Here is the problem (if you are a hospital director) – there is a lot of money to be made selling nonsense and snake oil to patients. In fact con-artists and fake medicine peddlers have done a fantastic job in the last few decades rebranding their snake oil as “alternative” and giving it a patina of legitimacy. Demand is rising, and people are apparently willing to pay lots of money out-of-pocket for false claims and wishful thinking.
Meanwhile, reimbursement for real medicine has declined as part of the attempt to contain skyrocketing health care costs. Profit margins are slimmer than ever. There is only so much you can do by becoming more efficient and cost effective.
If only there were some way to tap into the burgeoning alternative medicine industry. We could market them as “complementary” or “integrative,” that way they will be offered in addition to real medicine. That’s a win-win, because then profits from alternative medicine will be entirely incremental, and we can reassure ourselves that at least we are still giving our patients real treatments.
But there is still the pesky problem of professional ethics. Hospitals sell medical care, not used cars. Medical care is a profession with strict ethical constraints. Since the Flexner report in 1910 in America, there has also been this burdensome tradition of basing medical care on science and evidence. There is an evidence-based standard of care, and some doctors might actually object to violating that standard, violating basic professional ethics, and exploiting patients by making false claims and selling them worthless snake oil. If those doctors make a stink it might be inconvenient.
Still, hospitals are businesses, and businesses can’t afford to leave so much money on the table.
What to do?
Let the rationalizations begin
A recent article in STATnews (in which, full disclosure, I am quoted extensively) discusses the phenomenon of prestigious hospitals offering dubious services. They do a decent job of outlining the problem, and provide some useful quotes from “integrative” proponents. Unfortunately, they felt the need to end with the usual false equivalency and balance, rather than coming to the obvious conclusion that the rest of the article demands. In a way they demonstrated the exact same cognitive process that they critique in their article. They essentially answered their own question without realizing it.
The thought process that I parody above, in my opinion, is far more accurate. Further, there is a minority of true-believers that significantly promote dubious treatments, and can serve as “experts” hospitals can rely on to sell their snake oil.
This creates a feedback loop in which hospitals partly respond to demand, but in doing so increase that demand which justifies further efforts to meet it. In the end hospitals have exactly what they want – they can make lots of money selling snake oil to their patients, alongside real medicine, and can justify it to themselves and the outside world with prepared rationalizations that the con-artists who created the alternative medicine industry have carefully curated and market-tested over the years.
The STATnews article nicely documents these rationalizations, but there are countless other examples. It also showcases that hospitals are often still a little shy about the whole thing. On some level some of the people involved must know this is all thinly veiled BS. They don’t quite buy it themselves, and would be happy if the entire endeavor did not garner too much attention. Some of the alternative medicine directors refused to comment for the article, even citing in one case fear of backlash.
That is very telling. If they thought they were objectively doing the right thing, they would not be shy about shouting it to the world and defending their position. It seems that they fear they can’t defend their position, and so refuse to comment. Just look the other way while we shamelessly exploit our patients and squander the legitimacy of our profession.
I could have scripted the response of those who did choose to comment, they are so predictable. Here we go:
“Yes, as scientists, we want to be rigid. But me, as a physician, I want to find what’s best for a patient. Who am I to say that’s hogwash?” said Dr. Linda Lee.
A gastroenterologist, Lee runs the Johns Hopkins Integrative Medicine and Digestive Center, which offers acupuncture, massage therapy, and reiki — a therapy that the center’s website describes as laying on hands “to transmit Universal Life Energy” to the patient.
This is a common argument – I just want to offer my patients anything that might work. Lee follows up with, how can she possibly know if a treatment is “hogwash?” It’s not as if we have carefully evolved a system by which we can rigorously and systematically test our therapies in order to tell objectively which ones work and which don’t. It’s not as if we have the basic science to have any meaningful understanding of how the universe works so that we have a basis for making informed judgments about plausibility. Maybe at some point in the distant future we will have this “science” to determine such things. In the meantime, how could I possibly know that a magic treatment with no plausibility and lack of clinical evidence doesn’t actually work?
Of course, if the medical profession cannot be expected to determine that a nonsensical treatment with evidence that it does not work, in fact does not work, then they cannot be held to any science-based standard of care. And that’s the point. In such a world, anything goes. Hospitals can offer treatments to patients that they know are snake oil, but really, who are they to say?
It is statements like this which demonstrate that the alternative medicine movement (however you rebrand it) is, at its core, about eliminating or at least fatally weakening the standard of care. Standards are a barrier to selling magic beans to desperate farmers.
“Here at UF, we do not have alternative medicine. We do not have complementary medicine. We have integrative medicine,” said Dr. Irene Estores, medical director of the integrative medicine program at the University of Florida Shands Hospital in Gainesville, Fla.
This is both wrong and irrelevant. As our own Mark Crislip is fond of noting, when you mix cow pie with apple pie, it doesn’t make the apple pie any better, and doesn’t do much to improve the cow pie either. There is no justification for “integrating” unscientific treatments, which are either unproven or that we have already demonstrated do not work, into science-based medicine.
Further, all of the marketing spin about “integration” is a lie. Over the years, while the marketing has evolved, the offered treatments have largely stayed the same. It is still all about selling homeopathy, energy medicine, acupuncture, and useless herbs and supplements. They are still offered with the same unjustified and implausible claims. They are still offered as if they treat diseases. All this talk about integration is just to help hospital directors sleep at night, and to wave off the criticisms of those who actually think we need to have a real standard of care. As the article notes:
Duke’s Integrative Medicine store, for instance, sells “Po Chai Pills” that are touted on the hospital’s website as a cure for everything from belching to hangovers to headaches. The site explains that taking a pill “harmonizes the stomach, stems counterflow ascent of stomach qi, dispels damp, dispels pathogenic factors, subdues yang, relieves pain.” None of that makes sense in modern biomedical terms.
They then act surprised when the very people they hired specifically to sell snake oil to their patients get caught selling snake oil, as the recent Cleveland Clinic debacle demonstrates. The Chief Executive of Cleveland Clinic still defends this:
“The old way of combating chronic disease hasn’t worked,” Cosgrove wrote in a column posted on the hospital’s website. “… We have heard from our patients that they want more than conventional medicine can offer.”
The first claim here is that science-based medicine has not “worked” for chronic disease. This is a dubious and vague claim. What constitutes “working?” Would you say that a patient with diabetes today is better off than a century ago? Ask a diabetic, or a doctor who treats diabetics. Or, you know, read the scientific literature.
There is no question that modern medicine has been incredibly effective at treating and managing many chronic illnesses. Of course, there are many chronic illnesses that cannot be cured (only managed) and there are those for which we still lack effective treatment, or there is much room for improvement. Is Cosgrove saying that the bar for “working” is a complete cure, and anything short of that is a failure? That is the alternative medicine propaganda position, into which he appears to be falling.
Further, the fact that science-based medicine has not completely cured everything yet, in addition to being an absurd standard, does not mean that any alternative is effective or is better. This is the equivalent of an argument from ignorance, or a god-of-the-gaps argument. Whatever science has not yet figured out, insert your preferred belief system. Just because we have not cured a disease does not justify waving your hands over patients to manipulate non-existent energy fields.
Cosgrove ends with the “demand” gambit. As I said, demand is a more complex phenomenon than the rationalizers suggest. They are not just meeting demand, they are creating it. Further, in a profession like medicine, that is not a justification. Like all professions, we don’t just give our clients anything they want without limit. A client cannot demand of his lawyer that he break the law in defending them. A patient cannot demand of a physician that they violate their professional ethics.
Next up, when in doubt, play dumb:
Asked about the Cleveland Clinic’s promotion of reiki, Dr. Richard Lang, the recently named interim director of the clinic’s Wellness Institute, said he hadn’t had a chance to think about it. “I don’t know that I could give you a plus or minus on that,” he said. Lang served as a vice chair of the wellness institute for nearly a decade before taking the top post.
The obvious implication here being that, if Dr. Lang was vice chair for the Wellness Institute for a decade, a decade in which it offered reiki, he should have an opinion about whether or not this major service they offer actually works. It is easier, however, to “see no evil.”
There is also the strategy of just fully embracing pseudoscience:
At the University of Pittsburgh, Glick echoed that sentiment: “We’re an academic institution … [so] we’re offering services that have greater evidence basis [and] scientific explanation.”
Translation – we rely on worthless preliminary studies that are designed to guarantee a false positive result in order to shield the fact that we are selling rank snake oil to our patients. Or, it’s possible that they simply are not competent to properly interpret the scientific literature and actually think that small studies lacking rigor are sufficient to justify an implausible treatment, which is an even deeper problem.
The STATnews article then goes off the rails and shows how successful some alternative medicine propaganda has been (you guessed it, with acupuncture):
A 3,000-year-old Chinese therapy, acupuncture is based on the belief that by stimulating certain points on the body, most often with needles, practitioners can unlock a natural healing energy that flows through the body’s “meridians.” Research suggests it helps with certain pain conditions and might help prevent migraine headaches — but it also suggests that the placebo effect may play an important role.
Acupuncture is no less pseudoscience than homeopathy or energy healing. It just has better PR. First, it’s not 3,000 years old. What currently passes for acupuncture is decades old. Second, the research has shown that acupuncture does not work for any indication. I just reviewed the evidence a few weeks ago showing that it does not work for migraine prevention, despite that fact that it is promoted as working with the usual low-quality studies.
The article disappointingly ends with a false equivalency argument:
“We do use things that aren’t necessarily 100 percent evidence-based, but I would argue that’s also true within all of medicine,” said Dr. Jill Schneiderhan, co-director of the University of Michigan’s integrative family medicine program. “I feel like it’s not black and white.”
The false equivalency argument is particularly insidious, and has become very popular recently. It’s so common that John Oliver felt the need to expose it with satire on his show:
“Not all problems are the same,” Oliver explains. “It’s like comparing ‘La La Land,’ an Academy Award–nominated movie with glaring flaws, to ‘The Human Centipede,’ a thing that barely counts as a film. Yes, one movie is people sewn mouth-to-anus, but, you know, Ryan Gosling looks at his feet when he dances, so it all evens out in the end.”
Yes, mainstream medicine has problems (pointing out those problems is a major theme of this blog), but what is being sold as alternative medicine “barely counts as medicine.” The two things are not equivalent.
It is important for consumers to understand the phenomenon of hospitals, even prestigious hospitals, offering dubious treatments, and how we got here. Don’t be fooled by the apparent endorsement of nonsense. It is still nonsense. What we need to do is create an understanding that leads to more demand for high standards in medicine. I feel, based on my interaction with many patients, like there is a silent majority of patients who want and expect that they will not be sold lies and false hope. People usually don’t go out of their way to express negative demands.
Many (I would say most) of those who think they want alternative treatments don’t really want to buy magic beans. They are just being misled. They falsely think that a hospital would not be offering the treatment if it were not legitimate. The hospital then uses the dubious demand that they help generate to justify further generating demand. The only thing that will stop the cycle is patients and doctors demanding ethical, science-based medicine.