

Many observers expect that Lauterbach – after getting the pandemic under control (not an easy task by any measure) – will indeed stop the reimbursement of homeopathy. Germany’s largest homeopathy producer reacted swiftly and is currently running an expensive campaign with full-page advertisements in German newspapers trying to improve the much-damaged public image of homeopathy:

In the advertisement above, for instance, it is implied that homeopaths are all in favor of vaccination. Regular readers of my blog will know that this is not true…

… and so does Dr. Lauterbach!

Psychosocial distress, depression, or anxiety are frequent problems of women after a breast cancer diagnosis and treatment. Many try so-called alternative medicine (SCAM) in an attempt to deal with them. But is this effective?

The purpose of this study was to assess the potential benefit of lavender oil as a perioperative adjunct to improve anxiety, depression, pain, and sleep in women undergoing microvascular breast reconstruction.

This was a prospective, single-blinded, randomized, controlled trial of 49 patients undergoing microvascular breast reconstruction. Patients were randomized to receive lavender oil or a placebo (coconut oil) throughout their period of hospitalization. The effect of lavender oil on perioperative stress, anxiety, depression, sleep, and pain was measured using the hospital anxiety and depression scale, Richards-Campbell Sleep Questionnaire, and the visual analogue scale.

Twenty-seven patients were assigned to the lavender group and 22 patients were assigned to the control group. No significant differences were seen in the perioperative setting between the groups with regard to anxiety (p = 0.82), depression, sleep, or pain scores. No adverse events were noted, and no significant differences in surgery-related complications were observed. When evaluating the entire cohort, postoperative anxiety scores were significantly lower than preoperative scores, while depression scores were significantly higher postoperatively as compared with preoperatively.

The authors concluded that, in the setting of microvascular breast reconstruction, lavender oil and aromatherapy had no significant adverse events or complications; however, there were no measurable advantages pertaining to metrics of depression, anxiety, sleep, or pain as compared with the control group.

One could argue that the sample size of the trial was too low to pick up small differences in the outcome measures. Yet, even then, the findings do not suggest that the treatment did make a large enough difference to justify the effort and expense of the treatment.

One could also argue that – who cares? – if a patient wants aromatherapy (or another SCAM that is harmless), why not? The answer to this is the fact that researchers have the ethical duty to identify the most effective treatment, and clinicians have the ethical duty to employ not just any odd therapy but the one that works demonstrably best. Seen from this perspective, the place of SCAM in cancer care seems far less certain than many enthusiasts try to make us believe.

The 13th European Congress for Integrative Medicine is about to take place online between 4 and 7 November 2021. It will host 125+ speakers presenting from around the world. The programme will cover the following topics.

Even looking at the more detailed list of lectures, I did not find a single contribution on conventional medicine (“Integrative medicine combines conventional medicine with…” [see below]) or a lecture that is remotely critical of integrative medicine. The definition of INTEGRATED MEDICINE (IM) adopted here seems similar to the US definition we recently discussed. Here is the European definition:

Integrative medicine combines conventional medicine with evidence-informed complementary medicine and therapies to achieve the optimum health and wellbeing of the patient. Focusing on a holistic, patient-centred approach to healthcare, it takes into consideration the patient’s physical and psychological wellbeing and treats the whole person rather than just the disease.

Allow me to do a quick analysis of this definition by looking at its key elements:

  • Evidence-informed: While proper medicine is BASED on evidence, IM is merely INFORMED by it. The difference is fundamental. It allows IM clinicians to use any un- or disproven so-called alternative medicine (SCAM) they can think of or invent. The evidence for homeopathy fails to show that it is effective? Never mind, IM does not need to be evidence-based, it is evidence-informed. IM physicians know homeopathy is a placebo therapy (if not they would be ill-informed which would make them unethical), but they nevertheless use homeopathy (try to find an IM clinic that does not offer homeopathy!), because IM is not EBM. IM is evidence-informed!
  • Therapies that achieve optimum health and wellbeing. This is odd because the website also states that “therapies can include anything from acupuncture, yoga, massage, aromatherapy, herbal medicine, nutrition, exercise along with many more approaches, tailored to the needs of the individual” indicating that virtually anything can be included. Anyway, “optimum health and wellbeing” seems a strange and unachievable criterion. In fact, it is nothing but a ‘bait and switch‘ salesmen’s trick.
  • Holistic: This is a little trick that IM proponents love. With it, they imply that normal medicine is not holistic. However, this implication is demonstrably wrong. Any good medicine is holistic, and if a sector of healthcare fails to account for the whole person, we need to reform it. (Here are the conclusions of an editorial I published in 2007 entitled ‘Holistic heath care?‘: good health care is likely to be holistic but holistic health care, as it is marketed at present, is not necessarily good. The term ‘holistic’ may even be a ‘red herring’ which misleads patients. What matters most is whether or not any given approach optimally benefits the patient. This goal is best achieved with effective and safe interventions administered humanely — regardless of what label we put on them.) Creating a branch of medicine that, like IM, pretends to have a monopoly on holism is grossly misleading and can only hinder this process.
  • Patient-centred: This is the same mean little trick in a different guise. They imply that conventional medicine is not patient-centred. Yet, all good medicine is, of course, patient-centred. To imply otherwise is just daft.
  • Consideration of the patient’s physical and psychological wellbeing and treating the whole person rather than just the disease: Same trick yet again! The implication is that physical and psychological wellbeing and the whole person are not all that relevant in conventional medicine where only disease labels are being treated.

Altogether, this definition of IM is unworthy of anyone with the slightest ability to think critically. I find it much worse than the latest US definition (which already is fairly awful). In fact, it turns out to be a poorly disguised bonanza of strawman fallacies combined with ‘bait and switch’ deception.

How can this be?

How can a professional organisation engage in such mean trickery?

Perhaps a look at the list of speakers will go some way towards answering the question. Have a good look, you might recognize many individuals as members of our ALTERNATIVE MEDICINE HALL OF FAME.

PS

Registration costs £ 249 (standard rate)

PPS

Perhaps I should also mention at least 4 of the many commercial sponsors of the conference:

  • Boiron
  • Helixor
  • Iscador
  • Weleda

 

 

I was alerted to an interesting article about homeopathy in Switzerland. Its author points out that homeopathy is paid for by health insurance in Switzerland because of anything remotely related to evidence but because of a referendum in 2009. At the time, one of the arguments of the proponents was that health care costs would tend to decrease if more so-called alternative medicine (SCAM) would be paid for by the public purse. This is what Jacques de Haller, the president of the medical association, claimed: because SCAM is comparatively cheap and helps to prevent more expensive consultations, the total cost of health care would decrease.

This rather naive assumption was also one made in 2005 by the ‘Smallwood-Report’, commissioned by Charles and paid for by Dame Shirley Porter, specifically to inform health ministers. It stated that up to 480 million pounds could be saved if one in 10 family doctors offered homeopathy as an alternative to standard drugs. Savings of up to 3.5 billion pounds could be achieved by offering spinal manipulation rather than drugs to people with back pain. (Because I had commented on this report, Prince Charles’ first private secretary asked the vice-chancellor of Exeter University, Steve Smith, to investigate. Even though I was found to be not guilty of any wrongdoing, specifically of violating confidentiality, all local support stopped which led to my decision to retire early.)

In Switzerland, the assumption that SCAM saves money was refuted in 2019 by the Swiss health insurance association Santésuisse in a proper cost analysis. According to this analysis, doctors who also prescribed homeopathy caused 22% more costs per patient than those practicing conventional medicine. As it turned out, SCAM would be charged in addition to existing conventional medical services. Consequently, from a point of view of health economics, SCAM should not be called “alternative”, but rather “additive”, Santésuisse wrote at the time.

More evidence comes from a German study (authored by proponents of homeopathy!) that confirms these findings. Integrated care contracts for homeopathy by German health insurers were shown to result in higher costs across all diagnoses.

The recognition that homeopathy lacks sound evidence has already led to an end of reimbursement in the UK and France. Both in Germany and Switzerland, strong pro-homeopathy lobbies have so far succeeded in preventing similar actions. Yet, there is no doubt that, in these and other countries, the writing is on the wall.

When I yesterday reported about Charles’ new paper in a medical journal, I omitted to go into any sort of detail. Merely mumbling ‘this is bait and switch‘ and ‘there is no good evidence that social prescribing is effective‘, is not good enough. Charles deserves better! That’s why today I provide a more detailed analysis of what he wrote on social prescribing.

Social prescribing is a concept that emerged in the UK more than a decade ago [1]. It aims to connect patients to different types of community support, including social events, fitness classes, and social services. Trained professionals, often called link workers or community connections, work with healthcare providers to offer referrals to these types of support. Social prescribing largely exists to fill in healthcare treatment gaps. The basic medical treatment cannot address every concern. Primary care providers don’t always have enough time to get to know their patients and understand the complete picture of their lives.

For example, loneliness can cause stress, which can eventually affect sleep, nutrition, and physical health. Doctors may not be able to offer much help for this problem. That’s where link workers step in. They can provide more specialized support if someone struggles to meet basic wellness or social needs. They get to know a patient’s unique needs and help you take action to meet those needs by referring him or her to helpful resources in the community.[2]

Charles elaborated on social prescribing (or social prescription, as he calls it for some reason) as follows [the numbers in square brackets were added me and refer to my comments below]:

… For a long time, I have been an advocate of what is now called social prescription and this may just be the key to integrating the biomedical, the psychosocial and the environmental, as well as the nature of the communities within which we live and which have such an enormous impact on our health and wellbeing [1]. In particular, I believe that social prescription can bring together the aims of the health service, local authorities, and the voluntary and volunteer sector. Biomedicine has been spectacularly successful in treating and often curing disease that was previously incurable. Yet it cannot hold all the answers, as witnessed, for instance, by the increasing incidence of long-term disease, antibiotic resistance and opiate dependence [2]. Social prescription enables medicine to go beyond pills and procedures and to recognise the enormous health impact of the lives we lead and the physical and social environment within which we live [3]. This is precisely why I have spent so many years trying to demonstrate the vitally important psychosocial, environmental and financial added value of genuinely, sustainable urban planning, design and construction [4].

There is research from University College London, for instance, which shows that you are almost three times more likely to overcome depression if you have a hobby [5]. Social prescription enables doctors to provide their patients with a bespoke prescription that might help them at a time of need …

When we hear that a quarter of 14–16-year-old girls are self-harming and almost a third of our children are overweight or obese, it should make us realise that we will have to be a bit more radical in addressing these problems [5]. And though social prescription cannot do everything, I believe that, used imaginatively, it can begin to tackle these deep-rooted issues [6]. As medicine starts to grapple with these wider determinants of health [7], I also believe that medicine will need to combine bioscience with personal beliefs, hopes, aspirations and choices [8].

Many patients choose to see complementary practitioners for interventions such as manipulation, acupuncture and massage [9]. Surely in an era of personalised medicine, we need to be open-minded about the choices that patients make and embrace them where they clearly improve their ability to care for themselves? [10] Current NHS guidelines on pain that acknowledge the role of acupuncture and mindfulness may lead, I hope, to a more fruitful discussion on the role of complementary medicine in a modern health service [11]. I have always advocated ‘the best of both worlds’ [12], bringing evidence-informed [13] conventional and complementary medicine together and avoiding that gulf between them, which leads, I understand, to a substantial proportion of patients feeling that they cannot discuss complementary medicine with their doctors [14].

I believe it is more important than ever that we should aim for this middle ground [15]. Only then can we escape divisions and intolerance on both sides of the conventional/complementary equation where, on the one hand, the appropriate regulation of the proven therapies of acupuncture and medical herbalism [15] is opposed while, on the other, we find people actually opposing life-saving vaccinations. Who would have thought, for instance, that in the 21st century that there would be a significant lobby opposing vaccination, given its track record in eradicating so many terrible diseases and its current potential to protect and liberate some of the most vulnerable in our society from coronavirus? [16] …

My comments are as follows:

  1. Is Charles not a little generous to his own vision? Social prescribing is not nearly the same as the concept of integrated medicine which he has been pushing for years.
  2. There is no good evidence that social prescribing will reduce ‘of long-term disease, antibiotic resistance, and opiate dependence’.
  3. Here Charles produces a classic ‘strawman fallacy’. Medicine is much more than pills and procedures, and I suspect he knows it (not least because he uses proper medicine as soon as he is really ill).
  4. Charles has not so much ‘demonstrated’ the importance of ‘psychosocial, environmental and financial added value of genuinely, sustainable urban planning, design, and construction’ as talked about it.
  5. That does not necessarily mean that social prescribing is effective; correlation is not causation!
  6. There is no good evidence that social prescribing is effective against self-harm or obesity.
  7. Medicine has been trying to grapple with ‘wider issues’ for centuries.
  8. Medicine has done that for many years but we always had to be mindful of the evidence base. It would be unwise to adopt interventions without evidence demonstrating that they do more good than harm.
  9. Many patients also choose to smoke, drink, or sky-dive. Patient choice is no indicator of efficacy or harmlessness.
  10. Yes, we should embrace them where they clearly improve their ability to care for themselves. However, the evidence all too often fails to show that they improve anything.
  11. As we have seen, this discussion has been going on for decades and was not always helped by Charles.
  12. The best of both worlds can only be treatments that demonstrably generate more good than harm – and that’s called evidence-based medicine. Or, to put it bluntly: in medicine ‘best’ does not signify royal approval.
  13. ‘Evidence-informed’ is an interesting term. Proper medicine thrives to be evidence-based; royal medicine merely needs to be ‘evidence-informed’? This new term seems to imply that evidence is not all that important. Why? Perhaps because, for alternative medicine, it is largely not based on good evidence?
  14. If we want to bridge the gulf, we foremost require sound evidence. Today, plenty of such evidence is available. The problem is that it does often not show what Charles seems to think it shows.
  15. Even the best regulation of nonsense must result in nonsense.
  16. The anti-vaccination sentiments originate to an alarmingly large extent from the realm of alternative medicine.[4]

REFERENCES

[1] Brandling J, House W. Social prescribing in general practice: adding meaning to medicine. Br J Gen Pract. (2009) 59:454–6. doi: 10.3399/bjgp09X421085

[2] Social Prescribing: Definition, Examples, and More (healthline.com)

[3] Schmidt K, Ernst E. MMR vaccination advice over the Internet. Vaccine. 2003 Mar 7;21(11-12):1044-7. doi: 10.1016/s0264-410x(02)00628-x. PMID: 12559777.

Prince Charles has published his views on integrated health several times before in medical journals. In 2001, authored an editorial in the BMJ promoting his ideas around integrative medicine. Its title: THE BEST OF BOTH WORLDS.[1] This was followed in 2012 by an article in the JRSM where he expressed his views even more clearly.[2] Here is an excerpt: 

… By integrated medicine, I mean the kind of care that integrates the best of new technology and current knowledge with ancient wisdom. More specifically, perhaps, it is an approach to care of the patient which includes mind, body and spirit and which maximizes the potential of conventional, lifestyle and complementary approaches in the process of healing. Integrated health, on the other hand, represents an approach to individual and population health which respects and includes all health-related areas, such as the physical and social environment, education, agriculture and architecture…

… I have been attempting to suggest that it might be beneficial to develop truly integrated systems of providing health and care. That is, not simply to treat the symptoms of disease, but actively to create health and to put the patient at the heart of this process by incorporating those core human elements of mind, body and spirit…

This whole area of work – what I can only describe as an ‘integrated approach’ in the UK, or ‘integrative’ in the USA – takes what we know about appropriate conventional, lifestyle and complementary approaches and applies them to patients. I cannot help feeling that we need to be prepared to offer the patient the ‘best of all worlds’ according to a patient’s wishes, beliefs and needs. This requires modern science to understand, value and use patient perspective and belief rather than seeking to exclude them – something which, in the view of many professionals in the field, occurs too often and too readily…

Now, surely, is the time for us all to concentrate some real effort in these areas. We will need to do so by deploying approaches which, at their heart, retain the crucial bedrock elements of traditional and modern civilized health care – of empathy, compassion and the enduring values of the caring professions.

Now Charles has used the current health crisis to do it again. His new article has just been published in the RCP’s ‘Future Healthcare Journal’ [3]. Allow me to show you a crucial section from it:

For a long time, I have been an advocate of what is now called social prescription and this may just be the key to integrating the biomedical, the psychosocial and the environmental, as well as the nature of the communities within which we live and which have such an enormous impact on our health and wellbeing. In particular, I believe that social prescription can bring together the aims of the health service, local authorities, and the voluntary and volunteer sector. Biomedicine has been spectacularly successful in treating and often curing disease that was previously incurable. Yet it cannot hold all the answers, as witnessed, for instance, by the increasing incidence of long-term disease, antibiotic resistance and opiate dependence. Social prescription enables medicine to go beyond pills and procedures and to recognise the enormous health impact of the lives we lead and the physical and social environment within which we live. This is precisely why I have spent so many years trying to demonstrate the vitally important psychosocial, environmental and financial added value of genuinely, sustainable urban planning, design and construction.

There is research from University College London, for instance, which shows that you are almost three times more likely to overcome depression if you have a hobby. Social prescription enables doctors to provide their patients with a bespoke prescription that might help them at a time of need (such as advice on housing and benefits) but which may also provide them with opportunities, hope and meaning by being able to engage in a range of physical, environmental and artistic activities, which resonate with where they are in their lives. Furthermore, social prescription has the potential not only to transform our understanding of what medicine is and does, but also to change the communities in which we all live. I understand, for instance, that alongside social-prescription link workers, there are now people responsible for redesigning and increasing the capacity of the local volunteer and voluntary sector, who can help to create a new social infrastructure and eventually, one might hope, communities that make us healthier rather than making us ill.

When we hear that a quarter of 14–16-year-old girls are self-harming and almost a third of our children are overweight or obese, it should make us realise that we will have to be a bit more radical in addressing these problems. And though social prescription cannot do everything, I believe that, used imaginatively, it can begin to tackle these deep-rooted issues. As medicine starts to grapple with these wider determinants of health, I also believe that medicine will need to combine bioscience with personal beliefs, hopes, aspirations and choices.

Many patients choose to see complementary practitioners for interventions such as manipulation, acupuncture and massage. Surely in an era of personalised medicine, we need to be open-minded about the choices that patients make and embrace them where they clearly improve their ability to care for themselves? Current NHS guidelines on pain that acknowledge the role of acupuncture and mindfulness may lead, I hope, to a more fruitful discussion on the role of complementary medicine in a modern health service. I have always advocated ‘the best of both worlds’, bringing evidence-informed conventional and complementary medicine together and avoiding that gulf between them, which leads, I understand, to a substantial proportion of patients feeling that they cannot discuss complementary medicine with their doctors.

I believe it is more important than ever that we should aim for this middle ground. Only then can we escape divisions and intolerance on both sides of the conventional/complementary equation where, on the one hand, the appropriate regulation of the proven therapies of acupuncture and medical herbalism is opposed while, on the other, we find people actually opposing life-saving vaccinations. Who would have thought, for instance, that in the 21st century that there would be a significant lobby opposing vaccination, given its track record in eradicating so many terrible diseases and its current potential to protect and liberate some of the most vulnerable in our society from coronavirus?

The new article has, I think, all the hallmarks of having been written by Dr Michael Dixon (who has featured many times on this blog). Like the previous papers under Charles’ name, it is a simple ‘BAIT AND SWITCH’ affaire (Bait and switch is a morally suspect sales tactic that lures customers in with specific claims about the quality or low prices on items that turn out to be unavailable in order to upsell them on a similar, pricier item. It is considered a form of retail sales fraud, though it takes place in other contexts).

The bait, in this case, is ‘social prescribing’ (the new hobby horse of Dixon) and the switch is the good old so-called alternative medicine (SCAM). I have discussed social prescribing before, looked at the evidence, and concluded as follows:

The way I see it, it will be (and perhaps already is) used to smuggle bogus alternative therapies into the mainstream. In this way, it could turn out to serve the same purpose as did the boom in integrative/integrated medicine/healthcare: a smokescreen to incorporate treatments into medical routine which otherwise would not pass muster. If advocates of this approach, like Michael Dixon, subscribe to it, the danger of this happening is hard to deny.

The disservice to patients (and medical ethics) would then be obvious: diabetics unquestionably can benefit from a change of life-style (and to encourage them is part of good conventional medicine), but I very much doubt that they should replace their anti-diabetic medications with auto-hypnosis or other alternative therapies.

So, was I right with my prediction that social prescribing will be used to smuggle bogus alternative therapies into the mainstream?

Sadly, the answer seems to be YES.

 

REFERENCES

[1] The best of both worlds | The BMJ

[2] Hrh. Integrated health and post modern medicine. J R Soc Med. 2012 Dec;105(12):496-8. doi: 10.1258/jrsm.2012.12k095. Epub 2012 Dec 21. PMID: 23263785; PMCID: PMC3536513.

[3] HRH The Prince of Whales: A message from HRH The Prince of Wales, honorary fellow of the Royal College of Physicians. Future Healthcare Journal 2021 Vol 8, No 1: 5–7

 

PS

Charles new article has a footnote: Address for correspondence: Clarence House, London SW1A 1BA, UK

If you feel strongly about his message, please do write to him and let us know what his response is.

For some time now, I have been using the umbrella term ‘so-called alternative medicine’ (SCAM). As I explain below, I think it is relatively well-suited. But this is not to say that it is the only name for it. Many other umbrella terms have been used in the past.

Is there perhaps one that you prefer?

  • Fringe medicine is rarely used today. It denotes the fact that the treatments under this umbrella are not in the mainstream of healthcare. Some advocates seem to find the word derogatory, and therefore it is now all but abandoned.
  • Unorthodox medicine is a fairly neutral term describing the fact that medical orthodoxy tends to shun most of the treatments in question. Strictly speaking, the word is also incorrect; the correct term would be ‘heterodox medicine’.
  • Unconventional is also a neutral term but it is open to misunderstandings: any new innovation in medicine might initially be called unconventional. It is therefore less than ideal.
  • Traditional medicine describes the fact that most of the modalities in question have been around for centuries and thus have a long tradition of usage. However, as the term is sometimes also used for conventional medicine, it is confusing and far from ideal.
  • Alternative medicine is the term everyone seems to know and which is most commonly employed in non-scientific contexts. In the late 1980s, some experts pointed out that the word could give the wrong impression: most of the treatments in question are not used as a replacement but as an adjunct to conventional medicine.
  • Complementary medicine became subsequently popular based on the above consideration. It accounts for the fact that the treatments tend to be used by patients in parallel with conventional medicine.
  • Complementary and alternative medicine (CAM) describes the phenomenon that many of the treatments can be employed either as a replacement of or as an adjunct to conventional medicine.
  • Holistic medicine denotes the fact that practitioners often pride themselves to look after the whole patient – body, mind, and spirit. This could lead to the erroneous impression that conventional clinicians do not aim to practice holistically. As I have tried to explain repeatedly, any good healthcare always has been holistic. Therefore, the term is misleading, in my view.
  • Natural medicine describes the notion that many of the methods in question are natural. The term seems attractive and is therefore good for business. However, any critical analysis will show that many of the treatments in question are not truly natural. Therefore this term too is misleading.
  • Integrated medicine is currently popular and much used by Prince Charles and other enthusiasts. As we have discussed repeatedly on this blog, the term is nevertheless highly problematic.
  • Integrative medicine is the word used in the US for integrated medicine.
  • CAIM (complementary/alternative/integrative medicine) is a term that some US authors recently invented. I find this attempt to catch all the various terms in one just silly.
  • So-called alternative medicine (SCAM) is the term I tend to use. It accounts for two important facts: 1) if a treatment does not work, it cannot possibly serve as an adequate alternative; 2) if a therapy does work, it should be part of conventional medicine. Thus, there cannot be an ‘alternative medicine’, as much as there cannot be an alternative chemistry or an alternative physics.

Yet,some advocates find ‘SCAM’ derogatory. Intriguingly, my decision to use this term was inspired by Prince Charles, arguably the world’s greatest champion of this sector of healthcare. In his book ‘HARMONY’, he repeatedly speaks of ‘so-called alternative treatments’.

You don’t believe me?

Fair enough!

In this case – and in order to save you the expense of buying Charles’ book for checking – let me provide you with a direct quote: “Some so-called alternative treatments seek to work with these functions to aid recovery…” (page 225).

And who would argue that Charles is dismissive about alternative medicine?

 

 

 

I was alerted to an article in which some US doctors, including the famous Andrew Weil, promote the idea that so-called alternative medicine (SCAM) has a lot to offer for people recovering from Covid-19 infections. There would be a lot to argue about their recommendations, but today I will not go into this (I find it just too predictable how SCAM proponents try to promote SCAM on the basis of flimsy evidence; perhaps I am suffering from ‘BS for Covid fatigue’?). What did, however, strike me in their paper was a definition of INTEGRATIVE MEDICINE (IM) that I had not yet come across:

Integrative medicine is defined as healing-oriented medicine that takes account of the whole person, including all aspects of lifestyle. It emphasizes the therapeutic relationship between practitioner and patient, is informed by evidence, and makes use of all appropriate therapies.

Ever since the term IM became fashionable, there have been dozens of definitions of the term (almost as though IM proponents were not quite sure themselves what they were promoting). And ever since I first heard about IM, I felt it was a thinly disguised attempt to smuggle unproven treatments into the routine of evidence-based medicine (EBM). In 2002, I published my 1st comment on the subject. In it, I warned that IM must not become an excuse for using every conceivable untested treatment under the banner of holism. Nineteen years on, this is exactly what has happened, and one definition of IM after the next is soaked in platitudes, falsehoods and misunderstandings.

So, let’s see how reasonable this new definition is. I will try to do this by briefly discussing each element of the two sentences.

  1. IM is healing-oriented medicine: this is a transparently daft platitude. Does anyone know a medicine that is not oriented towards healing? Healing is the process of becoming well again, especially after a cut or other injury, or of making someone well again. Healing is what medicine has always been and always be aimed at. In other words, it is not something that differentiates IM from other forms of healthcare.
  2. IM takes account of the whole person: This is the little holistic trick that IM proponents like to adopt. It implies that normal medicine or EBM is not holistic. This implication is wrong. Any good medicine is holistic, and if a sector of healthcare fails to account for the whole person, we need to reform it. (Here are the conclusions of an editorial I published in 2007 entitled ‘Holistic heath care?‘: good health care is likely to be holistic but holistic health care, as it is marketed at present, is not necessarily good. The term ‘holistic’ may even be a ‘red herring’ which misleads patients. What matters most is whether or not any given approach optimally benefits the patient. This goal is best achieved with effective and safe interventions administered humanely — regardless of what label we put on them.) Creating a branch of medicine that, like IM, pretends to have a monopoly on holism can only hinder this process.
  3. IM includes all aspects of lifestyle: really, all of them? This is nonsense! Good physicians take into account the RELEVANT lifestyles of their patients. If, for instance, my patient with intermittent claudication is a postman, his condition would affect him differently from a patient who is a secretary. But all lifestyles? No! I fear this ‘over the top’ statement merely indicates that those who have conceived it have difficulties differentiating the important from the trivial.
  4. IM emphasizes the therapeutic relationship: that’s nice! But so do all other physicians (except perhaps pathologists). As medical students, we were taught how to do it, some physicians wrote books about it (remember Balint?), and many of us ran courses on the subject. Some conventional clinicians might even feel insulted by the implication that they do not emphasize the therapeutic relationship. Again, the IM brigade take an essential element of good healthcare as their monopoly. It almost seems to be a nasty habit of theirs to highjack a core element of healthcare and declare it as their invention.
  5. IM is informed by evidence: that is brilliant, finally there emerges a real difference between IM and EBM! While proper medicine is BASED on evidence, IM is merely INFORMED by it. The difference is fundamental, because it allows IM clinicians to use any un- or disproven SCAM. The evidence for homeopathy fails to show that it is effective? Never mind, IM is not evidence-based, it is evidence-informed. IM physiciance know homeopathy is a placebo therapy (if not they would be ill-informed which would make them unethical), but they nevertheless use homeopathy (try to find an IM clinic that does not offer homeopathy!), because IM is not EBM. IM is evidence-informed!
  6. IM makes use of all appropriate therapies: and the last point takes the biscuit. Are the IM fanatics honestly suggesting that conventional doctors use inappropriate therapies? Does anyone know a branch of health care where clinicians systematically employ therapies that are not appropriate? Appropriate means suitable or right for a particular situation or occasion. Are IM practitioners the only ones who use therapies that are suitable for a particular situation? This last point really does count on anyone falling for IM not to have the slightest ability to think analytically.

This short analysis confirms yet again that IM is little more than a smokescreen behind which IM advocates try to smuggle nonsense into routine healthcare. The fact that, during the last two decades, the definition constantly changed, while no half decent definition emerged suggests that they themselves don’t quite know what it is. They like moving the goal post but seem unsure in which direction. And their latest attempt to define IM indicates to me that IM advocates might not be the brightest buttons in the drawer.

As though the UK does not have plenty of organisations promoting so-called alternative medicine (SCAM)! Obviously not – because a new one is about to emerge.

In mid-January, THE COLLEGE OF MEDICINE AND INTEGRATED HEALTH (COMIH) will launch the Integrated Medicine Alliance bringing together the leaders of many complementary health organisations to provide patients, clinicians and policy makers with information on the various complementary modalities, which will be needed in a post COVID-19 world, where:

  1. patient choice is better respected,
  2. requirements for evidence of efficacy are more proportionate to the seriousness of the disease and the safety of the intervention,
  3. and where benefit versus risk are better balanced.

We already saw this in 2020 with the College advocating from the very beginning of the year that people should think about taking Vitamin D, while the National Institute for Clinical Excellence continued to say the evidence was insufficient, but the Secretary of State has now supported it being given to the vulnerable on the basis of the balance between cost, benefit and safety.

Elsewhere we learn more about the Integrated Medicine Alliance (IMA):

The IMA is a group of organisations and individuals that have been brought together for the purpose of encouraging and optimising the best use of complementary therapies alongside conventional healthcare for the benefit of all.

The idea for this group was conceived by Dr Michael Dixon in discussion with colleagues associated with the College of Medicine, and the initial meeting to convene the group was held in February 2019.

The group transitioned through a number of titles before settling on the ‘Integrated Medicine Alliance’ and began work on developing a patient leaflet and a series of information sheets on the key complementary therapies.

It was agreed that in the first instance the IMA should exist under the wing of the College of Medicine, but that in the future it may develop into a formal organisation in its own right, but inevitably maintaining a close relationship with the College of Medicine.

The IMA also offers ‘INFORMATION SHEETS’ on the following modalities:

I find those leaflets revealing. They tell us, for example that the Reiki practitioner channels universal energy through their hands to help rebalance each of the body’s energy centres, known as chakras. About homeopathy, we learn that a large corpus of evidence has accumulated which stands the most robust tests of modern science. And about naturopathy, we learn that it includes ozone therapy but is perfectly safe.

Just for the fun of it – and free of charge – let me try to place a few corrections here:

  • Reiki healers use their hands to perform what is little more than a party trick.
  • The universal energy they claim to direct does not exist.
  • The body does not have energy centres.
  • Chakras are a figment of imagination.
  • The corpus of evidence on homeopathy is by no means large.
  • The evidence is flimsy.
  • The most robust tests of modern science fail to show that homeopathy is effective beyond placebo.
  • Naturopathy is a hotchpotch of treatments most of which are neither natural nor perfectly safe.

One does wonder who writes such drivel for the COMIH, and one shudders to think what else the IMA might be up to.

Today, HRH the Prince of Wales has his 72th birthday. As every year, I send him my best wishes by dedicating an entire post to a brief, updated summary of his achievements in the area of so-called alternative medicine (SCAM).

EARLY INFLUENCE OF LAURENCE VAN DER POST

Aged 18, Charles went on a journey of ‘spiritual discovery’ into the Kalahari desert. His guide was Laurens van der Post (later discovered to be a fraud and compulsive fantasist and to have fathered a child with a 14-year old girl entrusted to him during a sea voyage). Van der Post wanted to awake Charles’ mind and attune it to the ideas of Carl Jung’s ‘collective unconscious’, and it is this belief in vitalism that provides the crucial link to SCAM: virtually every form of SCAM is based on the assumption that some sort of vital force exists. Charles was impressed with van der Post that he made him the godfather of Prince William. After Post’s death, he established an annual lecture in his honour (the lecture series was quickly discontinued after van der Post was discovered to be a fraud).

CHIROPRACTIC and OSTEOPATHY

Throughout the 1980s, Charles lobbied for the statutory regulation of chiropractors and osteopaths in the UK. In 1993, this finally became reality. To this day, these two SCAM professions are  the only ones regulated by statute in the UK.

THE BRITISH MEDICAL ASSOCIATION

In 1982, Prince Charles was elected as President of the British Medical Association (BMA) and promptly challenged the medical orthodoxy by advocating SCAM. In a speech at his inaugural dinner as President, the Prince lectured the medics: ‘Through the centuries healing has been practised by folk healers who are guided by traditional wisdom which sees illness as a disorder of the whole person, involving not only the patient’s body, but his mind, his self-image, his dependence on the physical and social environment, as well as his relation to the cosmos.’ The BMA-officials ordered a full report on alternative medicine which promptly condemned this area as implausible nonsense.

Six years later, a second report, entitled ‘Complementary Medicine – New Approaches to Good Practice’, heralded U-turn stating that: “the demand for non-conventional therapies had become so pressing that organised medicine in Britain could no longer ignore its contribution“. At the same time, however, the BMA set in motion a further chapter in the history of SCAM by insisting that it was “unacceptable” to allow the unrestricted practice of non-conventional therapies, irrespective of training or experience.

THE FOUNDATION OF INTEGRATED HEALTH

In 1993, Charles founded his lobby group which, after being re-named several times, ended up being called the ‘Foundation for Integrated Health’ (FIH). It was closed down in 2010 amidst allegations of money laundering and fraud. Its chief executive, George Gray, was later convicted and went to jail.

MOSARAF ALI

In 2001, Charles worked on plans to help build a model hospital of integrated medicine. It was to train doctors to combine conventional medicine and SCAMs, such as homeopathy, Ayurvedic medicine and acupuncture, and was to have around 100 beds. The prince’s intervention marked the culmination of years of campaigning by him for the NHS to assign a greater role to SCAM.

INTEGRATIVE MEDICINE

In 2001, Charles published an editorial in the BMJ promoting his ideas around integrative medicine. Its title: THE BEST OF BOTH WORLDS. Ever since, Charles has been internationally recognised as one of the world’s most vociferous champions of integrated medicine.

GERSON DIET

In 2004, Charles publicly supported the Gerson diet as a treatment for cancer. Prof Baum, an eminent oncologists, was invited to respond in an open letter to the British Medical Journal: ” …Over the past 20 years I have treated thousands of patients with cancer and lost some dear friends and relatives to this dreaded disease…The power of my authority comes with knowledge built on 40 years of study and 25 years of active involvement in cancer research. Your power and authority rest on an accident of birth. I don’t begrudge you that authority but I do beg you to exercise your power with extreme caution when advising patients with life-threatening diseases to embrace unproven therapies.”

THE SMALLWOOD REPORT

In 2005, the ‘Smallwood-Report’ was published; it had been commissioned by Charles and paid for by Dame Shirley Porter to inform health ministers. It stated that up to 480 million pounds could be saved, if one in 10 family doctors offered homeopathy as an “alternative” to standard drugs for asthma. Savings of up to 3.5 billion pounds could be achieved by offering spinal manipulation rather than drugs to people with back pain. Because I had commented on this report, Prince Charles’ first private secretary asked my vice chancellor to investigate the alleged indiscretion; even though I was found to be not guilty of any wrong-doing, all local support at Exeter stopped which eventually led to my early retirement.

WORLD HEALTH ORGANISATION

In a 2006 speech, Prince Charles told the World Health Organisation in Geneva that SCAM should have a more prominent place in health care and urged every country to come up with a plan to integrate conventional and alternative medicine into the mainstream. Anticipating Prince Charles’s sermon in Geneva, 13 of Britain’s most eminent physicians and scientists wrote an “Open Letter” which expressed concern over “ways in which unproven or disproved treatments are being encouraged for general use in Britain’s National Health Service.” The signatories argued that “it would be highly irresponsible to embrace any medicine as though it were a matter of principle.”

TRADITIONAL CHINESE MEDICINE (TCM)

In 2007, the People’s Republic of China recorded the visit of Fu Ying, its ambassador in London at the time, to Clarence House, and announced that the Charles had praised TCM. “He hoped that it could be included in the modern medical system . . . and was willing to make a contribution to it.”

HERBAL MEDICINE

In 2009, the Prince held talks with the health Secretary to persuade him to introduce safeguards amid a crackdown by the EU that could prevent anyone who is not a registered health practitioner from selling remedies.

In the same year, Charles urged the government to protect SCAM because “we fear that we will see a black market in herbal products”, as Dr Michael Dixon, medical director of the FIH and Charles’ advisor in SCAM, put it.

UK HEALTH POLITICS

In 2009, the health secretary wrote to the Prince suggesting a meeting on the possibility of a study on integrating SCAM in England’s NHS. The Prince had written to Burnham’s predecessor, Alan Johnson, demanding greater access to SCAM in the NHS alongside conventional medicine. Charles stated that “despite waves of invective over the years from parts of the medical and scientific establishment” he continued to lobby “because I cannot bear people suffering unnecessarily when a complementary approach could make a real difference”.

In June 2014, BBC NEWS published the following text about a BBC4 broadcast entitled ‘THE ROYAL ACTIVIST’ aired on the same day: Prince Charles has been a well-known supporter of complementary medicine. According to a… former Labour cabinet minister, Peter Hain, it was a topic they shared an interest in. He had been constantly frustrated at his inability to persuade any health ministers anywhere that that was a good idea, and so he, as he once described it to me, found me unique from this point of view, in being somebody that actually agreed with him on this, and might want to deliver it. Mr Hain added: “When I was Secretary of State for Northern Ireland in 2005-7, he was delighted when I told him that since I was running the place I could more or less do what I wanted to do. I was able to introduce a trial for complementary medicine on the NHS, and it had spectacularly good results, that people’s well-being and health was vastly improved. And when he learnt about this he was really enthusiastic and tried to persuade the Welsh government to do the same thing and the government in Whitehall to do the same thing for England, but not successfully,” added Mr Hain.

In October 2015, the Guardian obtained the infamous “black spider memos” which revealed that Charles had repeatedly lobbied politicians in favour of SCAM.

THE COLLEGE OF MEDICINE

In 2009, it was announced that the ‘College of Integrated Medicine’ (the successor of the FIH) was to have a second base in India. In 2011, Charles forged a link between ‘The College of Medicine’ and an Indian holistic health centre. The collaboration was reported to include clinical training to European and Western doctors in Ayurveda and homoeopathy and traditional forms of medicine to integrate them in their practice. The foundation stone for the extended campus of the Royal College known as the International Institution for Holistic and Integrated Medicine was laid by Dr Michael Dixon in collaboration with the Royal College of Medicine.

In 2020, Charles became the patron of the College of Medicine which, by then, had re-christened itself ‘College of Medicine and Integrated Health’. The College chair, Michael Dixon, was quoted stating: ‘This is a great honour and will support us as an organisation committed to taking medicine beyond drugs and procedures. This generous royal endorsement will enable us to be ever more ambitious in our mission to achieve a more compassionate and sustainable health service.”

DUTCHY ORIGINALS DETOX TINCTURE

In 2011, after the launch of Charles’ range of herbal tinctures, I had the audacity to publicly criticise Charles for selling the Duchy Herbals detox tincture which I named ‘Dodgy Originals Detox Tincture’.

ANTIBIOTIC OVERUSE

In 2016, speaking at a global leaders summit on antimicrobial resistance, Prince Charles warned that Britain faced a “potentially disastrous scenario” because of the “overuse and abuse” of antibiotics. The Prince explained that he had switched to organic farming on his estates because of the growing threat from antibiotic resistance and now treats his cattle with homeopathic remedies rather than conventional medication. As some of you may be aware, this issue has been a long-standing and acute concern to me,” he told delegates from 20 countries “I have enormous sympathy for those engaged in the vital task of ensuring that, as the world population continues to increase unsustainably and travel becomes easier, antibiotics retain their availability to overcome disease… It must be incredibly frustrating to witness the fact that antibiotics have too often simply acted as a substitute for basic hygiene, or as it would seem, a way of placating a patient who has a viral infection or who actually needs little more than patience to allow a minor bacterial infection to resolve itself.”

DUMFRIES HOUSE

In 2017, Charles declared that he will open a centre for SCAM in the recently purchased Dumfries House in Scotland. Currently, the College of Medicine and Integrated Health is offering two-day Foundation Courses at this iconic location. Gabriel Chiu, a US celebrity cosmetic and reconstructive surgeon, and his wife Christine, joined the Prince of Wales as he opened the integrated health and wellbeing centre on the Dumfries House Estate in East Ayrshire in 2019. As he unveiled a plaque, Prince Charles said: “I’m so glad that all of you have been able to get here today, particularly because I could not be more proud to see the opening of this new integrated health centre at Dumfries House. It’s something I’ve been wanting to do for the last 35 years. I’m also so proud of all the team at Dumfries House who built it, an all in-house team.”

HOMEOPATHY

Generations of royals have favoured homeopathy, and allegedly it is because of this influence that homeopathy became part of the NHS in 1948. Homeopathy has also been at the core of Charles’ obsession with SCAM from its beginning. In 2017, ‘Country News’ published an article about our heir to the throne stating that Prince of Wales has revealed he uses homeopathic treatments for animals on his organic farm at Highgrove to help reduce reliance on antibiotics, the article stated. He said his methods of farming tried wherever possible to ‘‘go with the grain of nature’’ to avoid dependency on antibiotics, pesticides and other forms of chemical intervention.

In the same year, it was revealed that UK farmers were being taught how to treat their livestock with homeopathy “by kind permission of His Royal Highness, The Prince Of Wales

In 2019, the Faculty of Homeopathy announced that His Royal Highness The Prince of Wales had accepted to become Patron of the Faculty of Homeopathy. Dr Gary Smyth, President of the Faculty of Homeopathy commented, “As the Faculty celebrates its 175th anniversary this year, it is an enormous honour for us to receive the Patronage of His Royal Highness The Prince of Wales and I am delighted to announce this news today.” Charles’ move amazed observers who saw it as a deliberate protest against the discontinuation of reimbursement of homeopathy by the NHS.

In 2020, Charles fell ill with the corona-virus and happily made a swift recovery. It was widely reported that his recovery was due to homeopathy, a notion denied by Clarence House.

_______________________

Happy Birthday Charles

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