A week ago at QEDCon, I was honored to give a talk about “integrative” medicine, specifically how it is little more than a vehicle for advocates of pseudoscience to use to “integrate” quackery with medicine. Unsurprisingly, the University of California, Irvine (UCI) featured prominently in the talk, specifically the $200 million donation by Susan and Henry Samueli to “transform” the medical campus by creating a new center for integrative medicine that will encompass at least four schools and provide 15 endowed chairs to promote research, education, and clinical practice in integrative medicine. Naturally, we at SBM were quite critical. Steve Novella, for instance, used one of my favorite terms to refer to it as quackademic medicine at UCI, noting how Michael Hiltzik had reported that UCI started frantically trying (and failing) to scrub all references to The One Quackery To Rule Them All (homeopathy) from its online presence. Meanwhile, a friend of the blog noticed that studying homeopathy had been baked into a 2003 gift agreement between the Samuelis and UCI. In response, advocates of integrative medicine, stung by the criticism, lashed out, with one even going so far as to charge that those of us critical of UCI’s integration of quackery with medicine have “blood on our hands” while trying to paint us as “anti-science” and repeating his tired old trope of comparing critics of integrative medicine to Donald Trump.
We at SBM frequently discuss how integrative medicine serves as a vehicle to integrate quackery, such as acupuncture, naturopathy, functional medicine, and even homeopathy, into medicine. This is indeed a pernicious effect. Less often do we speak of what integrative medicine does to actual potentially science-based treatment modalities involving lifestyle, nutrition and diet, exercise, and the like, which is to “rebrand” it as somehow being “alternative” and thus of a piece with all the quackery. That’s why I think it’s worth discussing UCI once again, because it has published the fall issue of its magazine with the Samuelis on the cover and the tagline, “reimagining the future of health,” and there are several articles in it touting integrative medicine at UCI and what the school will do with the Samueli donation.
But, first, a word from Andrew Weil…
If there’s anyone who could be called the Big Kahuna of the world of integrative medicine, it’s Andrew Weil. That’s why a letter to the editor of the LA Times, which published Hiltzik’s critical article about the UCI gift, “A $200-million donation threatens to tar UC Irvine’s medical school as a haven for quacks,” by Weil caught my eye as a nice prelude to wading into the UCI Magazine articles themselves. In a letter entitled “Why more doctors are embracing scientifically sound integrative medicine,” Weil provides us with a succinct example of what UCI and the Samuelis do on a regular basis: Try to represent integrative medicine as being science-based. First, he takes umbrage:
We take umbrage at Michael Hiltzik’s column challenging the Samueli family’s $200-million donation to UC Irvine for integrative medicine. Hiltzik is concerned that the donation will “integrate quackery” into the curriculum and “tar” the reputation of the medical school. (“A $200-million donation threatens to tar UC Irvine’s medical school as a haven for quacks,” Sept. 22)
Take all the “umbrage” that you want, Dr. Weil. The truth hurts. Dr. Weil then attacks a straw man:
“Quackery” refers to dishonest practices performed by those who pretend to have special knowledge and skill in some field. In contrast, integrative medicine, or IM, is defined as healing-oriented medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the entire patient and body systems, is informed by evidence, and makes use of all therapeutic and lifestyle approaches to achieve optimal health and healing.
No, quackery refers to ineffective and/or pseudoscientific treatments represented as medicine. Although many quacks are dishonest, quack practices do not necessarily have to be dishonest, nor do the practitioners have to “pretend to have special knowledge.” I can point you to an example of someone who illustrates that principle quite nicely: Britt Hermes, the naturopath who realized that what she was doing was quackery and as a result left naturopathy to study to become a scientist and to tell the world about her former profession. I just spent some time talking to her at QEDCon, and I also know from her past articles and talks that when she was a naturopath she really believed in what she was doing and that naturopathy did great good. I have no doubt that the Samuelis, the UCI, and even Dr. Weil himself believe that the quackery they embrace improves medicine.
Let’s take a look at that definition, though. It’s basically a minor rephrasing of the definition of integrative medicine on the University of Arizona Center for Integrative Medicine website, other variations of which can be found all over the place in integrative medicine literature. Typically, it incorporates many of the tropes that integrative medicine advocates want you to believe about the “discipline.” I call them tropes because they are oft-repeated by advocates, but, more importantly, there is a major assumption behind all of them, which is that conventional medicine doesn’t do these things or that it disagrees with these things. For instance, take a look at the list on the UA website after the definition of integrative medicine that Dr. Weil paraphrased:
The Defining Principles of Integrative Medicine
- Patient and practitioner are partners in the healing process.
- All factors that influence health, wellness, and disease are taken into consideration, including mind, spirit, and community, as well as the body.
- Appropriate use of both conventional and alternative methods facilitates the body’s innate healing response.
- Effective interventions that are natural and less invasive should be used whenever possible.
- Integrative medicine neither rejects conventional medicine nor accepts alternative therapies uncritically.
- Good medicine is based in good science. It is inquiry-driven and open to new paradigms.
- Alongside the concept of treatment, the broader concepts of health promotion and the prevention of illness are paramount.
- Practitioners of integrative medicine should exemplify its principles and commit themselves to self-exploration and self-development.
No one—and I mean no one advocating for science-based medicine—disagrees with #1, 2, 5, 6, 7, or 8. In fact, we wouldn’t have (much of) a problem with #3 if it didn’t include alternative medicine in it or even #4 if it didn’t make the false assumption that natural is better and instead stuck with suggesting only that less invasive therapies should be used whenever possible. I also can’t help but point out that when you compare reality to #5 you will often find that in much of integrative medicine alternative medicines are accepted uncritically. UCI itself is a great example, given the history of naturopaths using homeopathy there, but I could also point to Harvard, Georgetown, George Washington University, the Cleveland Clinic, and the University of Kansas, among many others.
Dr. Weil then tells us integrative medicine is all about the evidence, man:
These studies have yielded robust enough results that medical societies include IM in clinical guidelines. For example, the American Heart Assn. states that meditation “may be considered a reasonable adjunct to guideline-directed cardiovascular risk reduction,” and the American College of Physicians recommends acupuncture and mind-body approaches for low back pain.
I’ve discussed the ACP recommendations before. They’re based on really weak evidence, as I mentioned when last I discussed the Samueli gift. Similarly meditation and mindfulness studies are plagued with methodological problems, not the least of which is an extreme lack of standardization of definitions of basic terms, such as “meditation” or “mindfulness,” as Steve Novella pointed out recently. That’s probably why the best even an advocate can point to is a statement from the AHA that meditation “may be” a “reasonable adjunct” to guideline-based modalities. One can’t help but wonder why, if integrative medicine is so science-based, Dr. Weil couldn’t come up with better examples to support his argument than this truly thin gruel. Moreover, even if it turns out that meditation has cardiovascular benefits, then it would simply become part of science-based medicine, no need for a separate specialty devoted to rebranding lifestyle medicine as somehow “alternative” needed.
Integrative medicine everywhere, but not a mention of what it really is
Like nearly all universities, UCI produces a slick quarterly magazine in which it touts its activities and achievements, the better to garner donations from alumni and other interested parties. The cover of the fall issue features the Samuelis beaming at the camera as they apparently “reimagine” the future of health. Within the pages are five—count ’em, five!—articles on integrative medicine, UCI, and the Samuelis, plus a graphic defining health:
There’s also a quote from Dr. Howard Federoff, the Vice chancellor for health affairs and CEO of UCI Health:
The future of health lies in an integrative approach that recognizes no two patients are alike. Our individual genomes, history, lifestyle and decisions make each of us unique and deserving of the best possible care. At UCI, doctors and allied health professionals will use scientific evidence, cutting-edge therapies and traditional medicine to pave the way for a healthier tomorrow.
Yes, each of us is unique, but we’re also not so unique that we can’t identify what treatments work in large groups of us.
Here are the articles:
- “Just What the Doctor Ordered“
- “A Heart for Healing“
- “Wellness Champion“
- “Whole-Body Experience“
- “A Picture of Health“
Each is slick. Each is glossy. Each is very PR-savvy. Recall, now, that the $200 million is to be allocated thusly: $50 million towards construction of a facility to house the Susan and Henry Samueli College of Health Sciences, which, we learn, is to be matched by UCI, which will also contribute $50 million to build this facility, projected to open in 2021. We also learn that one-third of that space will be occupied by the Susan Samueli Integrative Health Institute, described as a “hub for educational programs and research on nonconventional and complementary treatments, such as acupuncture to relieve pain and meditation to control stress.”
Over and over and over again, the articles emphasize how science-based everything is going to be. For instance, in the first article, here’s Dr. Federoff:
Dr. Howard Federoff, vice chancellor for health affairs and CEO of UCI Health, says that several nonconventional treatments are “poised to go mainstream” but need further study before they’re “ready for prime time.” Anecdotal evidence isn’t enough, he cautions. Citing aromatherapy as an example, he says the benefits described by patients must be confirmed by “rigorous” experiments.
I’m always amused at how integrative medicine proponents are always claiming that there are “several unconventional treatments” that are on the verge of being validated and “going mainstream,” but somehow none of them ever really do. It would be one thing if this infiltration of alternative medicine into academia were a new thing, but it’s been going on close to 25 years now, and yet it’s always the same old song. As for aromatherapy, yes, humans like good smells. They can lift our spirits. It’s like massage. It feels good when done properly. The problem, as with so much of “complementary” medicine is when specific medical claims are made for such modalities.
Dr. Shaista Malik, a cardiologist who directs UCI’s existing Susan Samueli Center for Integrative Medicine echoes Dr. Federoff’s sentiment:
Malik agrees: “The science for many of these remedies isn’t there yet, except in bits and pieces. Our mission in the next 10 years is to research not only whether a method works, but how it works.” Among other things, that entails taking steps to rule out “placebo effects.”
Once a treatment’s effectiveness is scientifically validated, UCI will offer it to all patients and think about incorporating it into the curricula, Federoff says.
I’ll give Dr. Malik credit for speaking the right words. For instance, she says “whether” a method works, but if there’s one thing I’ve come to discover about advocates of integrative medicine, it’s that whenever they say they will study “whether” and “how” a treatment works, the evidence they accept as confirming “whether” a study works is generally pretty low quality and they tend to spend their time doing what Harriet Hall likes to call “tooth fairy science” studying “how” a pseudoscientific treatment works. Acupuncture is a fantastic example. Despite the manner in which the totality of the evidence base for acupuncture strongly supports the conclusion that it does not work detectably better than placebo for anything, there is a huge cottage industry of researchers studying “how” acupuncture “works,” complete with functional MRI studies, animal models, and electrophysiology.
None of this professed devotion to hard core scientific evidence, I note, stops UCI from offering an optional three-year integrative track for its family medicine residents, in which residents cover acupuncture, mineral supplements, traditional Chinese medicine and “holistic cures.” Depressingly, two-thirds of the residents opt for this track. That’s because integrative medicine is all about the future, ma-an, unlike us hidebound relics of the past:
“The current generation of students is far more open-minded” than the medical establishment, Federoff notes. For that reason, it may take a decade or so for UCI’s approach to gain wide acceptance, he says.
Federoff, an exercise buff who formulated a few ideas for UCI’s new health paradigm during early morning runs and bike rides, says his own receptiveness to avant-garde therapies grew out of nearly 30 years as a neuroscientist. Having watched one dogmatic theory after another get toppled by new discoveries, he says, “I came to believe there’s a lot we don’t know. You can’t look at the world through a lens that was ground 100 years ago and believe that’s the only way to look at the world.”
Of course, this is utter and complete nonsense. Science has changed medicine in unbelievable ways over the last 100 years—even over the last 30 years. In my own specialty, I’ve watched and adapted as breast cancer treatment has changed radically since my time in medical school. Let’s put it this way. If we were truly viewing medicine through a lens that was ground 100 years ago, we’d still be doing radical mastectomies for breast cancer and treating people for “autointoxication” from their own feces as the root cause of ailments large and small, even psychiatric ones. (Anyone remember Dr. Henry Cotton?) I would counter that integrative medicine is the force in medicine looking at the world through a lens that was ground 100 years ago—or even 1,000 or 5,000 years ago—not conventional medicine.
A picture of health?
Of the remaining articles, two focus on faculty members studying integrative medicine, one on patient testimonials (yes, patient testimonials), and the last one on Susan Samueli. One faculty member, Dr. Malik, provides an excellent example of how conventional science-based medical interventions are relentlessly “rebranded” as somehow “integrative.” In the profile of her, we learn that she became a cardiologist because there was a strong history of heart disease in her family, with many family members having heart attacks in their 40s and 50s, and that, observing how so many patients just went back to their same unhealthy lifestyles after stenting or bypass surgery, she decided to try to do something about it:
Hoping to break the cycle, Malik launched a cardiac prevention program at UCI five years ago. Over eight 90-minute sessions, participants conferred with a dietitian and an exercise physiologist on strategies to lose weight and restore their well-being.
The results were often dramatic, she says: “I could see the power of nutrition and lifestyle adjustments to improve people’s health trajectory.”
None of this is outside of science-based medicine, and none of this is in any way “alternative.” Unfortunately, as is so often the case in integrative medicine, it wasn’t long before she went down a pseudoscientific path. First, it was stress reduction, which isn’t pseudoscientific, which led to yoga, which isn’t pseudoscientific as long as it is treated as a form of exercise, but then she went down a dubious road:
After noticing that her cardiac group exercised more and ate better while practicing stress management techniques, Malik started exploring other treatments offered by the Samueli Center.
“I had women with microvascular disease who were taking eight or nine medications but still showing symptoms,” she recalls. So Malik added acupuncture to their treatment plans and, she says, the symptoms cleared up.
Another set of patients couldn’t take anti-cholesterol statin drugs because of side effects. Malik put them on herbal supplements – such as berberine (derived from barberry), artichoke extract and citrus bergamot, alone or in combination with decreased statin doses – and again achieved positive results, she says.
Overall, she notes, the cardiac prevention program’s success rate (loosely defined as long-term weight loss, regular exercise and lower cholesterol) rose from roughly 35 percent before integrative methods to nearly 55 percent after. About 300 people have been through the program, which also includes lab tests, genetic screening and cardiac imaging to assess heart disease risks.
I was interested to see if Dr. Malik had published any of these amazing observations. So I did a PubMed search, which is rather difficult because Malik is a common name but somewhat easier because apparently her entire career thus far has been at UCI. To her credit, she has a nice large R01 grant to “study how blood, genetic and imaging tests can predict who will develop heart disease,” none of which involves the “integrative” modalities she’s touting. In fact, her publication record is admirably and boringly…conventional. If she’s published her results with herbal supplements, acupuncture, and success rate of her program, I haven’t been able to find it. It’s almost as though a double standard were operating, where she does rigorous science for “conventional” cardiology but accepts a lesser standard of evidence for all the “integrative” stuff. Annoyingly, the article conflates her NIH grant with the woo she’s into.
As for rigorous science, the article on UCI physicians and researchers rather belies that claim. Yes, there are researchers examining exercise and nutrition. Dr. David Kilgore, for instance, works on managing stress, helping patients learn to eat a healthier diet, and manages a healthy food pantry. There’s also an orthopedic researcher named Joyce Keyak who is testing a technique to add radioisotopes to bone glue and using it to “precisely treat cancerous tumors while fortifying weakened or fractured bones.” What this has to do with “integrative medicine,” I have no idea. Then there’s Dr. Mahtab Jafari studying Rhodiola rosea, a golden flowering plant that grows in the Arctic, as a potential anti-aging drug. In other words, she’s doing traditional pharmacognosy. Finally, there’s Dr. Aimee Pierce, who is part of the 18-month, national EXERT Study, which aims to determine if exercise by seniors can prevent or delay the onset of Alzheimer’s disease. None of these studies or activities are in any way “alternative” or objectionable from a scientific standpoint.
However, there’s also quackademic medicine there, too. For instance, Dr. Anna Monique Halbeisen practices osteopathic manipulation:
Halbeisen practices neuromusculoskeletal/osteopathic manipulative medicine with an eye toward integration, working with a team of highly qualified health professionals to empower her patients to take a proactive role in their own care, particularly when it comes to managing stress.
“I don’t see a single patient with low back pain that doesn’t deal with stress,” she says. “But we all hold stress differently in our bodies, depending on our life experiences and our injury patterns. When times get tough, usually that’s when we see a lot more physical manifestations of issues. You really cannot separate the mind and spirit from the actual physical body.”
Hint: Osteopathy is not supported by anything resembling rigorous science.
Then there’s Dr. John Longhurst, who is studying acupuncture:
Now the lab is examining auricular acupuncture, which stimulates different points of the ear, to determine its effects on pain and hypertension. The team also is looking into how electroacupuncture might benefit menopausal women.
“Acupuncture is just one of many forms of therapy that activate our body’s own ability to heal itself,” Longhurst says. “It triggers endorphins, enkephalins and dynorphins – opiates that we produce naturally. We can demonstrate how acupuncture works down to the cellular level. When we do that, it changes people’s notions about it.”
Um, no. You can’t. Because acupuncture doesn’t work. Auricular acupuncture, in fact, is based on completely pseudoscientific ideas mapping organs and body parts to places on the ear. Let’s just put it this way. If you’re studying auricular acupuncture with the belief that it might have benefits, you are not being “scientifically rigorous.”
This is what integrative medicine does, though. It “integrates” quackery with science as though they were equivalent, using scientifically plausible treatments, such as nutrition and exercise, as cover for the pseudoscience like osteopathy and acupuncture.
We see this in the testimonials prominently featured. One patient, Dannie Cassell, has metastatic breast cancer and developed heart disease. Dr. Malik helped her alter her lifestyle and diet to increase healthy eating and have her do more exercise. Mel Shubash has chronic back pain and came to Gottschalk Medical Plaza’s Center for Pain Management, where he has been receiving science-based approaches, such as physical therapy, epidural injections, and steroid injections, but also doing yoga and acupuncture. Justina Cortes was obese and prediabetic, and suffered from panic attacks as well. She’s been undergoing lifestyle and nutrition counseling and has done very well, to the point where she is no longer prediabetic. Lesley Ginsburg was diagnosed with ovarian cancer and underwent grueling surgery and chemotherapy. I found what her doctor, Dr. Robert Bristow, director of gynecologic oncology services for UC Irvine Health was quoted as saying to be highly telling:
Bristow says he’s a “huge fan” of integrative health. “For the most part, modern medicine is driven by clinical trial-based work that’s been proven and published in the New England Journal of Medicine,” he says, “but we can lose sight of other treatments that are also effective. We limit ourselves as doctors.”
He advocates everything from art therapy to acupuncture – not as a substitute, but to offer relief from highly invasive traditional cancer care. Painting classes, for example, could provide a beneficial routine for cancer patients also suffering from depression – and could be vital. If people can’t get out of bed, he notes, they’re not going to make it to chemotherapy.
This is, of course, true, but one doesn’t need acupuncture to overcome depression and fatigue. Similarly, there’s nothing wrong with painting classes, music, or other activities to keep one’s mind occupied while going through care. We used to call such activities patient support or morale services. What integrative medicine does is to medicalize them unnecessarily.
The author of it all
The final article is a portrait of Susan Samueli, the author of it all. What is revealing, if you know it, is more what is left out of this portrait than what is told. For instance, after she married her husband Henry:
Eventually, they married, moved to a comfortable San Fernando Valley home of their own and began a family. She gave up her IBM career after 13 years. It was then that she began fully exploring her newfound passion for complementary care approaches.
“I started learning everything I could about what was then called alternative medicine,” Samueli says. “I was using a different side of my brain than I did with computer programming, and it felt great. And then my children were born.”
When their first daughter became sick at 4 months old and was given antibiotics, she suffered side effects that troubled her mother.
Samueli discussed it with her husband and said, “I’m going to take her off the antibiotics and try alternative treatments.” He agreed, noting that the baby might have a virus anyway, rendering the antibiotics useless. To her delight, their daughter was quickly restored to good health.
What we know from other sources is that Susan Samueli’s passion for alternative medicine developed when she developed a cold on a trip to France and was offered a homeopathic remedy (aconite), which she tried. Because she had a cold, she got better, but she became a believer. Indeed, she is now a homeopath herself, having received a PhD in nutrition from the American Holistic College of Nutrition in 1993 and a Diploma in Homeopathy from the British Institute of Homeopathy in 1994. She converted her husband, who is now a believer himself, such that he has been quoted as saying:
When I feel a cold or flu coming on, rather than run to the doctor, I run to Susan to figure out which homeopathic remedy or Chinese herb I should be taking.
Indeed, she quacks:
She earned nutrition and naturopathy degrees and opened a nutrition business in Northridge. Her clientele grew, she recalls, as she guided other people weaning their children off antibiotics.
“Very often, they were hyperactive because of antibiotics, and so the parents were very, very thankful that we could get them off round after round and get them healthy,” says Samueli, who – working with doctors and their care plans – also was able to help adults going through chemotherapy avoid nausea and anxiety and help chronically ill individuals experience less stress and greater well-being.
One wonders what these children were on antibiotics for.
Quackademic medicine ascendant
In the end, the Samuelis’ $200 gift will indeed transform biomedical sciences and medical education at UCI—and not in a good way. Remember what “integrative medicine” is. What is being “integrated” into medicine is, of course, quackery. Oh, sure, integrative medicine also emphasizes lifestyle modification, such as diet and exercise, but that is part of “conventional medicine” already. There is no good scientific or medical rationale for a separate specialty devoted to just that. What integrative medicine does is that it rebrands perfectly science-based modalities, such as diet and exercise, as somehow “alternative” and then “integrates” quackery, like naturopathy, acupuncture, functional medicine, applied kinesiology, homeopathy, and basically any form of quackery you can think of. Without the quackery, there is no integrative medicine. Worse, the phenomenon has resulted in a most pernicious effect in medical academia, the infiltration of outright quackery into the research and education efforts there, a phenomenon I like to refer to as “quackademic medicine.” What is happening at UCI is the ultimate triumph of quackademic medicine.
Of course, The Very Serious Academics In Very Serious and Very Pressed White Coats who have come to believe in integrative medicine to the point of devoting their careers to it, such as Dr. Federoff and Dr. Malike, vehemently disagree with my characterization. I’m referring to the sort of doctors who present at conferences of learned academics and write what they claim to be evidence-based care guidelines for breast cancer patients. Perhaps the best thing to mention to rile up serious academic advocates of integrative medicine is homeopathy. Any mention of homeopathy is guaranteed provoke paroxysms of self-righteous denial. “Oh, no,” they’ll say, “homeopathy is pseudoscience! It’s quackery. Integrative medicine is evidence-based, and we would never do anything that isn’t evidence-based!” Sadly, as I’ve pointed out time and time again, you can’t have naturopathy without homeopathy, as homeopathy is an integral part of naturopathy. As long as you have naturopaths, you will have homeopathy. Oddly enough, many of these The Very Serious Academics In Very Serious White Coats are utterly oblivious to this simple fact, even ones who write Very Serious Clinical Guidelines with naturopaths and welcome naturopaths into their Very Serious Medical Society.
Dr. Federoff and Dr. Malik might actually believe that their center will be different from all the other integrative medicine centers, that theirs will be a scientifically rigorous integrative medicine program. As long as they stick with the modalities that integrative medicine has claimed from science-based medicine and rebranded, like nutrition, exercise, lifestyle, and stress reduction, they might have a chance to pull it off. However, Susan Samueli is a strong believer in homeopathy. There are doctors offering quackery like auricular acupuncture and osteopathy at UCI. There is at least one naturopath there whose “preferred mode of treatment” is homeopathy:
If Dr. Federoff is serious about being rigorously science-based, the first thing he needs to do is to get rid of all the doctors using auricular acupunctures, naturopaths, and homeopaths. Will we see that? Of course not. That’s why any claim made by the UCI administration that somehow its integrative medicine center and activities will be science-based is either a lie or self-delusion.