PRELUDE
Once upon a time, there was quackery.
Long ago, back in the mists of time before many of our current readers were even born and far back in the memory of even our wizened elders of medicine, “quackery” was the preferred term used to refer to ineffective and potentially harmful medical practices not supported by evidence. Physicians, having a grounding in science and prior plausibility, for the most part understood that modalities such as homeopathy, reflexology, and various “energy healing” (i.e., faith healing) methodologies were based either on prescientific vitalism, magical thinking, and/or science that was at best incorrect or at the very least grossly distorted. More importantly, physicians weren’t afraid to call quackery quackery, quacks quacks, and charlatans charlatans.
Not surprisingly, quacks and charlatans did not like this.
Then, a few decades ago, most likely beginning in the 1960s and 1970s, supporters of quackery decided that they would never get anywhere selling their products, except to a small minority of people, if they continued to allow physicians to define their favorite quackery as being…well, quackery. To change this, they joined with physicians whose scientific rigor could best be described as…questionable. Together, these practitioners of pseudoscience and the credulous physicians smitten with the romance of that pseudoscience decided that a new term was needed, a more soothing, reassuring term, a term that was not so derogatory. As a consequence, the term “quackery” somehow morphed into “alternative medicine.” Alternative medicine was (and, when the term is used, still is) medicine that does not fit into the current scientific paradigm, a term used to describe medical practices that were not supported by evidence, were ineffective and potentially harmful, and were used instead of effective therapies. Physicians understood that modalities such as homeopathy, reflexology and various “energy healing” (i.e., faith healing) methodologies were based either on prescientific vitalism, magical thinking, and/or on science that was at best incorrect or grossly distorted. More importantly, they weren’t afraid to say so.
Although practitioners of alternative medicine liked this term better than the terms “quackery” and “quacks,” they were, not surprisingly, still not satisfied.
That’s why, sometime lost in the mists of time of the 1990s, alternative medicine practitioners (i.e., quacks) decided that they would never get anywhere selling their products, outside of a small minority of people, if they themselves defined their very own products as somehow being outside the mainstream of scientific medicine by calling them “alternative.” Such was not the way to win friends, influence people, and, above all, become (or at least seem) respectable. Thus was born the term “complementary and alternative medicine,” which had the nice, pithy abbreviation of “CAM.”
CAM was (and is) medicine that does not fit into the current scientific paradigm, including treatments that are not supported by evidence and are ineffective and/or potentially harmful. The difference? CAM therapies are used in addition to real medicine. Over a relatively brief period of time, the name change had its intended effect. No longer did many physicians automatically view modalities that were once considered quackery, later considered “alternative,” and now considered “CAM” as quackery, and those that still did were dismissed as close-minded, stubborn, and dogmatic, relics who were trying to swim against the coming wave of wonderful CAM magic. Modalities such as homeopathy, reiki, various energy healing methods, and even reflexology were no longer reflexively (sorry, couldn’t help it) dismissed. Despite several of them (especially homeopathy and the various energy healing modalities) violating known laws of physics and requiring that our understanding of physics be not just wrong, but spectacularly wrong, for them to work, somehow methodolatrists preaching “evidence-based medicine,” valuing randomized, double-blind, placebo-controlled trials above all else even when physics, chemistry, and common sense should tell them that a treatment (such as homeopathy) cannot work, allowed the background noise of clinical research caused by the occasional false positive clinical trial to convince them that there might be something to these modalities. Also, by using their former quackery in addition (i.e., as complementary) to real medicine, CAM practitioners (mostly) neutered the biggest complaint about alternative medicine, namely the concern that patients forego effective therapy in order to pursue alternative medicine. Meanwhile, many physicians who might have in the past opposed the infiltration of such quackery/alternative/CAM therapies turned into shruggies and no longer cared enough to speak out. The stage was set for the widespread adoption of CAM by medical schools.
And CAM practitioners did declare that this was indeed good–but not good enough.
That’s why CAM advocates, even though they had made huge inroads introducing quackademic medicine into medical schools and academic medical centers, bolstered by the influence of the National Center for Complementary and Alternative Medicine (NCCAM) and the Bravewell Collaborative, an organization founded by Christy Mack, the wife of a wealthy investment banker, for the express purpose of promoting the study and use of CAM in medical academia, decided that even their remarkable success was not good enough. Thus was born in recent years a new term for CAM. CAM practitioners (formerly alternative medicine practitioners, formerly quacks) hit upon the perfect term for their treatments. It is a term so media-friendly, so seemingly reasonable that it is a wonder that no one had thought of it before.
“Integrative medicine.”
No longer were CAM practitioners content to have their favorite quackery be “complementary” to real medicine. After all, “complementary” implied a subsidiary position. Medicine was the cake, and their wares were just the icing. That wasn’t good enough. They craved respect. They wanted to be co-equals with physicians and science- and evidence-based medicine. The term “integrative medicine” (IM) served their purpose perfectly. No longer were their treatments merely “complementary” to real medicine. Oh, no. Now they were “integrating” their treatments with those of science- and evidence-based medicine! The implication, the very, very, very intentional implication, was that alternative medicine was co-equal to science- and evidence-based medicine, an equal partner in the “integrating.”
And to IM practitioners, it was very good indeed. Quackery had successfully infiltrated scientific medicine to such an extent that it could metastasize everywhere.
It’s all about the branding
No doubt, there will be some who proclaim my little introduction above to be too “harsh.” Too “strident,” even. Not nearly diplomatic or “respectful” enough. So be it. My narrative has the advantage of being largely true, and only mildly exaggerated for (I hope) dramatic effect. The terms “CAM” and “integrative medicine” are not serious, sober names for a serious, sober, science-based specialty. They are about the branding of quackery. They have always been about the branding of quackery. They are about double standards whereby treatments that can’t pass scientific muster are admitted to the “club” of science-based medicine under lowered standards. I frequently repeat a cliche, but just because it’s become a cliche does not make it untrue. There is no such thing as “alternative” medicine. There is medicine that has been proven safe and effective through science; there is medicine that has not; and there as medicine that has been proven unsafe and/or ineffective through science. Whatever you call it, “alternative,” “CAM,” or “integrative” medicine, when medicine, whatever its source, is demonstrated to be safe and effective through science, it ceases to be “alternative” or “complementary.” It becomes simply “medicine” and is automatically integrated into the current armamentarium of medicine, no special name needed, no special consideration needed to provide a lower standard of evidence.
If you have any doubt that the term “integrative medicine” is all about the branding, I present to you a couple of examples. First, here’s Mark Stoiber on both that wretched hive of scum and quackery, The Huffington Post asking Who Will Own the Brand of Integrative Medicine? His post is mirrored on his own blog as well. In this post, Stoiber, who is an advertising talent who describes himself as “creative director, entrepreneur, green brand specialist and writer,” describes a model of “integrative medicine” pharmacies that stock everything from real medicine to fake medicine (i.e., homeopathic remedies). In this case, he is talking about “integrating” pharmacies with the “vitamin shop model” and the “natural remedies” model, using the Pharmaca pharmacy chain as an example:
Pharmaca has demonstrated the market power of this common sense, scaling from one pharmacy in Boulder to 23 stores in Colorado, New Mexico, California, Oregon and Washington State.
Panzer attributes the success not to stocking shelves with products running the gamut from conventional pharma to natural remedies and homeopathy. Instead, it’s about creating crossover expertise.
The common US model is one pharmacist, and a bunch of clerks stocking shelves. In our case, we have the highly trained pharmacist, but also highly skilled practitioners with homeopathic or naturopathic backgrounds. No one expert has the full answer. Instead, we collaborate to offer our customers a more holistic approach to managing their health.
Stoiber then cites another advocate of “integrative” pharmacy:
Speaking with Bob Mehr, President of Pure Pharmacy in Vancouver, the importance of evidence-based remedies becomes apparent.
Up to now, there’s been a polarization between advocates of traditional and conventional pharmacy. We believe the way forward lies in using treatments that are backed by evidence, regardless of their origin.
Mehr says the only path to mass-market acceptance of integrative medicine will be with evidence. “I want to get rid of the whole east meets west stereotype. This isn’t about east meets west. It’s about getting the best product, or combination of products, for our customers. And those products come with proof of efficacy.”
The evidence-based model of integrative medicine is de facto in Europe. In Germany, for example, pharmacists at the ‘Apotheke’ feel completely comfortable prescribing conventional pharma, along with herbal and homeopathic supplements to augment recovery.
I realize that it’s just the reductionistic, “Western,” materialism-based scientist in me, but I have to say to Mr. Mehr and Mr. Stoiber: “Evidence.” You keep using that word. I do not think it means what you think it means. After all, if the “integration” in medicine that they recommend were truly evidence-based, then homeopathy would not be a part of it at all. In fact, any truly evidence-based paradigm, be it science-based medicine (SBM) or IM, homeopathy should be excluded because in the end homeopathic remedies are, after all, water. Indeed, for homeopathy to work, huge swaths of well-established sciences, such as physics, chemistry, and biochemistry, would have to be not just wrong, but spectacularly wrong. Both Pharmaca and Pure Pharmacy sell homeopathic remedies; they cannot plausibly claim to be evidence-based, regardless of how much they “integrate” such nonsense with scientific medicine. Indeed, Pure Pharmacy has a homeopath on its staff and offers non-evidence-based services such as thermography, which is not a validated or reliable test for the early detection of breast cancer; bioenergetic health scans, which are devices akin to William C. Nelson’s infamous Quantum Xrroid Interface System; various detoxification products, none of which have any value; and bioidentical hormones, which are neither safer nor more effective than conventional hormone replacement therapy.
I said it at our panel discussion at TAM9, and I’ll say it again: “Integrative medicine” is in reality the “integration” of quackery with real medicine.
CAM is dead?
But back to the marketing aspect of the term “integrative medicine.” Last week, I saw a post from a supporter of IM who made the case, albeit inadvertently, better than I ever could. In fact, the man who wrote this is Glenn Sabin, a board member for the Society of Integrative Oncology who is described as a “staunch proponent and leader in the area of integrative medicine” even goes so far as to proclaim that CAM is dead:
Over the past 25 years, practitioners integrating the best of Western, Eastern and other evidence-based models of medicine into their practices have endured a series of catch-all titles that describe their model of care. Not long ago, all medicine not tacking closely to conventional allopathic care was termed “alternative”. Then about 15 years ago the term complementary and alternative medicine (CAM) began to seep into the medical vernacular. NIH’s National Center for Cancer and Alternative Medicine (NCCAM) became a full-fledged center in 1991. Although most of the major hospitals and cancer centers did not introduce their integrative centers until a decade later, NCCAM’s “CAM” acronym stuck, and had an influence on new private clinics and centers across the country.
Mr. Sabin apparently doesn’t know much about history of NCCAM. In 1991, NCCAM was indeed born, except that it was not a full-fledged center. Rather, thanks to woo-friendly Senator Tom Harkin (D-IA) and $2 million of discretionary funding, NCCAM started its life as the Office of Unconventional Medicine, which was soon renamed the Office of Alternative Medicine (OAM). It was not until October 1998 that NCCAM received its current name and was elevated to a full center. Mostly, this was a big “screw you” from Tom Harkin to the then director of the NIH, Harold Varmus, who, responding to objections to the OAM from the scientific academic community, moved to place the OAM under tighter NIH control. The result? Tom Harkin introduced and passed legislation that elevated the OAM to an independent center within the NIH. Soon after, appropriations skyrocketed to over $100 million a year. NCCAM’s current budget hovers in the $125 million range.
One wonders what else Sabin gets wrong.
Whatever he might get wrong or right on a factual basis, Sabin echoes Stoiber’s message about “integrative medicine” that reveals the mindset of promoters of non-science-based medical treatments in the very next paragraph:
Today several integrative centers across the country still contain the words CAM in their name. This is both confusing to health consumers and damaging for these centers’ brand. Most clinics and centers launched during the last decade have evolved with their branding to include today’s more appropriate terminology of “integrative medicine”, “integrative services” or “integrative therapies”.
(Bold not mine, but rather Sabin’s.)
I will give Sabin credit. Whether he realizes it or not, he’s basically just admitted that the move to rename CAM as IM is all about the marketing of quackery. Yes, I know that he would never, ever admit that’s what he just did. After all, like Stoiber, Sabin liberally sprinkles his post with terms like “evidence-based integrative medicine,” which makes me wonder why IM aficionados haven’t renamed IM to “EBIM.” Perhaps that’s coming later in the next iteration of marketing buzzwords for quackery.
But I digress.
Getting back on track, I note that Mr. Sabin does a wonderful job of expressing the confusion at the heart of so-called “evidence-based integrative medicine,” almost certainly without realizing that he is doing so. See if you can figure out what I mean before I explain it:
Alternative medicine is often pushed in lieu of proven conventional care. Alternative medicine does not have an adequate science base behind it and is not practiced in clinics within an academic setting. Integrative medicine integrates proven therapies into conventional medicine. True, not all methods of mindfulness-based stress reduction techniques like, say, Reiki have a solid evidence base behind it, but in this case, many clinicians that offer services like Reiki do so because their clinical observations tell them that it helps many of their patients relax and may lessen the need of certain pain meds.
So, let me get this straight. IM is better than “alternative medicine” because alternative medicine is “often pushed in lieu of proven conventional care” while in contrast (allegedly) IM “integrates proven therapies into conventional medicine”? Is that what Sabin is saying? Yes, it is. Then, right after saying that, Sabin admits that “not all” IM methods have a solid evidence base behind them but that clinicians use them because of anecdotal observations. Here’s a hint for Mr. Sabin: Anecdotal observations are not the same thing as being “proven.” Far from it! As we have explained many times before right here on this very blog, anecdotal observations can be profoundly misleading, thanks to well-known phenomena that confound “clinical observations,” such as regression to the mean, confirmation bias, and placebo responses. That’s why “conventional” medical researchers long ago realized that well-designed clinical trials, preferably randomized and well-controlled, are necessary to minimize these biases and to correct for placebo responses. Mr. Sabin comes across as profoundly confused about the science in that he doesn’t seem to realize that the vast majority of “alternative medicine” modalities that he wants to see “integrated” with conventional medicine are not “proven” by any stretch of the imagination.
“Evidence-based.” You keep using that word, Mr. Sabin. I do not think it means what you think it means. Oh, wait. I used the same Princess Bride joke twice in one post. Inconceivable! (Sorry about that.)
Not that any of this stops Sabin from misrepresenting CAM as “personalized” medicine when it is anything but and the whole appeal to “personalized medicine” is a classic CAM bait-and-switch. Here’s how Sabin himself puts it:
CAM is dead. The evolution of evidence-based, personalized integrative medicine, and its implementation in clinic, lives on.
A similar sort of “bait-and-switch” is used by Stoiber near the end of his HuffPo article:
Speaking with Mehr and Panzer, I began to understand that the brand of integrative medicine demanded a shift in perspective. Instead of creating an omnipotent pharmacist, their models relied on collaboration. This bodes well for any integrative medicine brand that can open its doors to feedback, information sharing, education and ongoing learning.
This bait-and-switch is the bait-and-switch of representing CAM/IM as being all about “patient empowerment.” It is a ploy that I find particularly galling and very much akin to the trap that journalist David Freedman fell for when he wrote a completely credulous pro-CAM story for The Atlantic. His argument basically boiled down to this: Medicine as currently practiced all too often doesn’t permit doctors the time to spend with their patients to maximize the benefits of a caring physician-patient relationship, while CAM practitioners are all about spending that time. So let’s just cede that part of medicine to the quacks. As I said before, no, that’s not a straw man, either. Stoiber’s argument boils down to the same thing. If scientific medicine doesn’t sufficiently “empower” patients, then let’s “integrate” quackery into scientific medicine in order to give them choices that make them feel empowered. That’s it. Both are, of course, false dichotomies. It is not necessary to “integrate” quackery with scientific medicine to improve the doctor-patient relationship and realize the benefits that come from that or to “empower” patients. Neither require the quackery that is CAM or IM to achieve, but IM advocates really, really want you to think that they do.
As I said, first and foremost, IM is all about the marketing.
In the end, off course CAM is dead! CAM advocates themselves killed it because they sensed a better marketing opportunity if they could come up with a term that didn’t have the connotation that their treatments are inferior to those of conventional medicine. The killing of CAM was deliberate, calculated, and premeditated, but it is not yet complete. Rather, it is an ongoing process. But don’t worry. Marketers like Glenn Sabin and Marc Stoiber will make sure that before too long the corpse of CAM will be well and truly dead, cold, and buried. In its place will rise the zombie that is “integrative medicine.”
In fact, it’s already happening.