The Bravewell Collabortive is a private organization whose stated mission is to, “accelerate the adoption of integrative medicine within the health care system.” They are well-funded, and they have successfully used their money to advance their mission. They also now appear to be an effective propaganda machine, producing what they are calling a “landmark report” on the use of integrative medicine in the US. The report is indeed revealing, but perhaps not in the way Bravewell intends.
The report is simply a survey of 29 integrative centers in the US. Before presenting the major findings the report defines “integrative medicine:”
“an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual, and environmental influences that affect a person’s health. Employing a personalized strategy that considers the patient’s unique conditions, needs, and circumstances, it uses the most appropriate interventions from an array of scientific disciplines to heal illness and disease and help people regain and maintain optimum health.”
This is the standard marketing propaganda, which we have dissected many times before (so one more time won’t hurt). It is important to note that this is not a legitimate philosophy or approach to medicine, but pure marketing hype with the purpose of rebranding medical pseudoscience and quackery. There is a growing list of terms used for this rebranding – first “alternative” or “holistic” then “complementary” now “integrative”, “personalized”, and “patient-centered.” It’s the same nonsense, only the labels have evolved (market-tested, if you will).
The report first equates integrative medicine with patient-centered medicine. This is a false dichotomy based upon a straw-man vision of science-based medicine. Medical ethics places the patient at the center of health care and all health care decisions. The physician is ethically obligated to be an advocate of their patient first and foremost. Further, the modern (meaning in the last half-century) model of medicine is to treat the patient as a partner in their own health care (replacing the older paternalistic model). This was a process, of course, not a sudden change.
As part of that process, and the cultural evolution of the physician-patient relationship, the term “patient-centered care” was used within the medical literature to describe this change – centering decision-making more on the patient. It was a shaking off of the last vestiges of paternalism in medicine (at least within the standard of practice, if not ideally achieved by all practitioners). The integrative movement then co-opted this term and made it their own, as if they invented it, and then ironically accused mainstream medicine (who invented the idea and the term) of not being patient-centered. You will see this pattern repeated.
The next bit of propaganda is the description of holistic care (without using the term – I guess it’s not market-testing as well these days). This too is a fiction. In the 1980s I was taught in medical school about the biopsychosocial model of medicine – taking into account not just the biological illness but the social and cultural factors in which it is embedded, and the patient’s psychological response to their illness and the patient-physician relationship. This has been part of my training and practice from my first day in medical school. So I have always found it frustratingly odd that the integrative movement has (successfully, unfortunately) claimed that they invented this notion and that mainstream medicine is not “holistic”. We have argued on SBM (persuasively, I think) that science-based medicine is much more holistic than most “integrative” medical practices. We actually consider the patient’s biology, psychology, and social situation, whereas most alternative treatments are based upon a very narrow philosophy of all disease. They are the antithesis of holistic.
The tricky item of the integrative holistic list is “spiritual.” Mainstream medicine does consider the beliefs of the patient, and often must accommodate them in deciding on appropriate treatments. However – medical ethics dictates that we do not impose any religious belief onto our patients, neither are we judgmental. To our patients we are neutral on matters of faith, but can certainly be supportive of our patient’s use of faith as a support structure for dealing with their illness. In alternative medicine circles, however, “spiritual” can mean “faith healing” or its equivalent – actually treating the patient’s spirit or “energy”. This is not medicine – this is spiritualism and religion.
Next they throw in the “personalized” marketing term. Again, this is not a concept that is new to the integrative medicine movement. Regular science-based medicine is “individualized” (the term for what Bravewell and others now call “personalized”). The reason we take an elaborate history and perform a physical exam, followed by specific laboratory tests, is to individualize the diagnosis and treatment of each patient. There has been, in fact, a continuous evidence-based effort to more and more individualize treatments for patients, according to their age, sex, and genetic background. I often individualize treatment strategies to a patient’s educational level and socioeconomic status. This is just another false-dichotomy, another rebranding of ordinary medicine as a special feature of “integrative” medicine. It is just more marketing fiction and propaganda.
Next we get to the core fiction of integrative medicine, that it “uses the most appropriate interventions from an array of scientific disciplines.” That, of course, is a description of mainstream medicine. We use any intervention that is science-based – that has an appropriate combination of plausibility and direct evidence for safety and efficacy. Integrative medicine, rather, is the mixing of appropriate science-based interventions with treatments that are not science-based, that are highly implausible, or have been shown to not work. Otherwise they would already be part of medicine.
So what is integrative medicine? When you strip away the rebranding and co-opting of features and treatments of mainstream medicine, you are left with the usual list of pseudoscientific practices that have been trying to insert themselves into mainstream medicine for decades through a series of marketing and propaganda strategies. Bravewell has positioned itself at the forefront of that effort.
The body of the report I found to be almost entirely uninteresting and predictable – integrative centers are using integrative medicine and they feel (of course) that it works. Wow. The one bit I did find interesting was the list, in descending order, of the “integrative” methods these centers use:
First we see another rebranding – calling nutrition integrative or alternative. We have pointed out numerous times on SBM that nutrition is a medical science. It is already part of mainstream medicine, and it is mainstream medical researchers who have figured out everything we currently know about the role of nutrition in health and disease. This is just one more thing that the integrative movement has tried to steal (metaphorically) from mainstream medicine to make part of its brand.
Two items on the list, supplements and TCM/acupuncture, are methods that do not work but have been the most successful in being marketed to the public. A thorough exploration of these modalities is beyond the scope of this article, but you can find numerous articles on SBM demonstrating the lack of an evidence based for the most popular herbal supplements and for acupuncture, for any indication.
Yoga, meditation, and massage are essentially exercise, stress-reduction, and relaxation – all things commonly used and recommended by science-based practitioners. There is no evidence to support the notion that there is anything special about these particular manifestations of exercise, stress reduction, and relaxation. Most studies of Yoga, for example, have no comparison group to other forms of stretching and exercise. The implication is that there is something special or magical about transcendental meditation, for example, or Tai Chi, or specific forms of massage – again without evidence. There is no evidence that charging patients for a consultation with a specialist in one of these treatments is any more effective than just telling them to get more exercise – do something convenient and enjoyable.
About the only kernel of utility in this approach is that it may foster compliance with lifestyle changes. I say “may” because evidence is lacking for this as well. And again – there are already voices within mainstream medicine teaching a greater emphasis on patient education to foster compliance with lifestyle changes. Doctors are admittedly not very effective in changing patient behaviors, but that is because nothing is. It is very difficult to change behavior, and “integrative” practitioners have not hit upon any magical way to do so. They simply point out how bad mainstream medicine is, without acknowledging the fact that every studied method of changing lifestyle behaviors has a poor success rate. Even those that tout their success are just incrementally better than simply advising patients to quit smoking, exercise more, or lose weight.
What we need is to continue to experiment and research – to use science to figure out how to more effectively improve health behaviors in the public. Of course, if scientific research ever does develop a really effective method the integrative movement (or whatever it’s calling itself at that time) is likely to steal it and pretend that they invented it, then turn around and criticize mainstream doctors for not using it.
At the bottom of the list is pharmaceuticals. This does, perhaps, distinguish the integrative approach from some alternative approaches that are more purist in their pseudoscience. A homeopath, for example, uses only homeopathy. This appears to be a general trend with alternative practice, however. Naturopaths, for example, are fighting in many states and in Canada to get the right to prescribe actual medicine. This way they get to practice real medicine and then charge for a lot of extra stuff that is either worthless or just an expensive version of a simple healthy lifestyle. It’s quite a racket.
At the end of the report, under the category “next steps,” they write:
Providing funding for analysis of these data, which could provide important information about the efficacy of integrative medicine approaches as well as the treatment of chronic health conditions, should be a priority for funding sources and institutions.
Let me translate that for you, in the context of the whole report: Isn’t it wonderful that integrative medicine methods are being used, now let’s go see if they actually work. If there is anything that defines alternative, complementary, integrative medicine it’s putting practice before evidence. In fact, the evidence is irrelevant to practice. Practice is philosophy-based, not science-based. Evidence is an obstacle, used only for marketing purposes, not for determining which treatments are effective. That is why they keep trying to redefine scientific evidence in medicine. They need science to change to accommodate their treatments, not conform treatments to the science.
In my opinion the Bravewell Collaborative is a force for pushing pseudoscience and nonsense into mainstream medicine. This report reflects that reality.