Medicine is a collaborative practice. Hospitals are the best example, where dozens of different health professionals work cooperatively, sharing responsibilities for patient care. Teamwork is essential, and that’s why health professionals obtain a large part of their education on the job, in teaching (academic) hospitals. The only way that all of these different professions are able to work together effectively is that their foundations are based on an important, yet simple, principle. All of us have education and training grounded in basic scientific principles of medicine. Biochemistry, pharmacology, physiology – we all work from within the same framework. As a pharmacist, my role might include working with physicians and nurses to manage and monitor medication use. A team approach is only possible when you’re working from the same playbook, and with the same aim. And in medicine, that playbook is science.
That’s why “integrative” medicine frightens me so much. Integrative medicine is a tactic embedding complementary and alternative medical practices into conventional medical care. Imagine “integrating” a practitioner into the health system that doesn’t accept germ theory. Or basic disease definitions. Or the effectiveness of vaccines. Or even basic biochemistry – perhaps they believe in treatments that restore the body’s “vital force” or manipulate some sort of “energy fields”. Instead of relying on objective signs and symptoms, they base treatments on pre-scientific beliefs, long discarded from medicine. There may be entirely different treatment goals, which are potentially antagonistic to the scientific standard. Imagine a hospital or academic setting where this occurs, and the potential impact on the quality of care that is delivered.
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.
– Mark Crislip
Dr. Crislip’s health care “cow pie” is an effective metaphor for the reality of “integrative” medicine. Medicine today is based on a single scientific standard, with an array of providers divided by specialty and expertise. Integrative medicine explicitly seeks to “integrate” providers that do not provide science-based care, and instead offer treatments that run the spectrum of useless to unproven to potentially dangerous. Positioning of these treatments and services as “integrative” is simply a Trojan horse or branding exercise, aimed at distracting governments and health organizations from recognizing the obvious – that “integrative” products and purveyors can’t meet the established standard of care.
The branding of alternative medicine as “integrative” medicine has been a marketing tactic for at least a decade, with proponents continually citing it as the future of medicine (a future, perhaps, with compromised scientific standards), and opponents simply pointing out that there is no compelling need to “integrate” treatments into medicine that are not grounded in high-quality science.
There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. Whether a therapeutic practice is “Eastern” or “Western,” is unconventional or mainstream, or involves mind-body techniques or molecular genetics is largely irrelevant except for historical purposes and cultural interest. We recognize that there are vastly different types of practitioners and proponents of the various forms of alternative medicine and conventional medicine, and that there are vast differences in the skills, capabilities, and beliefs of individuals within them and the nature of their actual practices. Moreover, the economic and political forces in these fields are large and increasingly complex and have the capability for being highly contentious. Nonetheless, as believers in science and evidence, we must focus on fundamental issues—namely, the patient, the target disease or condition, the proposed or practiced treatment, and the need for convincing data on safety and therapeutic efficacy.
– Phil B. Fontanarosa & George D. Lundberd
Turning the clock back
Medicine wasn’t always grounded in rigorous science. In fact, it was very different just 100 years ago. Formal medical education varied dramatically from school to school prior to 1910, when the American Medical Association commissioned Abraham Flexner to evaluate American and Canadian medical education and make recommendations on their improvement. Flexner was highly critical of the education standards he observed, and recommended consolidating schools, increasing education prerequisites, enhancing the scientific rigor, and embedding the role of research in education. Flexner was also highly critical of dubious “alternative medical practices” and recommended the closure of under-performing institutions that continued to offer education and training based on principles other than science. Not all schools were evaluated to be weak. Highly rated schools included Michigan, Case Western Reserve, Johns Hopkins, and in Canada, McGill University and the University of Toronto.
The effects of the Flexner report on medical education and the practice of medicine (and affiliated professions, like pharmacy) can’t be overstated. Medical education, now grounded in a rigorous foundation of science, rejected and abandoned unscientific practices like naturopathy, homeopathy, chiropractic, and osteopathy. The result is the medical education and care you see today – and the consistent framework for health professionals. Of course, the purveyors and proponents of these now-rejected practices never fully disappeared. They retreated, regrouped, and fought back, craving the public legitimacy and credibility now offered to medicine and its related health professions. What was quackery became “alternative” medicine, and then “complementary and alternative” medicine (CAM), implying these practices could be used alongside other treatments. Today’s CAM is called “integrative” medicine. Old wine in a new bottle. Regardless of the qualifier, it’s simply an end run around the scientific standards that were defined back 1910.
All of this brings me to my hometown Toronto, and my alma mater the University of Toronto, and this job posting from the university:
Director – University of Toronto Centre for Complementary and Integrative Medicine
The Faculty of Medicine and the Leslie Dan Faculty of Pharmacy at the University of Toronto seek a Director to lead their new interdisciplinary program in complementary and integrative medicine, which will be housed in the new Centre for Complementary and Integrative Medicine (CCIM). The Centre will begin with two primary foci: Traditional Chinese Medicine and natural health products. It will support research and health professional education. Applications are invited for the position of Director for a 3-year renewable term effective January 1, 2014.
The mission of this new Centre is to facilitate, conduct, and obtain support for collaborative basic, clinical, and health services research in complementary and alternative medicine; to serve as an educational resource and to develop integrative curricula and educational programs on complementary and alternative medicine; to work collaboratively with other departments within both Faculties and their hospital partners to support the integration of evidence-based complementary and integrative medicine into existing clinical settings and clinical research programs.
Candidates must have a MD and/or PhD degree(s), a strong track record of scholarship and history of peer-reviewed extramural funding. The Director will be expected to maintain a vigorous and independent extramurally funded research program; to build productive collaborations within the University of Toronto and other local and global partners; and to grow CCIM into a nationally and internationally recognized Centre for natural products and complementary medicine education and research.
In addition to a record of academic excellence in a relevant area of research, the successful candidate will possess outstanding leadership, administrative management, communication, and relationship-building skills. The individual will bring an inclusive scholarly vision and strategies to enable the Centre to build and to sustain effective academic partnerships. Candidates should have demonstrated experience in multidisciplinary and collaborative academic environments. Candidates should have a track record of successful and innovative leadership in research and education, and must be eligible for academic appointment at the rank of Associate or Full Professor.
Much has been already been written at this blog about what’s been described as “quackademic” medicine. (Check out David Gorski’s talk on quackademic medicine and the evolution of quackery). Gorski started compiling a list back in 2008 of academic medical centers that offered one or more alternative medicine modalities. Disappointingly, U of T isn’t alone in its plan to push CAM, although this one is the first I’ve seen that includes two faculties: pharmacy and medicine. It’s a clever strategy: If the intent is to change the medical playbook, and the scientific foundation for medical care, you have to hit both the pharmacists and the physicians. Otherwise one will call out the other for quackery. Normalize it for both groups, and there’s less likelihood that either will notice. Most worrying is the explicit objective of pushing CAM interventions into university-affiliated hospitals. Again, normalize the pseudoscience with students, and then embed it in teaching centres, where other health professionals will see it. And finally, change the standard of care. The first salvo will be Traditional Chinese Medicine and then natural health products. None of this is surprising, given the Canadian context.
TCM: The invented tradition
“Even though I believe we should promote Chinese Medicine, I personally do not believe in it. I don’t take Chinese Medicine.”
– Chariman Mao, quoted in The Private Life of Chairman Mao
Traditional Chinese Medicine (TCM) is a collection of beliefs and practices that was accurately described in the 1930’s by a Chinese medical school dean as a “weird medley of philosophy, religion, superstition, magic, alchemy, astrology, feng shui, divination, sorcery, demonology and quackery.” Current practices that are labelled as TCM include herbalism, acupuncture, massage, energy therapy, and dietary interventions. Treatments are based on the idea that they are restoring “balance” or eliminating “energy blockages”. TCM moved from folklore to government embrace when Chairman Mao realized the potential for TCM in the 1950’s as a means of both boosting Chinese pride, but also to address acute physician shortages in a country of 500 million. Without Mao, there would likely be little TCM, so TCM is very much an “invented tradition”.
The “Traditional” qualifier in TCM gives away the game right away: TCM is simply an appeal to antiquity, the belief that because an idea has persisted, it automatically has merit. And just like the term “integrative”, it is yet another qualifier introduced to rationalize away the requirement to treat based on science-based principles. TCM is comparable to Traditional Western Medicine, except traditional “Western” practices that were demonstrably useless (e.g., bloodletting) were discarded from “Western” medical practice – in part because of Flexner’s work.
The remarkable thing about science-based medicine is that it knows no geographic boundaries. If it works, it works. The idea that the Chinese would respond differently to objective, scientific medicine is as absurd as thinking that “Canadian” medicine would differ significantly from “American” medicine simply because we Canadians love maple syrup, Tim Hortons coffee, and socialized health care. If a treatment objectively works, it’s simply called medicine – no qualifiers are needed. Artemisinin is an excellent example. The Chinese identified the herb Artemisia annua in the 1970’s as potentially effective against malaria. This wasn’t testing to see if it could unblock chi: researchers were looking at how effectively parasites were cleared from the body. Scientific research in China subsequently identified the active ingredient and isolated it. The use of the drug has spread worldwide – not as TCM, but simply as medicine. Unlike the herb, however, the drug is now synthetically manufactured, so the dose can be calculated precisely. And chemical variations of the drug have been developed that are consistently absorbed, resulting in a vastly safer and superior product than the herb itself.
- Performing a procedure on tissue below the dermis and below the surface of a mucous membrane for the purpose of performing acupuncture.
- Communicating a traditional Chinese medicine diagnosis identifying a body system disorder as the cause of a person’s symptoms using traditional Chinese medicine techniques
So TCM in Ontario encompasses two functions: The first is the ability to deliver a theatrical placebo which lacks any objective effects. The second is a reference to “traditional” diagnoses and treatment with “traditional” techniques – again, code for practices which are not based on scientific principles, but on historical one. In short, TCM in Ontario means objectively useless needling, as well as giving diagnoses of disease based on prescientific concepts, and giving treatments based on those principles.
TCM and natural health products
The support for TCM isn’t just coming from provincial regulators. Health Canada, the Canadian equivalent to the FDA, administers the Natural Health Product (NHP) Regulations, which are somewhat similar to the American Dietary Supplement Health and Education Act of 1994 (DSHEA). The NHP regulations, like DSHEA, effectively exclude the manufacturers of natural health products from meeting the regulatory standards for drugs. While the Canadian regulations have implemented important steps to improve manufacturing quality, the requirement to show product efficacy was effectively eliminated in the regulations. It’s a boon to manufacturers, but problematic to consumers, as there’s no guarantee that any product approved for sale actually works. Canadians now have access to hundreds of homeopathic remedies deemed “safe and effective” by Health Canada: even homeopathic insect repellent. On the supplement side, failed prescription drugs have been rebranded and marketed as a “natural supplement”, simply because there’s no barriers in place to their sale. And there are now hundreds of TCM products approved for sale. Health Canada approved the following labeling for horny goat weed (Epimedium sagittatum):
Traditional Chinese Medicine used to tonify the kidney and fortify the yang, for symptoms such as frequent urination, forgetfulness, withdrawal, and painful cold lower back and knees. Contraindicated in patients with fire from yin deficiency. If dizziness, vomiting, dry mouth, thirst or nosebleed occur, discontinue use.
In the science-based, reality-based world, there is no yang that needs to be fortified, just as there is no such thing as a yin deficiency. Yet your licensed TCM practitioner can sell you horny goat weed which is Health Canada approved to treat your forgetfulness and cold lower back. And if the University of Toronto is successful with its new Centre for Complementary and Integrative Medicine, this type of material may soon be “integrated” into its medical and pharmacy education. The entire concept is absurd. As an alumnus, I’m appalled and embarrassed. I like to think my pharmacy education was a good one. It was rigorous and grounded in the basic sciences (too much organic chemistry, I thought at the time). And I’ve trained alongside (and work with) many graduates of U of T’s medical school. The Faculty at both schools are among the best and brightest in Canada, and U of T has an international reputation for excellence in education. So it’s deeply disappointing to see this move by the university.
Moves to embed CAM into academic settings start with the assumption that “integrative medicine” is a good thing, in the absence of any data to show that is the case. Based on the information that does exist, it’s reasonable to assume that increasing the levels of “integrative” medicine at the University of Toronto will reduce and compromise the quality of medical and pharmacy education, and ultimately, the quality of care offered to patients. It’s sadly ironic that the University of Toronto, with a medical school lauded by Abraham Flexner in 1910, is now turning its back on those qualities, 103 years later.