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

social prescribing

In recent weeks, I have been thinking a lot about ‘INTEGRATIVE MEDICINE‘. Skeptics mostly see it as a way of smuggling quackery into conventional healthcare. This is undoubtedly true and important. But it occurred to me that there also is a somewhat different perspective that has so far been neglected. Let me try to explain by recounting a story. It is fictive, of course, but the fiction is based on the observation of many cases during previous decades.

The story is about a doctor – let’s call him George – who, to be frank, is not the most gifted of his colleagues. Already at medical school, he was not as dedicated as his teachers would have hoped. In fact, medicine had not been his first choice at all. Yet he ended up as a general practitioner and eventually became a partner in a practice with 5 GPs.

Over the years, it became clear that George lacked something to be a good doctor. He knew his stuff, alright, got most of the diagnoses correct, and made not too many mistakes. But something was not quite right. One could say that, relative to his colleagues, he lacked kindness, dedication, compassion, and empathy. He often found it unnecessary to respect his patients. Sometimes, he even joked about them and about what he perceived as their stupidity.

If we view medicine as being both a science and an art, one might conclude that George was just about alright with the science but notably deficient in the art of healthcare. Most of his patients were aware that something was amiss; many even avoided him and tried to consult one of his colleagues instead. On more than one occasion, patients had told George that they were disappointed with his attitude. Some had even told him to the face that he lacked kindness. Such conversations made George think. He had to admit to himself that his colleagues were better at building good relationships with their patients. Eventually, George decided that something ought to change.

As it happened, George’s wife had a friend who was a Reiki healer. One day, he asked the healer – let’s call her Liz – whether she would like to try working alongside the GPs in his practice. Liz was delighted and accepted. George did not believe for a minute that Reiki was more than hocus-pocus, but he knew that Liz was kind and had loads of the compassion that he was so obviously lacking.

Hence force George and Liz formed a team: George looked after his patients the best he could and whenever he felt that more empathy and compassion were required, he would send the patient to Liz. This partnership changed everything. The patients were content, George was happy, and Liz was beaming.

As some patients frowned at the idea of Reiki, George soon recruited an aromatherapist as well. After that, a lay homeopath and a reflexologist were employed. George’s GP partners (who made little use of the alternative practitioners) were sure that none of these therapies had any specific effects (incidentally, a belief not shared by the practitioners in question who felt they were doing wonders). But for George, the therapists clearly did supplement his limited interpersonal skills. Patients were delighted and the GP practice began to thrive. As for George, he became an increasingly outspoken and prominent advocate of INTEGRATED MEDICINE. The fact that there was no evidence to support it did hardly matter to him; what counted was that it rendered his own incompetence less visible.

About a year later, George convinced his slightly bewildered partners to rename their practice ‘THE INTEGRATIVE HEALTH CENTRE’.

End of story

In case you did not get my point, let me make it more bluntly: INTEGRATIVE MEDICINE can be a way for some doctors to delegate the art of medicine to quacks. Good doctors don’t need to do this because they are able to show compassion and treat their patients as whole human beings. Less gifted doctors, however, find INTEGRATIVE MEDICINE a practical solution to their own incompetence.

So, is INTEGRATIVE MEDICINE a good compromise then?

No, certainly not!

The last thing we need in healthcare is for doctors to start delegating the art of medicine to others. It would be a serious mistake, nothing less than abandoning the core values of medicine to charlatans.

But what is the solution?

Obviously, it is to make sure all doctors are competent. We need to select medical students adequately, tell them much more about the importance of kindness, compassion, empathy, holism, etc., and teach them how to show and use these qualities. We need to train doctors to be competent in both the science and the art of medicine. This has to begin in medical school and must continue throughout their professional career. We need to make sure that doctors like George understand the message; if they prove to be unable to do so, we should direct them to professions where compassion is not essential.

The worst solution we can possibly envisage is to allow charlatans to cover up the incompetence of people like George and call it INTEGRATED MEDICINE.

 

In a previous post, I reported about the ‘biggest ever’, ‘history-making’ conference on integrative medicine. It turns out that it was opened by none other than Prince Charles. Here is what the EXPRESS reported about his opening speech:

Opening the conference, Charles said:

“I know a few people have seen this integrated approach as being in some way opposed to modern medicine. It isn’t. But we need to combine this with a personal approach that also takes account of our beliefs, hopes, culture and history. It builds upon the abilities of our minds and bodies to heal, and to live healthy lives by improving diet and lifestyle.”

Dr. Michael Dixon, Chair of the College of Medicine, said:

“Medicine, as we know it, is no longer affordable or sustainable. Nor is it able to curb the increase in obesity, mental health problems and most long-term diseases. A new medical mindset is needed, which goes to the heart of true healthcare. The advantages and possibilities of social prescription are limitless. An adjustment to the system now will provide a long-term, sustainable solution for the NHS to meet the ever-increasing demand for funding and healthcare professionals.”

_______________________

Charles very kindly acknowledges that not everyone is convinced about his concept of integrated/integrative medicine. Good point your royal highness! But I fear Charles did not quite understand our objections. In a nutshell: it is not possible to cure the many ills of conventional medicine by adding unproven and disproven therapies to it. In fact, it distracts from our duty to constantly improve conventional medicine. And pretending it is all about diet and lifestyle is simply not true (see below). Moreover, it is disingenuous to pretend that diet and lifestyle do not belong to conventional healthcare.

Dr. Dixon’s concern about the affordability of medicine is, of course, justified. But the notion that “the advantages and possibilities of social prescription are limitless” is a case of severe proctophasia, and so is Dixon’s platitude about ‘adjusting the system’. His promotion of treatments like AcupunctureAlexander TechniqueAromatherapyHerbal Medicine, Homeopathy, Hypnotherapy, Massage, Naturopathy, Reflexology, Reiki, Tai Chi, Yoga Therapy will not adjust anything, it will only make healthcare less efficient.

I do not doubt for a minute that doctors are prescribing too many drugs and that we could save huge amounts by reminding patients that they are responsible for their own health while teaching them how to improve it without pills. This is what we learn in medical school! All we need to do is remind everyone concerned. In fact, Charles and his advisor, Michael, could be most helpful in achieving this – but not by promoting a weird branch of healthcare (integrative/integrated medicine or whatever other names they choose to give it) that can only distract from the important task at hand.

Today, a 3-day conference is starting on ‘INTEGRATIVE MEDICINE’ (IM) in London. Dr. Michael Dixon, claims that it is going to be the biggest such conference ever and said that it ‘will make history’. Dixon is an advisor to Prince Charles, chair of the College of Medicine and Integrated Health (CoMIH, of which Charles is a patron), and joint-chair of the congress. The other co-chair is Elizabeth Thompson. Both have been the subject of several previous posts on this blog.

Dixon advertised the conference by commenting: “I am seeing amongst by younger colleagues, the newly trained GPs, that they have a new attitude towards healthcare. They are not interested in whether something is viewed as conventional, complementary, functional or lifestyle, they are just looking at what works for their patients.  Through this conference, we aim to capture that sense of hope, open-mindedness, and patient-centred care”. I believe that this ‘history-making’ event is a good occasion to yet again review the concept of IM.

The term IM sounds appealing, yet it is also confusing and misleading. The confusion starts with the fact that our American friends call it integrative medicine, while we in the UK normally call it integrated medicine, and it ends with different people understanding different things by IM. In conventional healthcare, for instance, people use the term to mean the integration of social and medical care. In the bizarre world of alternative medicine, IM is currently used to signify the parallel use of alternative and conventional therapies on an equal footing.

Today, there are many different definitions of the latter version of IM. Prince Charles, one of the world’s most ardent supporter of IM, used to simply call it ‘the best of both worlds’. A recent, more detailed definition is a ‘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’. This seems to imply that conventional medicine is not healing-orientated, does not account for the whole person, excludes aspects of lifestyle, neglects the therapeutic relationship, is not informed by evidence, and does not employ all appropriate therapies. This, I would argue is a bonanza of strawman fallacies, i.e. the misrepresentation of an opponent’s qualities with a view of defeating him more easily and making one’s own position look superior. Perhaps this is unsurprising – after all, Dixon has been once named ‘a pyromaniac in a field of (integrative) strawmen’.

Perhaps definitions are too theoretical and it is more productive to look at what IM stands for in real life. If you surf the Internet, you can find thousands of clinics that carry the name IM. It will take you just minutes to discover that there is not a single alternative therapy, however ridiculous, that they don’t offer. What is more, there is evidence to show that doctors who are into IM are also often against public health measures such as vaccinations.

The UK ‘Integrated Medicine Alliance’, a grouping within the CoMIH, offers information sheets on all of the following treatments: Acupuncture, Alexander Technique, Aromatherapy, Herbal Medicine, Homeopathy, Hypnotherapy, Massage, ,Naturopathy, Reflexology, Reiki, Tai Chi, Yoga Therapy. The one on homeopathy, for example, tells us that “homeopathy … can be used for almost any condition either alone or in a complementary manner.” Compare this to what the NHS says about it: “homeopathic remedies perform no better than placebos (dummy treatments)”.

This evidently grates with the politically correct definition above: IM is not well-informed about the evidence, and it does use inappropriate treatments. In fact, it is little more than a clumsy attempt to smuggle unproven and disproven alternative therapies into the mainstream of healthcare. It does render medicine not better but will inevitably make it worse, and this is surely not in the best interest of vulnerable patients who, I would argue, have a right to be treated with the most effective therapies currently available.

The conference can perhaps be characterized best by having a look at its sponsors. ‘Gold sponsor’ is WELEDA, and amongst the many further funders of the meeting are several other manufacturers of mistletoe medications for cancer. I just hope that the speakers at this meeting – Dixon has managed to persuade several reputable UK contributors – do not feel too embarrassed when they pass their exhibitions.

 

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.

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