Integrative Neurology – More Bait and Switch

What, exactly, is “integrative medicine?” In science having a precise definition of terms is critical. It is a necessary starting point for investigation. In fact, we often refer to an “operational definition” which is not just a description, but a concrete specific set of procedures and outcomes with clear delineation. For example, a general definition of Type II diabetes might include insulin resistance resulting in poor glucose control. An operational definition would include, a 2-hour glucose tolerance test of >200.

A recent commentary on Medscape about integrative medicine in neurology defined it as, “healing-oriented practice with a focus on lifestyle interventions, offering patient-centered care addressing physical, mental, and spiritual well-being.” That is a vague definition. In my opinion, it is deliberately vague, specifically so that it can sound useful but in practice can include or exclude any intervention. The problem gets even deeper when we consider that the term “integrative medicine” is meant to distinguish certain practices and approaches from regular medicine. So it is not just defining a field, but also a demarcation line between integrative medicine and medicine. As lines go, this one is as fuzzy as it gets.

Being as charitable as possible, it seems there are four potential operational features of integrative medicine outlined in this quote: healing-oriented practice, lifestyle interventions, patient-centered care, and addressing physical, mental, and spiritual well-being. The problem is that none of these actually can be distinguished from medicine in general. “Healing-oriented practice” is extremely vague. Again, being charitable, in medicine we generally divide treatments into curative, functional, or symptomatic. The former is designed to alter the course of a disease, heal an injury, or cure a disease. Symptomatic treatments are intended to reduce symptoms and improve quality of life. Functional treatments, like physical therapy, improve function (so they are more than symptomatic) without necessarily curing the underlying condition. Many interventions combine aspects of two or three of these outcomes, but it’s important to understand the purpose of any treatment.

So, given that, what does “healing-oriented practice” mean? Does integrative medicine not include symptomatic or functional interventions? That would be odd, because the vast majority of their interventions are actually symptomatic. In the Medscape commentary, which reviews an integrative medicine conference, almost every intervention discussed is symptomatic, with the main outcome measure being quality of life or a subjective symptom like pain. Invoking “healing” is all about marketing, flipping reality onto its head. Reductionist science-based medicine combines all treatment goals, and cures illness whenever possible. Yet is has long been part of the alt med propaganda that mainstream medicine treats only symptoms, while magic-based medicine heals. This marketing claim does not hold up to even the slightest scrutiny.

The problem with the other three components, lifestyle interventions, patient-centered care, and addressing physical, mental, and spiritual well-being, is that they are already part of mainstream medicine, where the concepts originated. Integrative medicine (under any of its evolving marketing slogans) did not develop these concepts. They just stole them for their own. Research into the effect of lifestyle factors on health and illness has long been a part of scientific medicine.

Patient-centered care goes back at least 40 years in mainstream medicine, with increasing popularity as a term starting in the 1980s. The idea is to focus not just on treatment, but the total patient experience. This was a reaction to the reality of modern medicine, which requires increasingly complex systems to manage all components of health care. The concern was that the patient was getting lost in the mix, with the logistical, technical, and administrative needs of the system getting in the way. We needed to re-center the entire process around the patient to optimize their healthcare experience. Integrative medicine had nothing to do with this entire process – they just adopted the language because it sounds good.

In medical school in the late 1980s I learned about the “biopsychosocial” model of medicine. The term goes back to George Engel in the early 1980s, and you can see how quickly it became popular as within a few years it was being incorporated into medical school teaching. Similar to patient-centered practice, the idea was to make sure that the entire patient was being addressed, not just their biology. You are not treating a disease – you are treating a patient with a disease. This is a subtle but critical shift in attitude, and was meant to make sure the medicine profession was not so distracted by the advancing science of medical interventions that we lost focus on the whole patient. Mind-body-spirit is just a new-age version of biopsychosocial. The latter is actually much more appropriate to medicine. It is decidedly unprofessional and even unethical for a healthcare provider to intrude on their patient’s religious beliefs. We should be respectful but neutral, and certainly not impose any spiritual or religious beliefs onto our patients. We should understand their beliefs, their culture, and their psychology in order to address how that might impact their health and their care, but that is very different from basing an intervention on a spiritual belief.

By their own definition, therefore, there doesn’t seem to be any legitimate purpose for integrative medicine. It’s just repackaging and rebranding concepts that already exist within mainstream medicine. But any examination of the interventions that go under the integrative banner reveals what we have called here at SBM the “Trojan Horse” of alt med. The definition of integrative medicine is not what it is actually about, it’s just the branding designed to gain entry into mainstream medicine. It is the Trojan Horse. What spills out of that horse, however, is the real purpose of alt med – an eclectic collection of pseudoscience and magic-based treatments. The real purpose of the alt med/complementary/integrative brand is to eliminate the science-based standard of care in medicine, or at least carve out an exception, so that a variety of treatments previously considered to be health fraud can flourish.

Reviews have shown that the most common integrative medicine practices include: herbal medicine, homeopathy, chiropractic, acupuncture, and reflexology. Herbal medicine is simply pharmacology, but with poorly studied and regulated products. Homeopathy is 100% pure pseudoscience. Chiropractic is a mixed bag, but I think the best summary is – what chiropractors do that works is not unique to chiropractic, and what they do that is unique to chiropractic doesn’t work. Acupuncture is demonstrably nothing more than an elaborate placebo. Reflexology is also pure pseudoscience. How is any of this patient-centered or even holistic?

The review of the neurological presentations during the integrative medicine conference includes such insights as – pain is a brain processing phenomenon. Do tell. Loneliness has a negative impact on quality of life. Exercise is good for you. This is hardly a revolution in medicine. The author admits she was not impressed by the evidence presented for specific supplements, but overall “I left impressed by the depth and commitment to scientific rigor by the majority of presenters”. I don’t know if there was any straight-up pseudoscience, like homeopathy, at the conference. The list of topics [PDF] does not include references to specific interventions, so a lot of nonsense can be tucked away in specific talks. Some talks, such as those referring to thyroid testing, are very suspicious for common “functional medicine” pseudoscience. I also have to wonder about the qualifier “the majority of presenters,” which could be 51%. So there were some that were not committed to scientific rigor?

In any case, the review did leave me with a question. Perhaps integrative medicine is getting trapped in its own marketing (the pseudoscience is getting trapped inside the Trojan Horse). In order to get into mainstream medicine, they have to pretend to just be focusing on lifestyle and patient-centered medicine, but still be scientifically rigorous. This might attract some practitioners who actually believe the marketing. My question is – is there any chance that integrative medicine will evolve into a redundant but at least reasonably science-based philosophy within mainstream medicine? If they just repackage stuff we are doing already, and can’t really let loose the pseudoscience without contradicting their own marketing, then perhaps integration will change them more than it changes medicine.

That’s a very optimistic view, and I’m not willing to bet on it. It’s necessary to continue to expose integrative medicine for what it is – a thinly disguised conduit for pseudoscience into medicine. If proponents disagree, then fine – let’s all dedicate the practice of medicine, regardless of practice philosophy, to rigorous standards of science-based medicine. Our job is to make sure they don’t just pay it lip service, and that everyone understands what SBM standards really mean, and why they are necessary. They will have no choice but to fall into the trap, or admit they are not scientifically rigorous. In practice this means we will conflict over what SBM standards should be, and what the scientific evidence actually says. That is the risk – they are trying to change medicine, to water down the scientific standards, to distort research, and to weaken regulations. Unless we elevate them to rigorous standards, they will drag down all of medicine into pseudoscience.