integrative medicine

Experts in the psychology of human error have long been aware that even highly trained experts are easily misled when they rely on personal experience and informal decision rules to infer the causes of complex events. --Barry Beyerstein According to [Andrew] Weil, many of his basic insights about the causes of disease and the nature of healing come from what he calls "stoned thinking," that is, thoughts experienced while under the influence of psychedelic agents or during other states of "altered consciousness" induced by trances, ritual magic, hypnosis, meditation, and the like. --Arnold S. Relman, M.D. They have so many healers there [Nevada City/Grass Valley] it makes you sick. -- U. Utah Phillips 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

Integrative medicine is a synonym for "alternative" medicine that, at its worst, integrates sense with nonsense. At its best, integrative medicine supports both consensus treatments of science-based medicine and treatments that the science, while promising perhaps, does not justify. It mixes the scientific with the metaphysical ("spirit-mind-body connection" is a favorite expression) and the scientifically untested, discredited, or questionable. Defenders of integrative medicine have an exceptionally high opinion of things "natural" and "organic."

The expression is a marketing term popularized by Andrew Weil, M.D. Integrative medicine is not a medical "specialty," nor is it special or superior to plain old science-based medicine. As David Gorski, M.D., says, "integrative medicine" is a brand, not a specialty.note Weil's branding and marketing strategy has paid off. The University of Arizona has given him his own Institute of Integrative Medicine to direct.

Weil graduated from Harvard Medical School but did not complete a residency nor, as far as I can ascertain, ever take the medical boards in any state.

After a one-year internship at Mount Zion Hospital in San Francisco in 1968-69, he began what was supposed to have been a two-year tour of duty at the National Institute of Mental Health. He resigned after a year. He says it was because of official opposition to his work with marijuana. He then left the world of allopathic medicine entirely, to go off to an Indian reservation in South Dakota to study with a Sioux medicine man and learn about herbal medicine and ritual healing. "On the reservation," he says, "I participated in sweat lodge ceremonies, grew a beard, and `dropped out.'" At home afterward, "I started to practice yoga, experiment with vegetarianism, and learn to meditate." (Relman 1998)

Apparently, he continued his herbal research during an extensive stay in South America.

After medical school, he decided, he would forgo the young doctor's traditional apprenticeship as a hospital intern and resident and instead devote his time to traveling through the forests and villages of South America, studying not the great engine of Western medicine but the gentle power of the curative herb. Weil spent more than three years in the field in Peru, Ecuador, Colombia and elsewhere, and when he returned to the U.S. in the mid-1970s, he decided that he would make his living teaching, writing and otherwise spreading the alternative-medicine word. (Kluger 1997)

Today, Weil mixes scientific medicine with Ayurvedic and other forms of quackery and calls this practice "integrative medicine." One of his main tenets is: "It is better to use natural, inexpensive, low-tech and less invasive interventions whenever possible." However, there is no scientific evidence for the claim that natural interventions are always superior to artificial ones. Millions of people use herbs and natural products for a variety of conditions, such as calcium, echinacea, ginseng, ginkgo biloba, glucosamine, saw palmetto, shark cartilage, and St. John's wort. All of these, when tested scientifically, have failed to support the traditional wisdom regarding their healing powers. Pharmaceuticals and other treatments are much superior to most herbal remedies. If a plant has been shown to be effective as a healing agent, the active ingredient has been extracted and tested scientifically and is part of scientific medicine. Otherwise, any beneficial effect following use of the herb or plant is probably best explained as due to the placebo effect, natural regression, the body's own natural healing processes, or to some other non-herbal factor.

Why so many people—including many highly educated and medically trained people—believe in the efficacy of quack remedies is a complex issue. As Barry Beyerstein has pointed out in his most thorough analysis of this phenomenon, there are a "number of social, psychological, and cognitive factors that can convince honest, intelligent, and well-educated people that scientifically-discredited [or untested] treatments have merit" (Beyerstein 1999). The typical believer in untested or discredited medical treatments accepts uncritically the apparently clear messages of personal experience that such treatments are effective. To the uncritical thinker, many worthless or harmful treatments seem to "work" (the pragmatic fallacy). Such people are either unaware of or intentionally ignore the many perceptual and cognitive biases that deceive us into thinking there are causal relationships between quack treatments and feeling better or recovering from some illness or disease. They uncritically place "more faith in personal experience and intuition than on controlled, statistical studies" (Beyerstein 1999).

Furthermore, the mass media is rarely critical of "alternative" healing and often presents non-scientific medicine in a very positive light. And critics of complementary and alternative medicine (CAM) are often stereotyped as lackeys for the AMA or the pharmaceutical firms. For example, when a recent double-blind study of 225 men with enlarged prostates [benign prostate hyperplasia or BPH] found no statistically significant difference between those who took saw palmetto and those who took a placebo twice a day for one year, a user of saw palmetto wrote a letter to the editor of the Sacramento Bee in which he claimed that the study was

an attempt by the pharmaceutical industry to promote manufactured drugs that help the prostrate. I have had a long experience using saw palmetto in various formulations. It works and it has prevented me from having surgery in my 50s. I am now in my mid-60s. I was desperate at the time. Saw palmetto is a blessing. The Bee should investigate how the pharmaceutical industry manipulates public thought and perception. It's a much more interesting concept. (Letters to the editor, Sacramento Bee, Feb. 25, 2006).

Rather than accept the results of a scientific study, the letter writer—like many purveyors and proponents of quack treatments—trusts his interpretation of his personal experience, even though it is contradicted by a double-blind scientific experiment.* He also brings up a common claim among believers in quack remedies: the pharmaceutical industry has rigged the game so they can sell more drugs. The letter writer believes that the pharmaceutical industry has somehow manipulated the seven scientists who did this study, as well as the New England Journal of Medicine, which published their research.

The letter writer is probably not the least bit interested in the fact that the National Institutes of Health, which spends millions of dollars each year trying to validate quack treatments, has funded a major new study of saw palmetto and another commonly-used herbal treatment for BPH.* The new study will involve several hundred patients at 11 centers nationwide. Such information is probably of no interest to this letter writer, since he already knows that "saw palmetto is a blessing." Of course, if the results of the new study support the claim that saw palmetto is an effective treatment for BPH, he may view the study with a more positive eye, as it will confirm his bias. In any case, the fact that someone has not had prostate problems since he started taking some herb is not very strong evidence that the herb has had anything to do with it. His prostate problems—whatever they may have been—may have subsided had he done nothing. It is possible that he stopped drinking caffeinated beverages at the same time he started taking the herb and that the entire positive effect he feels is due to not ingesting caffeine. Perhaps he began ejaculating several times a week after his problem emerged.* A scientific study can control for various factors that might be causing an outcome and isolate the most likely significant factor. Intuition is unable to do this.

Many believers in integrative medicine are led to their uncritical evaluation of personal experience because of their deep commitment to metaphysical notions such as subtle energy or spiritual forces. They do not accept that the biological world is governed by mechanistic processes determined by laws of nature. Scientific or evidence-based medicine is rooted in a set of beliefs about reality that seem to contradict their beliefs in non-physical entities and forces that are at the core of their perception of reality. They don't necessarily reject science altogether, but they are as likely to put their faith in prayer, intuition, meditation, or visions induced by drugs, as they are in randomized, double-blind, controlled studies.

Scientific medicine is not infallible, of course. And we should not draw strong conclusions from a single study. That goes for both skeptics and believers. The results of a scientific study should usually be taken to hold tentatively, until significant replication or other strong supportive evidence leads to a consensus. Even then, the door should never be closed to further investigation, should new data arise that warrants it. The tendency of most of us, however, is to be uncritical and accepting of a study if it seems to support our beliefs. A skeptic might hail the Bent et al. study that found no significant benefit of saw palmetto, while a believer might reject the study because of a perceived fault. One need not speculate about drug company conspiracies to find a reason to reject a scientific study. No study is perfect. It is not difficult to find fault with nearly every scientific study ever done: the study did not go on long enough, the dosage was too small or too large or was given too frequently or not frequently enough, the placebo wasn't masked well enough, the sample was too small, the randomization process wasn't perfect, and so on.

Furthermore, each human being is a unique and extremely complex biological organism. The same chemicals may affect different people in significantly different ways. They may even affect the same person differently at different times. It is not uncommon for a well-designed double-blind study to contradict earlier studies (as was the case with the Bent et al. study). It should not be a shock to anyone if the next saw palmetto study finds that it significantly improves BPH, but if it does that should not be the end of such studies. Eventually, a consensus should be reached about the effectiveness of this smelly herb to heal the prostate. But even when that consensus is reached, there will still be a few contrarians who will continue to prescribe and sell saw palmetto to patients concerned about prostate problems. Some of these will base their contrary belief on their intuitions but others will say that further studies need to be done because, after all, there have been some studies that have indicated it is effective and there are still many men who swear by it. It is always possible that the next study will prove beyond a reasonable doubt that it is effective. And if it doesn't? Well, there is always the next study and the one after that.

Randomized double-blind studies are not perfect, but they are much more reliable than anecdotes and personal experience because they allow us the opportunity to control our observations in such a way as to minimize the effect of the many perceptual and cognitive biases that affect us all and are great sources of error. We are prone to wishful thinking, "a willingness to endorse comforting beliefs and to accept, uncritically, information that reinforces our core attitudes and self-esteem" (Beyerstein 1999). We often see patterns that aren't really there and find significance in coincidental occurrences.

The pioneers of the scientific revolution were aware of the large potential for error when informal reasoning joins forces with our penchant for jumping to congenial conclusions. By systematizing observations, studying large groups rather than a few isolated individuals, instituting control groups, and trying to eliminate confounding variables, these innovative thinkers hoped to reduce the impact of the frailties of reasoning that lead to false beliefs about how the world works. None of these safeguards exists when we base our decisions merely on a few satisfied customers’ personal anecdotes—unfortunately, these stories are the “alternative” practitioner’s stock in trade. Psychologists interested in judgmental biases have repeatedly demonstrated that human inference is especially vulnerable in complex situations, such as that of evaluating therapeutic outcomes, which contain a mix of interacting variables and a number of strong social pressures. Add a pecuniary interest in a particular outcome, and the scope for self-delusion is immense. (Beyerstein 1999).

The appeal of Weil's integrative medicine is that he mixes sound scientific knowledge and advice with illogical hearsay. For example, on his Men's Health Internet page, he provides scientific information regarding men with prostate problems. He offers common sense advice such as don't ingest caffeine and alcohol if you are having trouble with frequent urination, since these substances will increase the need to urinate. But he also advises men to eat more soy because: "Asian men have a lower risk of BPH and some researchers believe it is related to their intake of soy foods." As Sally Fallon and Mary G. Enig note, however: "the same logic requires us to blame high rates of cancers of the esophagus, stomach, thyroid, pancreas and liver in Asian countries on consumption of soy" (Soy Alert! 2001). Weil also states that saw palmetto "may help" BPH because: "There is clinical evidence that saw palmetto can help shrink the size of the prostate, and it may help promote healthy prostate function." Now we know there is clinical evidence that saw palmetto doesn't help shrink the size of the prostrate.

On the positive side, Weil notifies the reader: "You should inform your health care practitioner you are using this product." Your physician needs to know what supplements you are taking because what he or she prescribes to you may interact adversely with the herbs you are taking.

For those who want to study alternatives to scientific medicine, the University of Arizona seems like the hot spot. It not only supports the work of Gary Schwartz and the Center for Frontier Medicine in Biofield Science, Andrew Weil heads its integrative medicine program. Why would a major university risk its reputation by supporting such programs? Because these programs are very popular with the masses, the media, many medical schools and physicians, and politicians. Furthermore, there is significant grant money available to such programs through agencies like the NIH and the university gets a significant cut of whatever money the grantees take in. Someday we may look back at this period in our history and see the "alternative" science movement as a well-engineered social movement that created a very popular mass delusion on par with the tulip mania of 17th century Holland.

__________

Note: Although "integrative medicine is not recognized as a speciality by the American Board of Medical Specialities. The ABMS is, as one disgruntled practitioner of integrative medicine put it, "a guild." Membership requires approval by every subspecialty member and there are more than 100 subspecialties. Integrative medicine isn't one of them. Other certifiying boards are more like clubs. You meet some minimum requirement and you pays your dues and you're in. Weil has cleverly formed his own American Board of Integrative Medicine, which has been accepted as a member of the American Board of Physician Specialties (ABPS). The ABPS is more like a club than a guild. Physicians certified by ABPS and licensed by the Medical Board of California are prohibited from using the term "board certified" unless they are also certified by the American Board of Medical Specialties.* From 2000 until 2014, the American Board of Integrative and Holistic Medicine provided the only board certification exam in integrative medicine. As of May 2014, the American Board of Integrative Medicine will replace the ABIHM for board certification in integrative medicine. So, Weil will be soon able to create board certified practitioners of integrative medicine, but they will not be allowed call themselves "board certified" in California. I don't know about other states.

See also alternative medicine, complementary medicine, energy, frontier medicine, hidden persuaders, integrative oncology, holistic medicine, NCCAM, and supplements.

* Ray Hyman provides an example of a chiropractor who agreed to a double-blind controlled test of applied kinesiology (AK). After AK had failed the test, the chiropractor said: "You see, that is why we never do double-blind testing anymore. It never works!"

further listening

Point of Inquiry podcast: interview with Wallace Sampson, M.D. (Dr. Sampson was a major inspiration for writing this entry in The Skeptic's Dictionary.)

further reading

I have written several articles and short pieces about alternative-health related topics. The following is a list of those I think are most relevant to the article above.

Evaluating Personal Experience

Energy Healing: Looking in All the Wrong Places

Evaluating Acupuncture Studies: Laughable vs. Dangerous Delusions

The trouble with acupuncture, homeopathy, etc.

Sticking Needles into Acupuncture Studies

How safe are alternative therapies?

Oprah and Oz spreading superstition at the speed of night

Ancient Wisdom

Prescribing Placebos

Mesmerized by hypnotherapy

Statistics and Medical Studies

Review of R. Barker Bausell's Snake Oil Science: The Truth about Complementary and Alternative Medicine

Bunk 7 - Needles and Nerves

Acupuncture shown NOT to ease back and neck pain after surgery

cosmetic acupuncture

books and articles

Barrett, Stephen and William T. Jarvis. eds. The Health Robbers: A Close Look at Quackery in America, (Amherst, N.Y.: Prometheus Books, 1993).

Bausell, R. Barker. (2007). Snake Oil Science: The Truth about Complementary and Alternative Medicine. Oxford University Press.

Gardner, Martin. Fads and Fallacies in the Name of Science (New York: Dover Publications, Inc., 1957), ch. 16.

Hall, Harriet. (2006). "Andrew Weil: Harvard Hatched a Gullible Guru." Skeptical Inquirer. Volume 30, No. 1. This is a review of Weil's Natural Health, Natural Medicine.

Mackay, Charles. Extraordinary Popular Delusions & the Madness of Crowds (Crown Publishing, 1995).

Park, Robert L. Voodoo Science: The Road from Foolishness to Fraud (Oxford U. Press, 2000).

Randi, James. The Faith Healers (Amherst, N.Y.: Prometheus Books, 1989).

Raso, Jack. "Alternative" Healthcare: A Comprehensive Guide (Amherst, NY: Prometheus Books, 1994).

Raso, Jack. "Mystical Medical Alternativism," Skeptical Inquirer, Sept/Oct 1995.

Sampson, Wallace and Lewis Vaughn, editors. Science Meets Alternative Medicine: What the Evidence Says About Unconventional Treatments (Prometheus Books, 2000).

Shapiro, Rose. 2008. Suckers: How Alternative Medicine Makes Fools of Us All. Random House.

Singh, Simon and Edzard Ernst. 2008. Trick or Treatment: The Undeniable Facts about Alternative Medicine. W. W. Norton.

Stenger, Victor J. "Quantum Quackery," Skeptical Inquirer. January/February 1997.

news

The believers: Alternative therapies are increasingly mainstream. That means headaches for scientists—and no cure in sight "The $1.5 billion that taxpayers have devoted to NCCAM has brought meagre returns....In a paper in the New England Journal of Medicine last July [Ted Kaptchuk] described an experiment with asthma inhalers. The real ones improved patients’ lung function by 20%, compared with 7% for the alternatives: a dummy inhaler or acupuncture. But patients judged the effectiveness of the three therapies to be about the same." Not accounting for the difference in real vs. perceived benefits of treatment may explain why placebo medicine hasn't gone extinct.

Why Medical Schools Should Not Teach Integrative Medicine "Pseudoscience is insinuating itself into our medical schools across the nation, going by the name “Integrative Medicine.” Integrative medicine is just the latest buzzword for a collection of superstitions, myths, and pseudoscience that has gone by various names over the years. First it was Holistic medicine, and once that fell out of favor, it became Alternative medicine, followed soon after by Complementary and Alternative medicine (CAM), and lately Integrative medicine. These names can’t disguise the fact that many of the practices lumped together are bad medicine. What disturbs me particularly, as a professor, is that CAM is moving into the medical curriculum at respectable medical schools, including the University of Maryland."

UCSF Osher Center for Integrative Medicine Celebrates New Building The $37 million project was made possible through gifts from Bernard and Barbro Osher.... “Our hope,” noted the Oshers, “is that the activities undertaken in this structure, enhanced by the Takahashi meditation garden, will promote good health and wellness, respect for the healing traditions of many cultures and individual progress toward more balanced and meaningful lives.”

"The new Osher building underscores UCSF’s commitment to increasing access to integrative medicine and making it a larger part of the treatment relationship between medical caregivers and patients."

And that's a good thing? Orac doesn't think so.

websites

Integrative medicine and the point of credulity by John C McLachlan

In the spirit of Alan Sokal, McLachlan, a professor of medical education, responded to a mass circulated email invitation to submit a paper to something called “The Jerusalem Conference on Integrative Medicine.” Dr. McLachlan received the following response from the conference organizers:

We are happy to inform you that the Scientific Committee has reached it’s (sic) decision and that your paper has been accepted and you will be able to present your lecture. The time frame will be 15-20 minutes. Considering the tight schedule, I will appreciate if you’ll confirm your participation in the convention.

What was his proposal? It was a joke and should have been recognized as a joke by serious medical people. McLachlan's concern that "integrative medicine" is being used to smuggle alternative practices into rational medicine by way of lowered standards of critical thinking seems to have been justified. Here's his proposal:

...I have discovered a new version of reflexology, which identifies a homunculus represented in the human body, over the area of the buttocks. The homunculus is inverted, such that the head is represented in the inferior position, the left buttock corresponds to the right hand side of the body, and the lateral aspect is represented medially. As with reflexology, the “map” responds to needling, as in acupuncture, and to gentle suction, such as cupping. In my studies, responses are stronger and of more therapeutic value than those of auricular or conventional reflexology. In some cases, the map can be used for diagnostic purposes.

The Academic Woo Aggregator (a list of all the academic medical centers with woo programs)- Orac

A new use for magic mushrooms

Social and judgmental biases that make inert treatments seem to work by Barry L. Beyerstein (1999)

The Belief Engine by Jim Alcock (1995)

A Trip to Stonesville: Some Notes on Andrew Weil by Arnold S. Relman, M.D. (1998)

Why the National Center for Complementary and Alternative Medicine (NCCAM) Should Be Defunded by Wallace I. Sampson, M.D.

Mr. Natural by Jeffrey Kluger Time Magazine May 12, 1997

QuackWatch with Dr. Stephen Barrett

Fraud & Quackery: Internet Resources: Alternative Medicine

Alternatives to Medicine Topical Index Skeptic's Dictionary

The Museum of Quackery

The Medical Messiahs: A Social History of Health Quackery in Twentieth-Century America Chapter 18: Anti-Quackery, Inc. James Harvey Young, PhD

blogs

new Old wine in a new skin: The Society for Integrative Oncology promotes integrating pseudoscience into oncology by Orac "Any medical society that allows naturopaths to be members and touts “integrating” their “expertise” into medicine has automatically lost any claim to scientific legitimacy, given that naturopathy consists of a veritable cornucopia of pretty much every quackery known to humankind, including homeopathy (which is required study for naturopathy students and the knowledge of which is tested in the NPLEX, the naturopathic certification examination)....Proponents of “integrative oncology” are no doubt well-meaning practitioners who think they’re doing good. They even go out of their way to condemn quackery, as though to demonstrate that what they embrace is not quackery. However, as they try to distance themselves from obvious cancer quackery, as Barrie Cassileth, who heads up the integrative medicine service at Memorial Sloan-Kettering Cancer Center, did not too long ago, they seem oblivious to the fact that much of what they accept as potentially part of integrative oncology, such as traditional Chinese medicine, acupuncture, reiki, naturopathy, and the like, is based on the very same pseudoscience and magical thinking that the quackery they condemn."

See also: “Integrative” oncology: Trojan horse, quackademic medicine, or both? by David Gorski, M.D. "Cancer patients, as I say frequently, are among the most vulnerable of patients. Many of them are facing a very unpleasant death without treatment; seeing that they receive the most effective medicines and treatments we have, free of quackery, is a moral imperative, and I fear that we will soon be failing our patients. We now even have a Society of Integrative Oncology promoting the “integration” of pseudoscience into oncology." Also by Dr. Gorski: “Integrative oncology”: The Trojan horse that is quackademic medicine infiltrates ASCO.

Even my alma mater, UCSD, has jumped on this bandwagon. San Diego has its own Center for Integrative Medicine. A 2013 symposium list of topics indicates what they are up to: "Topics include: optimal nutrition, physical activity, massage, manual therapies, acupuncture, herbs, biofeedback, meditation, guided imagery, integrative psychiatry, biofield therapies, expressive arts, yoga, and tai chi." Yes, a true mixture of apple pie and cow pie.[/new]

Integrative Medicine Invades the U.S. Military: Part One by Jann Bellamy, July 25, 2013 "If integrative medical practitioners and their proponents were simply directing their time, energy and resources toward facilitating a better model for delivering health care I suppose no one would have any problem. But they aren’t. They are claiming rights to an entirely new specialty in medicine. Proponents do this by advancing two dubious arguments. First, integrative medicine alone can deliver on this “whole person” model of care. Second, inclusion of alternative medicine is essential to good patient care."

Integrative Medicine: “Patient-Centered Care” is the new Medical Paternalism by Kimball Atwood "...the two most consistent IM pitches in recent years—seen repeatedly in statements found in links from this post—are that IM is 'preventive medicine' and that it involves 'patient-centered care.' I demolished the 'preventive' claim a couple of years ago, as did Drs. Lipson, Gorski, and probably others. Today I’ll explain why the 'patient-centered care' claim is worse than fatuous."

“Integrative” oncology: Trojan horse, quackademic medicine, or both? "...ideologues such as the Bravewell Collaboration ... blur the lines between science and pseudoscience and promote the “integration” of quackery into science-based medicine....The claim behind 'integrative oncology' is that it is 'integrating the best of science-based and alternative medicine,' but in reality all too often it is 'integrating' quackery with science-based medicine. I have yet to hear an explanation of how 'integrating' pseudoscience or nonscience into science-based oncology benefits cancer patients...."

University of Buckingham does the right thing. The Faculty of Integrated Medicine has been fired - DC's Improbable Science This is a very long post. The bottom line is summed up in a message from Professor Andrew Miles:

The University of Buckingham has confirmed that it will terminate its association with one of its external collaborations, the Integrated Health Trust (which incorporates the Faculty of Integrated Medicine at Bath) following the completion of the Year 2 part-time Diploma in the Study of Integrated Medicine in September 2011. The University will maintain its duty of care to the students until they graduate in February 2012. Professor Andrew Miles, Associate Dean of Medicine at Buckingham and the Course Director for the DipSIM said: 'The DipSIM was a trial venture but we will not be authorising the intake of a second student cohort'.

The DipSIM program started last July.