The infiltration of complementary and alternative medicine (CAM) and “integrative medicine” into academia

A few years back, my co-blogger Wally Sampson wrote a now infamous editorial entitled Why the National Center for Complementary and Alternative Medicine (NCCAM) Should Be Defunded. When I first read it, I must admit, I found it to be a bit harsh and–dare I say?–even close-minded. After all, plausibility aside, I believed at the time that the only way to demonstrate once and for all in a way that everyone would have to accept that many of these “alternative” therapies were no more effective than a placebo would be to do high-quality randomized clinical trials to test whether they worked, and NCCAM seemed to be the perfect funding agency to see that this occurred. Yes, this attitude in retrospect was quite naïve, as I have since learned the hard lesson over several years that no amount of studies will convince advocates of complimentary and alternative medicine (CAM) that their favored therapy doesn’t work, be it chelation therapy for autism or cardiovascular disease, homeopathy, reiki, or various other “energy” therapies that invoke manipulation of qi as a means of “healing,” such as acupuncture, but that is what I believed at the time.

Why are CAM or “integrative therapies” so immune to evidence? One reason, of course, is ideology or even a religious component to devotion to these therapies, which is not surprising given that the whole concept of qi, a “life force” that science thus far has been utterly unable to detect but that “healers” claim to be able to manipulate for therapeutic effect, is far more religious in nature than scientific. Another reason is that many of these therapies were developed in pre-scientific cultures, long before germ theory and a much better understanding of human biochemistry and physiology led to therapies, both pharmacologic and surgical, that actually cured disease. Finally, according to the research studies of John Ioannidis, who has pointed out that it is not uncommon for random chance alone, coupled with the definition of statistical significance of p less than 0.05 can for hypotheses with an 80% chance of being false result in a 25% false positive rate, even if the studies are designed perfectly. Given that the prior probability of most CAM therapies being more effective than a placebo, based on scientific plausibility alone, is almost always less than 20%, that means the false positive rate for CAM research will be even higher, producing many studies that advocates can cite, while ignoring the totality of the evidence. Indeed, as I write this, we have a commenter pointing to such studies for purely “energy” medicine.

Dr. Sampson reminded me of this problem in his post last week about the infiltration of CAM into academic medicine. I’m extremely grateful for the historical perspective for a relative newbie to this debate. While I have only started to become alarmed at the infiltration of unscientific nonsensical CAM therapies being promoted and administered in academic medical centers as though they had evidence supporting them anywhere near the level of evidence expected for “conventional medicine,” Dr. Sampson first noted this trend in the 1980s, when I was in medical school and too busy learning medicine to bother worrying about trends in medical education and academia. It was a trend that continued into the 1990s, when I was similarly too busy doing my residency, PhD, and fellowship. It was only a couple of years ago that I started to become alarmed at this increasing acceptance of non-science-based and non-evidence-based therapy when I noticed them being offered at my own hospital.

Let’s get one thing straight right at the outset. I’m not opposed to teaching about CAM modalities in medical school. After all, many of our patients take various herbal remedies, and it’s important to know how they might interact with drugs or other treatments that we prescribe. Other patients may be using other CAM modalities besides herbs or supplements, and it is important to be able to discuss them. The key, however, is to think critically about these modalities, and, unfortunately, teaching the next generation of medical students to do this is something that academic centers teaching CAM (or, as it is being called more and more lately, “integrative medicine,” which to me is “integrating” unproven therapies with the proven to no benefit that I can detect) appear to be failing at utterly. Indeed, as Dr. Sampson and others have documented, very few CAM or “integrative medicine” programs actually teach a critical, evidence- and science-based appraisal of these therapies. Sadly, this teaching seems to be having an effect. There is at least some evidence that far too many medical students appear to be enthusiastically embracing non-evidence-based CAM therapies, as was reported by Chaterji et al in 2007, in which they found that 91% of medical students agreed that “CAM includes ideas and methods from which Western medicine could benefit.” (I wonder what ideas those are. The concept of qi, the undetectable life force that, it is claimed, various therapies can manipulate to therapeutic intent, perhaps?) Nor am I ideologically opposed to studying the more plausible therapies in randomized clinical trials. My concern about the current situation is that it is wasteful to allocate scarce research dollars to study after study therapies that are so highly implausible on the basis of science (such as homeopathy or reiki, for instance) when such money could be used to study more promising therapies and that the introduction of the less outlandish CAM therapies serves as a Trojan horse to let in the whole package, homeopathy, reiki, and all.

But how entrenched has CAM become in academic medicine in the U.S.? Certainly it’s become entrenched enough that alternative medicine mavens in the media, such as Julie Deardorff of the Chicago Tribune, have noticed. In fact, it’s becoming so noticed that national news magazines, such as the U.S. News & World Report, have published articles about the seeming embrace of these therapies by academia, articles that start out like this:

To be blunt, if my wife and I didn’t think it was helping him, we wouldn’t have continued with it,” says Dan Polley. He’s talking about Mikey, the Polleys’ 2½-year-old in the next room, who was diagnosed with acute lymphocytic leukemia when he was 6 months old. Chemotherapy, radiation, and a bone marrow transplant have been crucial elements of Mikey’s treatment. But the “it” his father speaks of is nothing like these aggressive, costly, and heavily researched exemplars of western care—it is a kind of touch therapy, from the camp of alternative medicine. Gentle and benign, “healing touch” is intended to rebalance the energy field that its practitioners believe surrounds the body and flows through it along defined pathways, affecting health when disrupted. Several times a week, therapist Lynne Morrison spends 20 minutes unblocking and smoothing Mikey’s energy field, which energy healers like Morrison say they can feel and correct.

This scene took place at, of all places, Children’s Memorial Hospital in Chicago, which is affiliated with Northwestern University. Moreover, this article is peppered with quotes from believers like Andrew Weil, who says: “I teach and urge people to use a sliding scale of evidence…The greater the potential to cause harm, the greater the standard of evidence should be.” One can hardly fail to note that, by that standard, homeopathy, which is, after all, nothing more than water, should require no evidence whatsoever. However, the article, in my mind, provided a more compelling reason than Wally Sampson’s original article, why NCCAM should be defunded and its functions folded into the rest of the Institutes and Offices of the NIH: NCCAM is actively promoting the teaching and adoption of “alternative” medicine in academic medical centers before science has validated the vast majority of its therapies:

Until the mid-1990s, most academic centers treated CAM like a pack of scruffy mutts, noisy and unworthy of notice. A large pot of federal and foundation research funds—now close to $250 million per year just from NCCAM and the National Cancer Institute, plus tens of millions more from private donors such as the Bravewell Collaborative—helped turn that sniffy attitude into solicitous attention, says longtime CAM commentator Donald Marcus. “The funding gave them respect from the medical school community,” says Marcus, a professor of medicine and immunology at Baylor College of Medicine in Houston, where he has long taught a CAM course. A survey of hospitals found that 27 percent offered CAM in 2005, up from 8 percent in 1998. At the Cleveland Clinic, for example, NIH money is behind a clinical trial to see whether reiki, another energy therapy, can reduce stress and anxiety in prostate cancer patients.

Enough money will do things like that, and the results have been startling. As an exercise, I set out to get an estimate by looking for centers of “integrative medicine” or CAM. It didn’t take me long to find at least 44 different such centers that offer and/or teach CAM. Indeed, I’m sure that the list that I am about to present to you is nowhere near complete, given that it includes only CAM or “integrative medicine” centers that are easily locatable through web searches and given that I didn’t wade too deeply into Google to find every last one. With those qualifications, here is the list that I came up with:

Of course, sheer number of programs matter relatively little. What really matters, at least to me, is what is being offered to patients and/or taught to students, residents, and fellows through these programs. So I did a little perusing. The first thing that became immediately apparent is that nearly all of the centers or programs above either offer to patients or teach all or most of the following CAM modalities:

Acupuncture
Guided imagery
Massage therapy
Nutritional counseling
Tai Chi
Yoga

The inclusion of these modalities as first choices in “centers of integrative medicine” is not surprising for two reasons. First, they are fairly harmless for the most part. Second, there is some evidence to support some of them. Indeed, some of them (guided imagery and nutrition, for example) are not necessarily even “alternative” but really should be considered part of “conventional” medical therapies. And, of course, massage therapy, outside of the possibility that it might have a therapeutic effect in certain conditions, at the very minimum feels very good, while Tai chi and yoga can be viewed as low impact exercise, and are probably also at the very least not harmful. Finally, who can argue with nutritional counseling? And why is nutritional counseling considered “complementary,” “alternative,” or “integrative,” anyway? Nutrition is a part of conventional medicine, whether alternative medicine mavens believe it or not. Of course, it depends upon what exactly patients are being told. If they’re being told that megadoses of this supplement or that will treat cancer, then that’s what I call “alternative” nutrition, rather than good, old-fashioned, boring, science-based nutrition. Overall, though, among CAM therapies, the above subset appears to include modalities chosen because they are the least bizarre and therefore the most “safe” for consumption by academic physicians.

To go a step further and find out how much truly unscientific medicine there is in academic medical centers, I decided to identify which centers, if any, either offered to patients or taught uncritically two of the most scientifically implausible of all CAM modalities: homeopathy (which is nothing more than a highly ritualized placebo in which a “remedy” is, as homeopaths will now admit, diluted to the point where there is not a single active molecule left) or reiki therapy (which postulates that a reiki master can somehow manipulate the flows of qi, or the life energy of the patient for therapeutic effect). Note that therapeutic touch, “healing touch,” and a variety of other “energy-based” healing modalities are very similar to reiki in that they postulate that there is some sort of “life force” that the healer can manipulate for therapeutic intent. Neither of these treatment modalities are supported by science. For example, for homeopathy to work, much of what we know about physics, chemistry, and biology would have to be wildly wrong. I therefore chose these two modalities, which are probably the most common of CAM/integrative medicine modalities with the least scientifical plausibility as a weathervane of sorts, to see which way the wind was blowing with respect to seriously non-evidence-based mystical fluff finding its way into medical schools as serious treatment options. The results were disturbing, to say the least, particularly what some of these ostensibly “academic” centers wrote about these modalities on their websites. Here are the medical centers that offer and/or teach reiki or some other form of “energy medicine,” along with what the each program’s web page says about it, if anything:

Cleveland Clinic: “Reiki is a method of energy-based healing involving the laying on of hands by the practitioner, promoting a deep sense of relaxation for the client. Reiki can help patients access their abilities to promote their own healing in body, mind and spirit.”
Integrative Medicine Program, Children’s Memorial Hospital, Northwestern University: “Our bodies are always trying to move toward balance and health. Energy healing encourages the flow of our natural energies. The term “energy healing” covers a wide range of styles and techniques which serve to positively affect the human energy field. Hands-on energy work assesses disturbances in the human energy field, and helps to aid the individual’s body to enhance the natural flow of healthy life force. Patients and their families report that energy healing often provides a sense of deep relaxation, and reduction in the experience of pain. Energy healing is also called “touch healing” in our studies. Research is presently being conducted to provide evidence to show how the disturbances and movement of these subtle energies may affect the physical condition of the human body.”
Albert Einstein College of Medicine: “I use Reiki in addition to other healing practices to help my patients activate their innate capacity for self-healing. By promoting a relaxed and peaceful state, stress is decreased, immune function is enhanced and the body has a greater ability to heal. As a practitioner I also benefit from this work; through centering myself I feel both calm and energized.” Aurora Ocampo, MS, RN, CS
Duke University: Reiki is a spiritual healing practice that helps restore emotional, mental, physical, and spiritual balance. “Rei” means universal or highest and “Ki” means subtle energy. Practitioners learn to channel primordial chi (or Tao), which may be thought of as universal consciousness. Essentially, both practitioner and client enter a space of meditation so that spiritual, mental, emotional, and physical healing is facilitated…The practitioner lays hands on several different places on the body for several minutes at a time as the individual lies fully clothed on a massage table. People typically feel very relaxed and peaceful during a treatment, and sometimes fall asleep. After a one of two day class from a reiki master, individuals can begin to practice reiki on themselves and others. This is recommended for people with chronic illness or chronic stress so that daily practice is possible to create more peace and support the ability of the physical body to heal itself.”
Beaumont Hospital: Energy balancing is a complementary method that focuses on promoting health and well being and decreasing responses to stress, anxiety and pain. During these relaxing, non-invasive techniques, the practitioner very gently places her hands in a series of positions on what are believed to be the energy centers/pathways of the body. Contemporary research in this area show some of common responses to treatment include: induced relaxation and calmness; reduction in stress and pain; promotion of wound healing.”
Scripps Center for Integrative Medicine: “In use at Scripps since 1993, Healing Touch is an energy-based, non-invasive treatment that restores and balances energy to help decrease pain and relieve associated anxiety. Healing Touch is performed by registered nurses who recognize, manipulate and balance the electromagnetic fields surrounding the human body, thereby promoting healing and the well-being of body, mind and spirit. Healing Touch is often used as an adjunct to surgery and other medical procedures to assist in pain reduction, relaxation and healing.
University of Connecticut Health Center
University of Maryland
UMDNJ: “Reiki is the natural healing energy that flows through the hands of the Reiki channel in a powerful and concentrated form. Reiki functions on all levels of a person’s being and adjusts itself according to the needs of the recipient, helping them to take responsibility for their life and to make changes in attitude and/or lifestyle to promote a happier and healthier life.” (At least they say that electromagnetic therapy is not scientifically unproven.)
University of North Carolina-Chapel Hill
University of Texas M.D. Anderson Cancer Center
University of Wisconsin
George Washington University: “The purpose of Reiki is to promote the client’s own natural healing process by providing deep relaxation, abatement of signs or symptoms of distress, or a sense of harmony or balance. Reiki can be used in conjunction with any other treatment to enhance and accelerate its effectiveness.”

Next, here are the medical centers that offer and/or teach homeopathy, along with what they say about it on their websites (that is, if they say anything at all):

Thomas Jefferson University: “Homeopathic medicines are intended to stimulate the body’s own healing abilities. Homeopathy utilizes a wide range of mostly naturally occurring substances such as plants and minerals. These medicines are prepared through a specific process of stepwise dilution. Many homeopathic medicines contain only an infinitesimal amount of original substance. Although the mechanism by which these “ultradilutions” can work is unexplained, studies have been published in medical journals showing homeopathic medicines may provide clinical benefit.”
University of Connecticut Health Center
University of Maryland
UMDNJ It doesn’t appear that UMDNJ actually offers homeopathy, at least not as far as I can tell, but this is what its website says about it: “Samuel Hahnemann, a German physician conceived the practice of homeopathic medicine, in the late eighteenth century. It was developed in response to the horrific medical practices of the time and is based on the Law of Similars, or ” like cures like”. It embodies the idea that large doses of a substance cause a symptom, and very small doses of that same substance can cure it. Hahnemann and colleagues gathered volumes of descriptions of the symptoms caused by the ingestion of various plants, minerals, animal products, and other substances. When a patient came into the clinic with a series of complaints, these texts were consulted, and the preparation that caused the most similar response was given to the patient. These books, called Homeopathic Pharmacopoeia, are the basis of modern homeopathic therapy. The focus of homeopathy is on the symptoms. Symptoms are seen as attempts by the body to restore health…It works slowly and is thought to have a number of systematic benefits. Homeopathic medicine is very individualized. Treatment is based on the person’s response to the disease, so the actual cause of the disease is not a focus. Remedies are very dilute substances, which are prepared through a process of potentization, which involves repeatedly diluting with either water or alcohol and shaking a remedy (perhaps 100 times). Some solutions are diluted as low as (10)-30 or (10)-20,000. Various homeopathic medicines have been incorporated into modern conventional medical practice. Nitroglycerin was first used as a medicine by a homeopath. Digitalis and gold salts are other examples.”
University of North Carolina-Chapel Hill
University of Washington School of Medicine: “When dilutions greater than 24x or 12c are prepared, basic chemistry holds that it is unlikely than even a single molecule of the original substance is still present in the remedy, leading many to question how such a therapy could work. Homeopathic theory explains that the vigorous shaking or succusions leave an imprint of the substance being diluted, and that it is this imprint which can stimulate healing in the body, stimulating the body’s own healing responses.”

This is by no means a complete list of schools offering “energy medicine” or homeopathy. One reason is that many of the sites don’t list the actual modalities that are offered. Instead, they describe their programs using vague generalities about offering multiple CAM modalities or about “integrative consultations.” Also, I didn’t exhaustively peruse each website, although I do note that in my surfing not a skeptical word was found. Some may say that it’s really not so bad that I found five, maybe six at the most, medical schools or academic medical centers that offer homeopathy to patients and/or teach it to trainees. That anyone in academia would think that shows just how far we’ve fallen. Personally, I found it truly depressing that even a single medical school teaches homeopathy uncritically and offers it to patients. After all, even NCCAM admits the scientific implausibility of homeopathy and has funded only one study of homeopathy.

I also looked at miscellaneous CAM modalities while perusing all these websites and noticed that there are even a couple of centers offering reflexology, including the University of Maryland and the University of Pittsburgh, the latter of which advocates it for migraines, hypertension, fibromyalgia, and menstrual cramps, among other things. One (the University of Wisconsin, whose integrative medicine pages appear to have been removed since I first started researching this post) even made a totally unsupportable statement about CAM for cancer about “choosing therapies that help prevent cancer or prevent a recurrence,” where preventing a recurrence is something for which there is no good evidence that CAM do. One other (Thomas Jefferson University) even touts Rudolf Steiner’s anthroposophically Extended Medicine. Sadly, that’s not all. I found the University of Maryland offering craniosacral therapy, while UCSF offers spinal manipulation. Meanwhile, the Susan Samueli Center for Integrative Medicine at UC Irvine claims to be able to treat depression, hypertension, leukopenia, schizophrenia, allergies, diabetes, and cornucopia of other conditions.

After looking over these websites, I came to the conclusion that the vast majority of university hospital-based CAM programs appear not to apply a critical, scientific view to CAM modalities. Rather, the impression I get is that the faculty in most of these programs are probably believers. Indeed, I found very few indications of any serious scientific examination of whether these CAM therapies actually work (i.e., result in more of an effect than a placebo for real disease or pathology). Worst of all, instead of first asking, “Do these therapies work?” these programs seem to be assuming that they do work and then asking either “How do these therapies work? or “How can we combine these therapies with conventional therapies?” A quote from the U.S. News & World Report article epitomizes this attitude:

Those who work in academic CAM programs freely concede there is much about CAM that they do not comprehend—yet—but they also argue that the standards of western medicine should not block its use. Just because all of the evidence isn’t in, says Donald Abrams, director of clinical programs at UCSF’s Osher Center, “should I never try these therapies with my patients?”

Not only is that a combination of a straw man argument and an appeal to other ways of knowing, but it’s also putting the cart before the horse and of questionable ethics to boot. One of the most accepted principles of medical ethics is that, unless a therapy has solid evidence to support it, that therapy should not be offered to patients outside of the context of a clinical trial designed to study its efficacy. Yet, here we have a respected physician arguing that unproven therapies shouldn’t be denied to his patients. He would have a point if there were compelling, but imperfect, evidence that they might work, but such is not the case. I would respond to him by saying that he could do basic science and randomized clinical trials to test these therapies but that he shouldn’t be offering them to patients outside the context of a clinical trial.

One question that remains after looking at the increasing acceptance and even boosterism for CAM and integrative medicine in academia is a simple one: Why? Insurance doesn’t pay for the vast majority of these therapies, insurance companies, whatever their greed and other well-known shortcomings, having decided that there is no evidence that they work. Consequently, it’s cash on the barrelhead for academic medical centers reeling from recent cuts in Medicare and Medicaid reimbursement.

Still, that’s not enough to explain it. So what is? It turns out that, if you look closely at these centers, many of them are the result of a donation or endowment from a wealthy donor (or donors), as is the case for Duke University, Thomas Jefferson University, Columbia University, UC Irvine, Children’s Memorial Hospital, just to name a few. If it’s not a wealthy donor, it’s the Bravewell Collaborative. Also not to be underestimated is the publicity and marketing clout that having a famous media doctor, such as Andrew Weil or Mehmet Oz on the faculty provides. Alternatively (if you’ll excuse the term), it’s NCCAM funding that drives the creation of these centers, which is a reason why I’ve become less hostile to Dr. Sampson’s view than I used to be. As he points out, the assault on science-based medicine being taken to the very heart of academia appears to be part of a broader agenda designed to transform the very nature of medicine away from science and evidence, and, either willingly or as a useful but unwitting ally, NCCAM appears to be doing a lot to promote this transformation. Remember, NCCAM was not created because scientists or doctors clamored for it; it was created because powerful politicians with a penchant for alternative medicine demanded it.

The final question that inevitably comes up in discussions of offering CAM at academic medical centers is: What’s the harm? Why be so negative? After all, patients seem to want it, and if it makes them happy, what’s the problem, as long as the therapies being offered appear to be harmless?

Academic medicine is supposed to be different. It is supposed to exist for the purpose of applying scientific principles to medicine and thereby making new discoveries to use to treat disease, testing them in clinical trials to find out if they are effective, and then applying them systematically. Uncritically introducing therapies that are by their very nature unscientific, therapies like homeopathy, reiki, reflexology, and “energy medicine” taints the entire scientific enterprise at these institutions. Worse, offering such therapies outside the context of a clinical trial in academic medical centers gives the patina of scientific credibility to therapies that have not earned it, promoting the impression that science supports their efficacy. Moreover, it is bandwagon medicine, where the therapy is offered and evidence is sought post hoc to demonstrate its efficacy. That this happens in “conventional” medicine as well (the rapid introduction of laparasocopic cholecystectomy 15-20 years ago, for example) and that it is driven by patient demand are not justifications for allowing it to happen for CAM as well. Neither is the fact that sometimes therapies adopted before clinical trials demonstrate efficacy (laparoscopic cholecystectomy again) do turn out to be an improvement. The adoption of CAM in so many medical schools, with many more clamoring to jump on the bandwagon, appears to be a step backward. Medicine has finally, after over a hundred years, evolved to the point where it can actually become truly science- and evidence-based. From my perspective, the growing uncritical acceptance of CAM in academic medicine is a major threat to the continuation of that evolution. There should be no such thing as “alternative” medicine, anyway. There is medicine that is effective, as determined by science and clinical trials, and there is medicine that is not or is as yet unproven. We should not be “integrating” the latter with the former, and especially not in academia.

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David Gorski

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The infiltration of complementary and alternative medicine (CAM) and “integrative medicine” into academia

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