I promised readers the “Advanced Course” for this week, which undoubtedly has you shaking in your boots. Fear not: you’ve already had a taste of advanced, subtle, misleading “CAM” language, and most of you probably “got” it. That was R. Barker Bausell’s analysis of how homeopathy is “hypothesized to work.” In the interest of civility, let me reiterate that I don’t think of Bausell as a horrible person or an ignorant boor for having written that statement. Rather, I think of him as having been so steeped in the de rigueur CAM” language distortions of the 1990s that he is largely unaware of their insidious power. I suspect too that he, like most of us who grew up when schools no longer stressed the rigors of English composition, has an underdeveloped sense of the relation between the craft of writing and the integrity of its content. That doesn’t excuse him from writing honest prose, of course.

Last week’s post cited blatant language distortions of “CAM”—euphemisms, slogans, and outright falsehoods—and some that were more subtle: question-begging, misrepresentation, and derogation. It would require a semester’s worth of seminars to delve into the overlapping categories of misleading “CAM” language, but here we can consider a few. Then, perhaps, we’ll engage in an amusing diversion—more about that at the end of this post.

Introduction to the Advanced Course

For the most part, what interests us are not the assertions of “CAM” practitioners themselves, whose misrepresentations tend to be simplistic and obvious. We are more concerned with statements by influential “CAM” apologists in academic medicine and government, because it is they who have the greater capacity to deceive the public. This was illustrated last week by quotations from the Federation of State Medical Boards. Such apologists are frequently somewhat nuanced in their misrepresentations, both because they are more clever than the “CAM” practitioners that they patronize, and because they must address their assertions to a more clever audience—namely, physicians and biomedical scientists whose skepticism of “woo” makes them wary.

Sometimes, however, statements by “CAM” practitioners and those emanating from influential apologists are one and the same, suggesting that the latter are ditzier than their status implies, or perhaps just lazier: witness the statement about “naturopathic medicine,” quoted in last week’s post, from the website of the University of Washington Dept. of Family Medicine (which itself quotes similarly inane language from the U.S. Dept. of Labor). Other examples, from WebMD (“Better information. Better health.”) and InteliHealth (The Trusted Source®), can be found here. InteliHealth has improved slightly since 2002; WebMD has not.

Some “CAM” language distortions are an inevitable result of Evidence-Based Medicine’s (EBM) incomplete definition of “evidence.” We have seen examples written by the CAM Field” of the Cochrane Collaboration (“The reliable source of evidence in health care”), whose EBM-style reviews are widely respected. More examples can be found on InteliHealth, which now buys much of its “CAM” information from Natural Standard (“The Authority on Integrative Medicine”). Whether or not the authors of such reviews are aware of established knowledge and other external evidence, the arcane rules of EBM (no longer surprising to SBM readers!) give them “plausible denial.”

Bait and Switch

For several years beginning in the late 1990s, there were clusters of “CAM” articles in a few influential medical journals. They are chock full of misleading language, but this discussion must be limited to a few examples. In the fall of 1999, the late virologist Stephen Straus became the first Director of the nascent National Center for Complementary and Alternative Medicine (NCCAM). Like many in the new academic world of “CAM,” Straus seemed innocent of “CAM.” Regarding the script of his new role, however, he was a quick study. In June of 2000 he wrote an article for Academic Medicine:

Both as an art and as a science, medicine is ever-evolving. Before the emergence of the empirical and experimental sciences, physicians relied heavily on the art of medicine. But in the past century, progressively detailed investigations of individual organs, cells, and molecules led to the emergence of biomedicine, with its heavy reliance on science, as the now-dominant and conventional basis for medicine.

A superficially innocuous and uncontroversial, politely deferential (for the benefit of snickering ex-colleagues at the NIH, I’d guess) introduction. But how innocuous is it? In that short passage are the seeds of garden variety “CAM” language distortions: by sleight of pen, the “art of medicine” will quickly change to “CAM” itself and then to “healing arts,” after fleeting stops at “rich dialogue” and “the healing process,” only to return to “CAM.” “Detailed investigations of individual organs, cells, and molecules” is a thinly-disguised reference to the objectionable “reductionist paradigm” of modern medicine, which by dint of its “heavy reliance on science” has overstayed its welcome.

The declaration that “biomedicine” is “the now-dominant and conventional basis for medicine” manages to “dis” modern medicine in ways that most physicians and scientists would hardly notice, but that the “CAM” crowd and its congressional patrons would hardly miss: “biomedicine” and “conventional” are mildly pejorative misnomers, as discussed last week; “dominant” is a potent adjective, intended to distract the reader from imagining that the emergence of modern medicine had something to do with the emerging understanding of nature over the past couple of centuries—and to replace it with the facile suggestion that medicine, like everything else, is a matter of power vs. oppression or privilege vs. exclusion. This kind of thinking had been fashionable in the academy for more than a generation, and was certain to win approving nods from such ex-hippie “CAM” luminaries as Andrew Weil, who authored an article for the same issue of Academic Medicine, and James Gordon, the Chairman of the White House Commission on Complementary and Alternative Medicine Policy. More from Dr. Straus’s piece:

Historical precedent predicts that a number of contemporary CAM therapies [will prove effective]…some of our most important pharmacologic agents…are derivatives of herbal products. Radiation therapy, once regarded as a radical approach to treating cancer, is now a standard of care, and acupuncture, considered arcane and primitive before Nixon went to China in 1971, is now routinely prescribed to manage pain.

First point: no, it doesn’t, and even if it did so what? Nothing in “CAM” consists of the rational screening, for useful medicinal properties, of substances found in nature (bait and switch). Second point (radiation therapy): What does that have to do with “CAM”? Second point (acupuncture): Routinely prescribed by whom? And even if it were so, it isn’t evidence. The counterpart to the “straw man” argument is the “false premise” argument in which the author asserts the existence of a premise that supposedly justifies the point he is about to make. Unlike the case of the “straw man,” the author approves of the premise; but like that of the “straw man,” the premise is either a figment of the author’s imagination or does not support his subsequent point.

Here is the obligatory, once-an-article skeptical posturing to reassure the reader that she is in the capable hands of the author and of the author’s like-minded colleagues:

Many people believe that if a product has been used for centuries, it must be effective, and if it is natural, it must be safe. To the contrary, there is mounting evidence that some CAM therapies expose patients to potentially toxic components or displace effective conventional treatments…St. John’s wort [and protease inhibitors, for example]…

That passage is particularly rankling for its hypocrisy. The evidence for the dangers of mixing herbs and HAART agents came from legitimate Institutes of the NIH, but not from the NCCAM. The NCCAM, on the other hand, through its funding of the Bastyr (Naturopathic) University AIDS Research Center, may have contributed substantially to the dangers of such herb-drug interactions, and certainly contributed to an ethically-dubious trial of “Garlic for hyperlipidemia caused by high [sic] active antiretroviral therapy (HAART).” Garlic is another substance that reduces blood levels of HAART agents. At about the same time that Dr. Straus must have been writing his article for Academic Medicine, personnel from Bastyr and the University of Washington were presenting an abstract in which they reported having temporarily stopped the garlic trial because of this new information, but “additional funding was later received from NCCAM for implementation of safety mechanisms to allow the trial to resume.” Those “safety mechanisms” did not include “therapeutic drug monitoring.”

More from the article:

Lacking such knowledge yet enamored of the appeal of CAM practices, the American people have demanded that these be studied.

The American people are neither “enamored of the appeal of CAM practices” nor have they “demanded that these be studied.”

The Wooification of Health Care

And now a cynical fest of question-begging, baiting and switching, and stated intentions that should make any reason-loving physician shudder:

…an especially vital role with respect to facilitating the integration of rigorously proven CAM approaches into the ongoing education of physicians and the daily practice of medicine…Dr. Andrew Weil…spoke of the need to train young physicians about CAM. Few would argue against the wisdom of this notion…Medical students should receive instruction about proven CAM methods…the curriculum should be enriched by exposures to the history of medicine, medical ethics, and medical economics…We also wish to work with the AAMC to overcome the reluctance of conventional physicians to consider CAM therapies that are proven safe and effective for their patients…in this way may we succeed in expanding the repertoire of ways to achieve and maintain health and restore an appropriate balance of both the art and the science of medicine.

We might be comforted by observing that there are no “CAM therapies that are proven safe and effective,” nor are there likely to be any; except that we already know that CAM” researchers, encouraged by misguided shills for EBM, don’t see it that way—and neither, if we don’t speak out, may medical schools, patients, insurance companies, and governments. The passage is yet another language distortion, which means exactly what “CAM” advocates choose it to mean.

The point is made even more pointedly by at least two other articles in that issue of Academic Medicine. The first instance is no surprise, coming from Andrew Weil and his pals at the University of Arizona:

The addition of proven CAM to conventional medicine would be an improvement, yet this combination alone is not what could be defined as integrative medicine….Integrative medicine is defined as healing-oriented medicine that reemphasizes the relationship between patient and physician, and integrates the best of complementary and alternative medicine with the best of conventional medicine. We believe that this synthesis of humanistic medicine, patient- and relationship-centered care, preventive health, allopathy, and CAM is the model for creating an improved system of health care.

So: it isn’t even just something that the ditzy members of the class can elect; if Weil and his gang have their way, it will be mandatory for all—it became so at Georgetown a couple of years ago, as reported by Orac. Such training already exists for “integrative medicine” fellows at U of Arizona and includes claims that don’t “fit with our Western paradigm,” scrapping RCTs in favor of “outcomes research,” asking “physicians to explore their beliefs about medicine and…the assumptions that underlie medical science,” preparing “physicians for new roles as partner, coach, teacher, motivator, and healer,” heightening “awareness of the different cultural healing systems,” “Chinese medicine, energy medicine, homeopathy, allopathic medicine, manual medicine, and Western herbalism,” and “physician self-care” that includes “therapeutic movement,”

facilitated sessions [for] examining [one’s] humanity, including the identities they have left behind and the physician-healers they are seeking to become.

These meetings occur regularly, often offsite, and in addition to traditional group work, include experiences ranging from listening to music, hiking, and reading plays and poetry to participating in Sufi dancing and sweat lodge ceremonies.

Please pass the homeopathic Ipecac.

The final few quotations are from another article in that issue of Academic Medicine, co-authored by Ralph Snyderman, who at the time was the Chancellor for Health Affairs at Duke University:

Integrative medicine is an approach to the practice of health care based on a sound scientific approach with an emphasis on the responsibility of the physician to engage the patient in his or her own unique plan for health. Essential aspects include the recognition of the importance of the mind-body relationship and a willingness to consider unconventional modalities with informed skepticism and scientific evaluation. Above all, integrative medicine encompasses the caring bond between the patient and the caregiver, and the responsibility of the latter to enable the patient to benefit from a full array of modalities that can be shown to benefit health.

What’s so remarkable about that statement is just how unremarkable it is. With the possible exception of “the mind-body relationship” and “unconventional modalities” (which could easily be changed to “psycho-social considerations” and “innovative treatments” without a literal change in meaning), if “integrative” were changed to “modern” it would hardly stir the dozing medical students in the back row. That, of course, is exactly why its misleading language is so pernicious: it can’t really mean “based on a sound scientific approach” or “with informed skepticism and scientific evaluation,” because those would preclude what’s really meant by “integrative.” Sure enough, the rest of the article is a paean to Weil’s “Arizona Program,” which the authors intend to emulate at Duke, and to the Consortium of Academic Health Centers for Integrative Medicine, which is also committed to the wooification of modern medicine behind the veil of “scientific studies” (quoted in Snyderman):

Our mission is to help facilitate the transformation of health care through rigorous scientific studies, new models of clinical care, and innovative educational programs that integrate biomedicine, the complexity of human feelings, the intrinsic nature of healing and the rich diversity of therapeutic systems.

There are now 39 medical schools among the members of the consortium, including, in all likelihood, yours. As my colleague Dave Gorski has discussed, there are others that also push woo. Be afraid.

And now for the amusing diversion…

That was depressing, to say the least. As an antidote, I’m proposing a weekly “language distortion” game: the Weekly Waluation of the Weasel Words of Woo (W^5 for short). It’s simple: each week on Friday, I’ll post a passage at the end of my blog. Feel free to comment on its misleading language over the weekend (please stop before Monday and limit yourselves to one submission each, or I’ll get overwhelmed and confused), and I’ll select the really good ones and heap praise upon you the following Friday. Feel free to draw upon “external evidence.” Here’s the first entry, which calls to mind at least two recent SBM posts, here and here (hint, hint):

For people with chronic pain or with other refractory conditions, the chiropractic visit itself can be a source of comfort even without the addition of a demonstrable scientific component. Treatment by a chiropractor can generate a sense of understanding and meaning, an experience of comfort, an expectation of change, and a feeling of empowerment. Chiropractic’s combination of vitalist “innate intelligence” and simple mechanical explanation can give rich vocabulary for just those illnesses conventional medicine remains poorly equipped to address. Research indicates that for many of the illnesses chiropractic treats, precise diagnosis, assurance of recovery, and physician-patient agreement about the nature of a problem hasten recovery.

Chiropractic finds its voice exactly where biomedicine becomes inarticulate. Too often, biomedicine fails to affirm a patient’s chronic pain. Patients think their experience is brushed aside by a physician who treats it as unjustified, unfounded, or annoying, attitudes that heighten a patient’s anguish and intensify suffering. Chiropractors never have to put a patient’s pain in the category of the “mind.” They never fail to find a problem. By rooting pain in a clear physical cause, chiropractic validates the patient’s experience.

Happy Waluating!

Post-post addendum

At least two studies in recent years, both published in Academic Medicine, have shown that “CAM” courses in medical schools are overwhelmingly uncritical and promotional. One of these was done by our colleague Wally Sampson; the abstract is here. The abstract of the other is here.

A recent issue of Academic Medicine was once again devoted to the teaching of “CAM” in medical schools. A perusal of the table of contents and the available abstracts confirms that “CAM” advocacy is, more than ever, the norm for such ventures.

The Misleading Language and Weekly Waluation of the Weasel Words of Woo series:

  1. Lies, Damned Lies, and ‘Integrative Medicine’
  2. Integrative Medicine: “Patient-Centered Care” is the new Medical Paternalism


Posted by Kimball Atwood