An SBM Advocate Goes To Washington

Last week I was invited to be involved in a roundtable discussion for a US senate committee on healthcare. This was a closed session without reporters, so I don’t feel at liberty to discuss details, but it did help crystalize for me the current thoughts and strategies of those promoting complementary and alternative medicine (CAM). I can give my overall impressions of where I think we are, partly informed by my recent experience.

Alternative, No – Complementary, No – Integrative

CAM proponents use a lot of bait-and-switch or what David Gorski has dubbed “Trojan Horse” strategies to push their treatments. Interestingly, it’s mostly the same exact treatments that have been around for 50 years or more. When we talk of CAM we are still mostly referring to homeopathy, acupuncture, chiropractic manipulation, energy medicine, and herbal medicine. There are branding tweaks, or new versions of these things, but the core concepts are the same. It doesn’t matter if you call them alternative, complementary, or integrative. It’s the same stuff.

The evolution of the branding, however, is to reassure those who care about things such as the standard of care in medicine that they will not be replacing proven therapies, and are offered in addition to them. First, this is never entirely true. If a CAM method is being placed somewhere in the hierarchy of treatments, then it is displacing or delaying non-CAM therapies. Also, health care is often resource limited. If a patient is availing themselves of acupuncture, that is using up their limited resources of time and health-care dollars. Proper treatment trials should also be done one at a time, or else you can’t know what is working. So while you are trying acupuncture (or whatever) you may not be doing the next thing.

Further, the very concept of “integrative” medicine is flawed to its core. What, exactly, are they integrating into what? Try to answer this question without just referring to euphemisms – no alternative or complementary methods, traditional, non-mainstream, etc. None of these really work, nor can they be operationally defined. If, for example, you define it as integrating non-mainstream methods into mainstream medicine, that provokes the question of why they are non-mainstream in the first place. And also – there already is a mechanism for that. It’s called science and evidence. The implication is that we should be integrating methods based on something other than the best available science. And once they are integrated, wouldn’t that then make them mainstream? So then what are they?

All of this rhetorical dancing is to avoid the obvious answer – integrative medicine is all about creating a double standard (legally, academically, professionally) so that treatments and methods that are below the line of scientific medicine can be integrated with those that are above the line. That’s it, and the laws that are pushed to promote CAM explicitly carve out this double standard.

Integrative medicine is preventive medicine/health promotion

This is the most annoying aspect of the CAM propaganda – the retconning of CAM into preventive medicine. This is nothing short of gaslighting. The first piece of this strategy is to slander mainstream medicine by saying it is not about disease prevention, only disease intervention. This is not to say we do a perfect job sufficiently emphasizing prevention. Healthcare is complex, it is very difficult to get people to change their habits, and we do nothing perfectly. But this does not mean we don’t do prevention or that CAM providers are better at it.

Most primary care is about disease prevention and health promotion. This is all science based – good nutrition, sleep hygiene, exercise, taking aspirin for vascular prevention, treating high blood pressure, lowering cholesterol, smoking cessation, etc. The amount of research being done on preventive strategies and slowly being integrated into the standard of practice is staggering. And it’s all mainstream science-based medicine. None of the CAM modalities I listed above have any preventive value (or arguably, any value).

But this line is rhetorically very powerful. If they can slip in this equivalency, then they have already won. To further support this approach CAM proponents are very liberal in defining what is CAM. They would love to include all nutrition and exercise – but again, this is anti-historical gaslighting.

Part of this complete breakfast

I believe I was the first one here to use this reference, because it is perfect for what is happening. Remember the old commercials where something like a breakfast pastry was shown next to orange juice, eggs, fruit, and toast and said to be “part of this complete breakfast”. Even as a child I saw through this scam – sure, it may be part of that breakfast, but it’s an irrelevant part.

Good science-based medicine should endeavor to isolate variables as much as possible. That is what the entire placebo-controlled trial is about. We cannot make causal conclusion unless the variable of interest is isolated. The problem for CAM proponents is that when you properly isolate the variable that is at the core of their treatment, it doesn’t work. After thousands of clinical trials, for example, acupuncture researchers still have not been able to demonstrate scientifically that acupuncture points mean anything. They do not appear to exist – their own research concludes this. Similarly, there is no “life energy” behind energy medicine, subluxation theory has been essentially disproven, and the principles of homeopathy are demonstrable nonsense.

The ideas and claims at the heart of these CAM methods have never been scientifically demonstrated, and go against pretty much all of modern biology, physiology, biochemistry, and even sometimes the laws of physics. So what’s a CAM proponent to do? One approach is to simply never isolate these core variables in a clinical study. Mix in a bunch of interventions that are almost guaranteed to be helpful (tracking nutrition, health coaching, sleep hygiene, compliance monitoring) and then claim that the CAM treatment “worked”. Or simply, don’t properly blind the study. That way you can claim that non-specific placebo effects are evidence that the treatment works. One way to do this is pragmatic studies, looking at real-world use. But these studies cannot be used to make efficacy claims – for the reasons stated, they are not blinded and don’t isolate variables. Pragmatic studies should only be done on treatments that have already demonstrated efficacy.

Appeal to anecdote

I almost always hear the phrase, “I have seen it work in my practice” from CAM proponents justifying their non-science based interventions. Of course, this is anecdotal, it means close to nothing. Anecdotal evidence leads us to the conclusions we want to be true (quoting Barry Beyerstein), not the truth. Legions of patients swore by all kinds of nonsensical treatments throughout history, that we now know to be nothing but snake oil.

The appeal to anecdote can also sometime be camouflaged with euphemisms. We see this treatment working individually, even if it cannot be demonstrated with group level data. Translation – this treatment does not work when studied scientifically, so I am going to refer to anecdotes instead.

This approach can be further obscured by referring to individualized or personalized medicine. These sound good, because they are, but the problem is – you should not be individualizing treatments that have no proven efficacy. When I give a patient a treatment trial, I give them something that has been proven statistically to work, and then I see if it works in them (you still never really know, you can only know the statistics). What you cannot do is use individual level data as if it were evidence for efficacy.

Oh, yeah!

One final strategy is to say that, well, mainstream medicine is not all evidence-based either. This is actually a complex question, and not statement like this can fairly capture that complexity. In scientific medicine we use a hierarchy of evidence, starting with the most evidence based treatments (individualized by history, comorbidities, and priorities), and then proceed from there as necessary. At the same time we are trying to improve the evidence base for everything we do. The vast majority of day-to-day medical practice is solidly evidence-based, but we don’t have proven treatments for everything, so we often have to make do with less-than definitive evidence.

However, there is a line we should not go below. We should not use treatments that have been adequately demonstrated to be harmful or worthless. We should also not use treatments that have no evidence to support their use and have a prior probability of close to zero. We also should not use treatments that have been studied for decades without being able to prove specific efficacy, and just pretend these are still experimental.

This also gets us back to my first point – the goal of scientific medicine it to improve the base of scientific evidence for medicine, to improve the standard of care, and to increase the effectiveness of translating evidence into best practice. Yes, medicine is not perfect. But like all sciences, it is self-correcting. While there is a major movement within medicine to constantly tweak and improve the scientific base, there is a simultaneous movement that seeks to carve out a double standard that explicitly lowers the standard of evidence, of science, and even of ethics within medicine.

At the end of the day, the CAM movement is all about integrating old, unscientific, failed treatments into modern medicine. Everything else is distraction.