The Integrative Medicine Wheel

The Integrative Medicine Wheel

 

UPDATE: Dr. Katz has responded to this post in his usual venue, The Huffington Post.

Alternative medicine was all about “potential” from the get go:

In 1991, the Senate Appropriations Committee responsible for funding the National Institutes of Health (NIH) declared itself “not satisfied that the conventional medical community as symbolized at the NIH has fully explored the potential that exists in unconventional medical practices.”

Thus, the Committee, led by chair Sen. Tom Harkin, directed the NIH to create an advisory panel that would “fully test the most promising unconventional medical practices.”

The advisory panel became the Office of Alternative Medicine, which became the National Center for Complementary and Alternative Medicine, which became the National Center for Complementary and Integrative Medicine, its current iteration.

This effort to unlock the “potential” of unconventional (renamed alternative, renamed complementary and alternative, renamed integrative) medicine forced an uncomfortable alliance between science and pseudoscience from the beginning. Advocates like Harkin, and his two quackery-promoting constituents, Berkeley Bedell (colostrum and something called “714-X,” derived from camphor) and Frank Wiewel (immuno-augmenative therapy for cancer), were all for “fully testing” until they realized what “fully testing” meant to a scientist: double-blind, placebo controlled trials. It was thus that the true believers discovered the value of special pleading: they “favored quick field studies that would validate alternative treatments.”

Taxpayer monies flowed into legitimate medical and scientific research institutions to conduct alternative medicine research: the Maryland School of Medicine, Harvard Medical School, University of California at Davis, and the Texas Health Science Center, among others, received funds for the study of antineoplastons, cartilage products, magnets, mind-body control, and even Bedell and Wiewel’s beloved “714-X” and immuno-augmentative therapy.

As we discovered hundreds of millions of taxpayer dollars later, the “potential” of alternative medicine was (surprise!) never realized.

Can I put you on hold?

Nearly a quarter century later, we are still waiting for the “potential” of integrative medicine, the grandchild of alternative medicine, to reveal itself. Proponents still argue that the scientific method must give way if we are to discover this potential. And taxpayers are still footing the bill.

A 2012 Health Resources and Services Administration (HRSA) grant is the perfect exemplar of the continued quest to unlock this much-ballyhooed potential. The American College of Preventive Medicine was the recipient of this grant, designed to establish an “Integrative Medicine in Preventive Medicine Education program,” in 12 preventive medicine residency programs (yet another exercise in quackademic medicine). A special issue of the American Journal of Preventive Medicine (AJPM) provides the details.

A familiar figure hovered behind this effort: Sen. Tom Harkin, who was involved in what is described as “an extended period of discussion . . . about the need for just such a program.” This appears to be yet another effort by members of Congress to rob HRSA of monies designed to improve access to health care so that pet projects devoted to integrating pseudoscience into medicine can be funded.

Another familiar promoter of integrative medicine (sometimes referred to as “IM”) was even more deeply involved: David Katz, MD, who teed off the special issue with an article: “Preventive Medicine Training: the Case for Integrating Integrative Medicine.” Joined by Ather Ali, ND, his protégé at Yale, he authored another article as well: “Disease Prevention and Health Promotion: How Integrative Medicine Fits.”

Dr. Katz has been the subject of several SBM posts. The Cliff Notes version is this: he is the director of the Yale-Griffin Prevention Research Center. Its goal, according to the website, is to “develop innovative approaches to health promotion and disease prevention that will directly benefit the public’s health.” Nothing wrong with that. But Dr. Katz has an unfortunate affinity for CAM, especially naturopathy.

Naturopathy: Abandoning patients into pseudoscience

Dr. Katz believes that CAM treatments can and should be offered to patients, apparently on the premise that, when conventional medicine has no proven treatments for a patient’s condition, physicians are free to proffer the unproven and implausible because, to do otherwise, would be to “abandon” patients. (Which is, as we at SBM have pointed out more than once, a false dichotomy.) His view of CAM providers is appallingly naïve: he apparently thinks that they are sitting around twiddling their thumbs until they get the call from a physician to administer a carefully curated treatment. He seems blind to the fact that naturopaths, chiropractors and acupuncturists are, in fact, practicing a vast array of quackery that he would never dream of suggesting to a patient.

Thus, he is a relentless promoter of integrative medicine, which he believes offers “the best of both” conventional medicine and CAM. And he can get testy when challenged on the subject. Which I am about to do.

The premise for the grant was, according to Dr. Katz:

Preventive medicine residents are trained to prevent disease and promote health. Integrative medicine places a considerable emphasis on these same goals, on holistic models of care to facilitate them, and on lifestyle practices.

Note that word: “goals.” Dr. Katz freely admits that these “goals” remain unrealized:

Integrative medicine . . . offers, in theory at least, the opportunity to combine the ‘best’ of the conventional healthcare system and practices and providers commonly considered to be CAM, and thereby produce better outcomes. . .

He then goes on to “discuss the potential for integrative medicine across the prevention spectrum,” admitting that this potential is not “fully elucidated” and that “data derived from direct tests of integrative care models are promising but preliminary.” And, despite much lip service being given to integrative medicine’s alleged emphasis on preventing disease and health promotion, he admits that “this potential” is unrealized: “the authors are not aware of evidence of enhanced screening and preventive services in integrative medicine.” However, “many CAM approaches have demonstrated promise . . . [and] the potential to improve outcomes rationally follows.”

Integrative medicine, as well, “has the potential to add to obesity prevention and control efforts,” although the “scientific evidence underlying [recommendations of dietary supplements] has long been suspect.” CAM therapies for pain “vary in demonstrated efficacy” and other integrative approaches for diabetes and cardiovascular risk markers “suggest public health benefits as well as possible cost savings.”

And so on: Integrative medicine offers “the promise of” achieving the goals of preventive medicine, outcomes research on models of integrative care “demonstrate promise” and “potential cost savings” and “some posit” a salutary effect of integrative research.

And, finally, in the penultimate paragraph of the Katz-Ali article:

Evaluating the current state of integrative medicine and preventive medicine leads to a number of fundamental research questions that can address essential gaps. The role of integrative medicine in areas germane to primary and secondary prevention needs to be better assessed in terms of rates of uptake of clinical preventive services, as well as the ability to demonstrably improve diet, physical activity, and smoking-cessation efforts. The question of whether integrative clinicians model healthy behavior and influence their patients in comparison to other clinicians is relevant, as well as cost-effectiveness studies of integrative practices in high-priority areas such as pain management and adjunctive cancer care.

In other words, according to Katz and Ali, here’s what we don’t know about integrative medicine:

  • Whether IM really offers the best of conventional medicine and CAM.
  • Whether IM produces better outcomes.
  • Whether IM is effective in the area of prevention, including obesity and cardiovascular risk.
  • Whether IM has anything to offer preventive medicine.
  • Whether future IM research will yield beneficial results.
  • Whether IM has a positive impact on utilization clinical preventive services, smoking cessation, diet and physical activity.
  • Whether IM is cost effective.

I think the only “case” Dr. Katz makes is that integrative medicine promoters need more research money to pursue the ever-elusive “potential” of integrative medicine, and preventive medicine residencies happened to be a convenient and free parking place for the moment. And they do it by taking funds from a limited pot of the public’s money that would otherwise be devoted to improving access to health care. What a waste.

Having admitted that they’ve got nothing, Dr. Katz ventures forth with what might be called the W.C. Fields protocol:

If you can’t dazzle them with brilliance, baffle them with bullshit.

Or, in his words:

The simple argument supporting integrative are is that modern medical science and knowledge, despite profound successes, comprises far less than patient need. Integrative care is not a comprehensive solution, but does expand the array of patient options, and can increase the likelihood of success that can be assembled across the stages of prevention.

The “array of patient options” being, in the language of Mr. Fields, the aforementioned BS, here in the form of CAM. Which nicely segues into Mark Crislip’s famous observation:

If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.

Warning: Tongue diagnosis may cause discomfort

The lack of evidence for integrative medicine is not the discipline’s (if one could call it that) only problem. As I’ve discussed before, there isn’t even a taxonomy of IM practices to guide a research agenda. More basically, there isn’t an agreed definition of the term “integrative medicine.” Dr. Katz admits this as well, noting the “competing definitions” and “perennial dissatisfaction with the relevant nomenclature.”

Another challenge was a distinct queasiness concerning incorporating pseudoscience into a science-based preventive medicine residency program. This, in turn, evolved into an interesting question: is CAM necessary to integrative medicine? We’ll return to that in a moment.

Some of the residency programs involved in the grant described their efforts in articles included in the AJPM issue. Each program incorporated IM in a different way (e.g., journal clubs, lectures, working with IM and CAM practitioners). As best I can tell from reading these reports, IM was presented by those in charge of implementation as worthy of incorporating into preventive medicine residency. Dr. Katz’s statements about the overlap between IM and preventive medicine goals, the “potential” for IM, and so forth, were repeated without questioning.

For example, from the IM training program at the University of California, San Diego, preventive medicine residency program:

PA [physical activity] and nutrition, the backbone of integrative medicine training programs, served as the curriculum framework.

Even though the Academic Consortium for Integrative Medicine and Health IM medical school curriculum mentions exercise only in passing. (Who’s that, you say? There’s another name change for you: this is the new name for the Consortium of Academic Medical Centers for Integrative Medicine.) Ironically, UC San Diego’s program doesn’t seem to have employed integrative medicine as part of its IM residency training at all. It based its so-called IM training on the “Exercise is Medicine” initiative developed by the American College of Sports Medicine and “utilizing guidelines developed by [the ACSM], Cooper Clinic, American Heart Association, International Society for Clinical Densitometry, and American Geriatric Society.” Because, you know, conventional medicine doesn’t know anything about exercise.

(Other articles cover the IM program in preventative medicine residencies at the University of Maryland, Rutgers, University of Michigan, Johns Hopkins, Boston Medical Center, and Yale.)

Despite the particular affinity of IM for CAM, the medical staff and residents were not all that warm to the idea of including pseudoscience.

At the University of Maryland:

Resident feedback suggested discomfort with concepts of Traditional Chinese Medicine such as tongue diagnosis as well as terms, such as “kidney” points and “obstruction” that may be interpreted differently by allopathic physicians and [TCM] practitioners.

And, at the University of Michigan:

Another concern addressed . . . involved the anti-vaccine beliefs held by a community-based IM physician that one of our residents visited and is incongruent with the principles and practice of public health and preventive medicine.

So, did the IM program kick this anti-vaxxer out? Apparently not.

Owing to this concern, [we] requested that the IM rotation become elective for future resident cohorts.

At Yale, the IM program wanted a “naturopathic physician” to attend clinic with the residents. To the clinic administration’s credit, this didn’t happen. For one thing, the administration was unwilling to bypass the normal credentialing process for the naturopath. He (or she) was allowed only limited access to educate the residents, but could not interact with patients.

In fact, the Yale Integrative Medicine Clinic closed its doors in 2014 due to lack of financial viability and residents can no longer do an elective IM rotation there, although it is still available at the Yale Stress Center where Dr. Katz is also involved.

At the end of the two-year grant, it was far from clear that the PM residency programs would continue with IM training. According to the post-program analysis, the most prevalent expectations were for IM rotations to continue, but only as elective rotations, and for IM lectures and grand rounds to become less frequent.

Is CAM necessary?

In the post-program analysis, the inclusion of CAM emerged as the main stumbling block in implementation of IM training in residency. This led to the observation that:

The [Institute of Medicine, IOM] definition of IM guiding this project does not require inclusion of what are generally thought of as CAM modalities, and the funder did not require CAM inclusion. Nonetheless, it is widely held that IM comprises both conventional Western and CAM practices.

(This definition is contained in the IOM’s “Integrative Medicine and the Health of the Public,” an effort Kimball Atwood deconstructed. His post also demonstrates that IM has long claimed, without evidence, that it is all about “prevention.”)

To Dr. Katz, CAM is essential to IM. IM is “the fusion . . . of conventional medical practices that fall under the . . . CAM rubric.” The “best” of both. Indeed, he says, “the rationale for integrative medicine depends largely on a rationale for CAM.” And he proposes a distinctly double standard for employing conventional versus CAM treatments.

Nevertheless, the authors of the post-program analysis think the “foremost” question to be answered in further discussion among the preventive medicine community in integrating IM into training and practice may be “the extent to which inclusion of CAM procedures is essential to the practice of IM.” They note that the IOM offers “little guidance” in answering this question and that the reference in the definition to “therapeutic factors known to be effective and necessary . . .” could exclude CAM just as well as include it.

Conclusion: When is enough, enough?

But if Dr. Katz is correct, if integrative medicine = conventional medicine + CAM, what is left of IM if the CAM is left out? Conventional medicine. Which we already have, so IM is unnecessary. Which has, in fact, always been the case.

But, more to the point, when is it time to abandon the search for this elusive “potential” of alternative/complementary/integrative medicine? What is a sufficient amount of time to allot to this expensive yet unyielding research? I’d say 25 years is a nice, round number. That would be 2016, or about two months from now.

 

 

Posted by Jann Bellamy

Jann J. Bellamy is a Florida attorney. She became interested in “alternative” medicine when the Florida Legislature tried to establish a chiropractic school within Florida State University in 2005. She joined others in leading opposition to the school, and this “done deal,” which was strongly opposed by the University faculty, was undone by the university system Board of Governors. During this process, Jann became intrigued that scientifically implausible and unproven healthcare claims could be presented as fact to the public, even to the point of being codified into law. Jann is a former law clerk to a federal judge, Florida Assistant Attorney General and long-time partner in a Tallahassee law firm, where she practiced mainly in the civil litigation area. She left the active practice of law in 2006 to form a non-profit, the Campaign for Science-Based Healthcare, which educates the public about “alternative” healthcare claims and advocates for a state law requiring that all healthcare offered in Florida meet a basic scientific standard. She is a founding member of the Institute for Science in Medicine and a columnist for Health News Florida.

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