Respectful Insolence

Over the last couple of days, I’ve discussed “complementary and alternative medicine” (CAM) in terms of a meme upon which evolutionary forces are acting to select certain forms of woo over others in academia. Although, in my usual inimitable fashion, I probably carried the concept one step too far, in the end I concluded that the relationship between CAM and academic medical centers is probably best characterized as parasitic rather than symbiotic.

After I finished that post, I started thinking (always a dangerous thing). Regular readers know that I’ve sometimes raised a bit of a ruckus by being very critical of certain academic medical centers for embracing non-evidence-based modalities of varying degrees of dubiousness in their scientific plausibility. As I’ve said before, I tend to suspect that it’s usually done more as a marketing tool more than out of genuine scientific interest; in other words, because patients want it, regardless of whether there is any evidence to support it. (And let’s not forget that most CAM therapies are not reimbursed by insurance, meaning that it’s cash on the barrelhead.) Still, even if we take the physicians supporting these programs at their word when they say the reason for CAM in academic medical centers is to teach it critically and scientifically and to subject it to the scientific method, in practice with few exceptions that does not appear to be what happens. If it did, I wouldn’t have a problem with the CAM curriculum in these medical schools (indeed, I would strongly support them). Unfortunately, many of these schools also offer these modalities before there’s any good evidence that they work, in essence putting the cart before the horse. Also, over time such programs tend to be taken over by true believers. Meanwhile, academic physicians who care about evidence-based medicine view CAM in their medical centers as either a harmless diversion, as not worthy of their consideration, or as something that’s become so entrenched that it’s not worth making the necessary waves and paying the price to fight it.

But how entrenched has CAM become in academic medicine in the U.S.?

That was the question I had. So I set out to get an estimate by looking for centers of “integrative medicine” (one buzzword for using woo alongside evidence-based medicine) or CAM centers. It didn’t take me long to find at least 39 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:

  1. The Cleveland Clinic
  2. The Richard and Hinda Rosenthal Center for Complementary and Alternative Medicine, Columbia University
  3. Cornell University Center for Complementary and Integrative Medicine
  4. The Continuum Center for Health and Healing, Albert Einstein College of Medicine of Yeshiva University
  5. Duke Integrative Medicine
  6. Henry Ford Health System (medical school affiliations: Wayne State University and Michigan State University)
  7. Georgetown University Medical Center (discussed here)
  8. Harvard Medical School Osher Institute, Division for Research and Education in Complementary and Integrative Medicine
  9. Jefferson-Myrna Brind Center of Integrative Medicine, Thomas Jefferson University
  10. Mayo Clinic Complementary and Integrative Medicine Program
  11. Northwestern Memorial Physicians Group Center for Integrative Medicine (Northwestern University)
  12. Integrative Medicine Program, Beaumont Hospitals (primary teaching affiliation now with Oakland University; other medical school affiliations with the University of Michigan and Wayne State University)
  13. The Ohio State University Center for Integrative Medicine
  14. Oregon Center for Complementary and Alternative Medicine in Neurologic Disorders, Oregon Health and Science University (Also, the OHSU Center for Women’s Health Integrative Medicine Program)
  15. Scripps Center for Integrative Medicine
  16. Stanford Center for Integrative Medicine
  17. Complementary & Alternative Research and Education Program, University of Alberta (pediatrics, yet!)
  18. University of Arizona Program in Integrative Medicine
  19. Susan Samueli Center for Integrative Medicine, University of California, Irvine
  20. University of California at Los Angeles Collaborative Centers for Integrative Medicine
  21. Osher Center for Integrative Medicine, University of California, San Francisco
  22. University of Colorado
  23. University of Connecticut Health Center (where a “debate” about homeopathy was recently held)
  24. University of Maryland Center for Integrative Medicine
  25. University of Massachusetts Medical School Center for Mindfulness
  26. Institute for Complementary & Alternative Medicine, University of Medicine and Dentistry of New Jersey (UMDNJ-ICAM)
  27. University of Michigan Medical School
  28. University of Minnesota Center for Spirituality and Healing (PZ hates this one.)
  29. University of New Mexico School of Medicine, Section of Integrative Medicine
  30. Program on Integrative Medicine, University of North Carolina
  31. PENNCAM, University of Pennsylvania
  32. Center for Integrative Medicine, University of Pittsburgh Medical Center
  33. University of Texas Medical Branch Complementary & Alternative Medicine Project
  34. University of Texas M. D. Anderson Cancer Center Integrative Medicine Program
  35. University of Washington School of Medicine Integrative Health Program
  36. University of Wisconsin Integrative Medicine
  37. Vanderbilt Center for Integrative Health
  38. Wake Forest Baptist Medical Center Program for Holistic and Integrative Medicine
  39. Center for Integrative Medicine at the George Washington University Medical Center

Of course, sheer numbers of programs matter little. What really matters 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:

  1. Acupuncture
  2. Guided imagery
  3. Massage therapy
  4. Nutritional counseling
  5. Tai Chi
  6. Yoga

The inclusion of these modalities as first choices in “centers of integrative medicine” is not surprising, as 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. Moreover, among CAM therapies, although I find it weak and unconvincing, there is some evidence that acupuncture might do…well, something. 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 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, evidence-based nutrition. Overall, though, among CAM therapies, the above subset appears to include modalities chosen because they are the least bizarre and the most “safe” for consumption by academic physicians.

To go a step further and find out how much serious woo there is in academic medical centers, I decided to identify which centers, if any, either offered to patients or taught uncritically two of the wooiest of woo-ey CAM modalities. Yes, I’m talking about either 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, and no one has ever been able to detect, much less demonstrate that anyone can manipulate, this life energy (qi) that is at the heart of reiki. I therefore chose these two modalities, which are probably the least scientifically plausible and the most common among serious woo, 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:

  1. 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.”
  2. 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
  3. 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.”
  4. Beaumont Hospitals: 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.”
  5. 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.
  6. University of Connecticut Health Center
  7. University of Maryland
  8. 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.)
  9. University of North Carolina-Chapel Hill
  10. University of Texas M.D. Anderson Cancer Center
  11. University of Wisconsin
  12. 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.”

This is by no means a complete list. For one thing, several 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.” For another thing, I didn’t exhaustively peruse each website, although I do note that in my surfing not a skeptical word was found. (The slight hope that maybe I missed a skeptical take on “energy” healing methods is the only hope I have right now.)

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):

  1. 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.”
  2. University of Connecticut Health Center
  3. University of Maryland
  4. 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.”
  5. University of North Carolina-Chapel Hill
  6. 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.”

Now, you may say that it’s 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. Personally, I found it truly depressing that even a single medical school offers homeopathy uncritically. Weep, advocates of evidence-based medicine!

As far as miscellaneous CAM modalities go, while perusing all these website, I noticed that there are even a couple of centers offering the quackery known as 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) even makes a totally unsupportable statement about CAM for cancer: “Integrative medicine gives patients resources for choosing therapies that help prevent cancer or prevent a recurrence,” where preventing a recurrence is something that CAM cannot do. At least there’s no good scientific evidence that it can. One other (Thomas Jefferson University) even touts anthroposophically Extended Medicine:

Anthroposophically Extended Medicine (AEM) is a Western system of natural medicine that treats the whole person and not just the disease or symptoms. AEM views the human being as far more than a physical machine: Therapy seeks to harmonize the relationship of body, mind and spirit. Anthroposophic medicines include herbal and homeopathic preparations; their aim is to support and guide the natural healing processes within each patient.

Anthroposophy? Rudolf Steiner’s brand of woo? Say it ain’t so! That’s the same philosophy that’s behind the woo of “biodynamic farming.”

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 these 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. They have, for the most part, drunk deeply of the Kool Aid. Frustratingly, on most sites, I found very few indications of any serious scientific examination of whether these CAM therapies actually work (i.e., provide more of an effect than a placebo for real disease or pathology). Indeed, 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?” To reiterate, that’s putting the cart before the horse. Unless these therapies have solid evidence to support them, medical schools should not be offering them outside of the context of a clinical trial. Even the Harvard Medical School Osher Institute, which comes the closest to saying the right things about the need to rigorously investigate whether any of these therapies have therapeutic benefit, can’t resist prefacing its discussion with this:

Integrative Medicine involves the integration of conventional medical and evidence-based complementary therapies. It also highlights the importance of patient participation and the patient-practitioner relationship. In 1997, Americans made an estimated 600 million office visits to providers of complementary therapies and spent roughly $30 billion out of pocket on complementary care. The budget for the National Institutes of Health to support research in this area has roughly doubled every two years since 1993, and currently exceeds $200 million annually. In addition, private support has allowed researchers and physicians to gather preliminary data and explore new avenues of scientific research.

It takes every bit of self-control for the cynic in me not to translate this as: “In other words, people spend a lot of money on this stuff, and we want our piece of the action.” (Oh, wait, my self-control failed.) Fortunately, Harvard seems to exaggerate how much the NIH through NCCAM spends every year. Unfortunately, the real amount is in the range of $121 million, unless I’m unaware of another $80 million or so that the government spends on CAM through sources other than the NIH. Whatever the true figure is, it represents your tax dollars hard at work promoting woo at the same time Medicare is slashing reimbursements for lymphoma treatments shown in well-designed clinical trials to be effective.

Going through this exercise has left me feeling not only tired from the effort (damn it when the blogging frenzy takes over) but profoundly depressed. Two days ago, a commenter characterized CAM as a “living fossil” that’s being pushed aside by scientific medicine. After perusing these 39 websites, I’m starting to feel like the fossil.

To help everyone see why, I encourage readers to peruse the 39 websites listed above, find the most outrageous examples of academic medical centers supporting nonsense, and then post them in the comments.

NOTE: I’ve updated this list and will now maintain the list of medical schools offering CAM to patients at my new Academic Woo Aggregator. Periodically, I will post about new entries to the Woo Aggregator and link back to the updated list.

Comments

  1. #1 N.B.
    November 14, 2007

    Well, at least my university hasn’t succumbed to woo yet, but as I posted yesterday, I’m not sure how willing they are to “fight” it. I guess “not teaching it as science” is all I can ask for.

    My professors have been very good about evidence; one of them actually thanked me enthusiastically when I emailed him a link to an article about “ear candling” after he mentioned it in his clinical assessment course in the context of inner ear infections. He had heard very little about the practice other than the fact that some people did it and was appreciative that he could get some more information.

    Maybe I’ll read through some more of the links later. I’m in the middle of exams, so the last thing I need is more soul-crushing, spirit-demolishing, depression-inducing bad news.

  2. #2 Marcus Ranum
    November 14, 2007

    Last night CNN (here in Dallas) had some woo peddler on who was talking about the medical benefits of prayer – as if all the research on that topic hadn’t thoroughly debunked it. It was a great performance of “proof by flat assertion” and there was only a few seconds of “designated prayer skeptic” Michael Shermer. It ended with a brief blurb of the woo peddler saying some mum mum mum about “of course we don’t recommend prayer and meditation as a complete replacement for medicine…”

    Teh st00pid! It burns!

  3. #3 Josh
    November 14, 2007

    Just wanted to point out that Henry Ford Hospital is associated with Wayne State, not University of Michigan

  4. #4 Orac
    November 14, 2007

    Is it? I guess that shows how long I’ve been away from Detroit. It used to be affiliated with U. of M. At least the Department of Surgery rotated residents and medical students to Henry Ford Hospital back in the day. I’m also surgery-centric (which can be my blind spot). Since I know Wayne State’s Department of Surgery doesn’t rotate residents over to Henry Ford, I guess I assumed there was no affiliation.

    My impression of HFH, though, was that it is a large, free-standing academic hospital on the Mayo Clinic model, with an independent research institute, its own residency programs, and only relatively weak affiliations to universities. Actually, Beaumont and the Cleveland Clinic are also very much like that, although I’m not sure whether Beaumont has its own residency programs. I do know that it has a Breast Surgery fellowship, though.

  5. #5 Annie
    November 14, 2007

    A brief overview of the modalities you list involve hands on and prolonged contact with patients for the most part. Could it be that the effects of that and a therapeutic relationship between provider and patient might be the key to understanding perceived benefit?

    I haven’t done the due diligence in reviewing studies for efficacy of therapy, but this jumps out. And what has been stripped of medicine and nursing at least since the early 1980s with the coming of prospective payment and HMO’s? Duration of visits has been dramatically curtailed, increased patient case loads, increased use of technology to diagnose, decreased use of hands on, decreased attention to establishing and nurturing therapeutic relationships.

    At least in nursing with primary care and modified primary care delivery systems, the nurse had some time to nurse the patient instead of the machines and the documentation. There was time to establish and build a therapeutic relationship built on trust, and there was time to be able to assess in more breadth and depth what concerns the patient had, and there was an ability to use touch and reassurance within the relationship.

    I’d be interested to learn whether anyone has investigated the qualitative aspects of the therapeutic relationship and correlated them with the reasons why patients seek out and use CAM.

    Thanks for writing this. Do I understand correctly that for your perspective woo = qualitative/ non-evidence-based aspects of medicine?

  6. #6 mark's tails
    November 14, 2007

    I know that several of those institutions are actually in the process of either designing or carrying out well-designed clinical trials of the various woo. What is still worrisome and remains to be seen is whether or not the negative results get published.

  7. #7 Orac
    November 14, 2007

    Thanks for writing this. Do I understand correctly that for your perspective woo = qualitative/ non-evidence-based aspects of medicine?

    No.

    Woo = Non-evidence-based claims without a sound basis in science, like homeopathy, energy healing, etc. Qualitative aspects of medicine can actually be studied scientifically; they also don’t rely on pseudoscience or magical thinking about things like the “memory of water” or the ability of a healer to magically manipulate a patient’s life energy flows.

    mark’s tails: I’m sure some of these institutions are doing just what you say. The question I have is whether these are the same institutions that are uncritically promoting the same woo on their websites. If they really mean to study it, what should be on their websites is something along the lines of, “We have no idea if [name of modality] works, even though a lot of people think it does based on unreliable data such as anecdotes, tradition, and uncontrolled studies. Given that, we cannot make any claims for it and do not offer it outside the context of a well-designed clinical trial.” Then there would be a link to the clinical trials page for interested patients.

    But that’s not what these university-based centers are doing, is it? Just peruse the links.

  8. #8 Theresa
    November 14, 2007

    Very well-written piece on CAM, and I couldn’t agree with you more.

  9. #9 Annie
    November 14, 2007

    Thanks for clarifying the woo definition, Orac.

  10. #10 PalMD
    November 14, 2007

    I have email-for-life addresses from several of the institutions listed. …sigh…
    So much work, so little time.

    What is interesting is that these “integrative” centers seem to be very separate from the rest of the institution, at least in some of my experience.

    Most of my residents have no idea that medical centers that they work at offer reiki, etc. When they find out, the shake their head, and ask me again what a good starting dose for carvedilol is.

  11. #11 T. Bruce McNeely
    November 14, 2007

    Here’s what my Alma Mater offers:
    http://www.med.ubc.ca/education/md_ugrad/clerkship_electives/
    bc_community_hospitals/Complementary_Medicine.htm

    Heck, I might have been tempted to take it back in my final year. A few weeks of banker’s hours in beautiful Victoria?
    Bring it on!

  12. #12 Abel Pharmboy
    November 14, 2007

    Like PalMD, I have found many of these centers to be quietly operating separately from the rest of the medical center and supported by philanthropy rather than general operating funds of the hospital. The centers often hire external PR firms to promote themselves (rather than university media relations), again operating under the radar of the academic information dissemination flow.

    Another observation is that many of the “leaders” and “executive directors” of these programs are often low-ranking faculty, many at the assistant professor level (no offense to asst profs, but how many asst profs are dept chiefs, cancer center directors, etc.?). Those who are MDs often seem to lack a publication track-record that indicates any experience in evidence-based medicine.

    Even worse, some centers seem to merely be vehicles (a la Andrew Weil) for one or two “faculty” to support their external integrative medicine persona, million-dollar book deals, and speaking engagement fees that put to shame anything that even pharma pays their “thought leaders.”

    Some of the 39 centers you list are at truly outstanding research institutions. My question is how distinguished faculty, especially those who become administrators, allow these centers to ride the coattails of some of the top academic reputations.

  13. #13 Dawn
    November 14, 2007

    OK, Orac, you’ve solved one problem for me. There is no wayI will let my child, looking at medical schools, attend one that teachs woo. Fortunately, Child currently wants to go to Eastern Virginia Medical School, which did not hit your list (and I hope they don’t teach woo…I’ll have to check it out.)

    Sorry to read that HFH and Willie B have succommed to woo. Maybe that’s why all my MI family goes to St John’s/Providence even though Willie B is the nearest hospital.

  14. #14 The Crack Emcee
    November 14, 2007

    Orac,

    Good job (I’m really liking the direction you’re taking these days) I feel like some real educational progress is being made. (I’m sure you remember my attitude in the beginning.) And, though I don’t have time to explain my own thinking on all this, here’s some more food for thought:

    Cerebralmum, commenting on Panda Bear’s site, made (what I think, with my cult/occult focus) is a good observation:

    “The more convoluted the explanation, the more unintelligible the [CAM] practitioners are, the more people may be inclined to believe them. It makes it appear as though it is privileged knowledge, like real medicine and auto tech.”

    That’s the occult, my friend, working in-and-out of the hospitals, on patients and practitioners. And this goes waaay further than just medical schools. Look carefully at the credentials working for the Lynx Collaborative Care Network, which I discovered after taking a friend to kidney dialysis and hearing him say all his nurses were pressuring him to let them do Reiki on him:

    http://www.lynxcare.net/biographies.html

    And, as you may know, TT, and other occult beliefs, seem to be spread through nursing as the late, great, (Apple Macintosh designer) Jef Raskin pointed out:

    http://jef.raskincenter.org/published/NursingTheoryForSite.html

    From what I can tell, there’s some epic men’s science/women’s science occult battle going on in medicine, which many doctors don’t even know is being fought – and it’s against them! It’s time they study it, acknowledge it, and speak up. I think you’re, finally, getting some of the outlines of the battlefield with this list of hospitals, though I think it’s scratching the surface. Still, it’s damn good work. Get some sleep, man.

    P.S.

    On my site, there’s a speech New Zealand’s Dr. Graham Sharpe gave on homeopathy that’s a real screamer, tying in fascism (as I’ve tried to state, only to be shouted down).

  15. #15 ludwig
    November 14, 2007

    Very well written, and timely. Thanks.

  16. #16 Sid Schwab
    November 14, 2007

    What an amazing effort you put in for this post. Admirable, and appreciated, even as it pushes me well over the edge into despondency. Those modalities at the top, which, as you said, have some sort of discernable value, don’t bother me very much. My local hospital — a non-teaching one — has just opened a very state-of-the-art cancer center, and has included pretty much the whole list in its armamentarium. But the H and R block (heh) — that they are included in otherwise respectible curricula means we’ve finally dumbed down to irreversible levels; or that there are unrepentant cynics calling the shots; or even that some have concluded the only way to attract students is to be willing to feed them crap. If so, it’s even worse than I thought.

  17. #17 Miki
    November 14, 2007

    Truthfully, I think there’s a very simple reason for the upsurge in woo offerings from medical schools across the country.

    We’re in a time of especially tight NIH funding, and grants that would have been a slam dunk 10 years ago aren’t getting through today. Many (if not most) of the PIs I work with seem well aware that if your department is absolutely strapped for cash, NICAM is the NIH institute that it’s the “easiest” to get funding from.

    Of course, here in my department, that funding has been used to conduct double-blinded, placebo-controlled, randomized trials of woo — which, in my mind, is real science and not woo. But a lot of the NICAM RFAs are specifically about teaching providers, “integrating medicine”, etc.

    And when you think about it, given how many people in the US go for the woo, it makes sense to have their health care providers educated about it — after all, some forms of woo have potential adverse effects that providers should be trained to watch out for, some can mix badly with some prescription meds, etc. That, of course, would require an evidence-based education about woo — but from what I know, at least some of the medical schools you mention above are attempting to do just that. Yes, they teach students about how homeopathy is conducted, and what theories its practitioners believe — and they also teach them about the evidence (and lack thereof) from clinical trials.

    – Miki, an epidemiologist at one of those medical schools who has done the power calculations for a few of those RCTs.

  18. #18 guthrie
    November 14, 2007

    In my completely objective evidence free viewpoint, I think Anne has hit it on th head for one reason why so many people go for woooooo.
    Really, they wouldn’t even need to go to such alternative places, friends and family can provide such therapy as well.

  19. #19 Abel Pharmboy
    November 14, 2007

    Miki, I’d be interested to know what kind of luck your colleagues are having with getting NCCAM proposals funded. Contrary to the perception that it is “easy money,” there are so many submissions relative to their budget that NCCAM’s payline is actually worse relative to many NIH institutes. One might also suffer if one’s application is not deemed alternative enough or if they are not in the ‘CAM club,’ much like some other study sections are reputed to operate.

  20. #20 Miki
    November 14, 2007

    So far, our batting average with NCCAM seems to be a lot better than for our more usual sources (NICHD, NIMH, AHRQ). It may help that we have a well-regarded naturopath school in town that actually is interested in working with university people here to develop a real evidence-base — i.e., they actually seem open to studies that might show that their particular woo doesn’t work. NCCAM may be getting a lot of submissions, but I wonder if a larger chunk of those are just completely not fundable? After all, the payline is a percentile…

    The other institute it seems like everyone is trying to send stuff to these days is NIDDK.

  21. #21 Miki
    November 14, 2007

    And in the above, I should probably clarify that by “well-regarded naturopath school” I mean that it’s one of the “in kids” in the CAM club.

  22. #22 Spaulding
    November 14, 2007

    Re: Reiki:
    I think that it’s been conclusively shown that human touch has therapeutic effects. And the nice, relaxing nap would probably help most people too. I’m dubious about how much training those two things ought to require, or how much a patient ought to pay for them. But they would probably beat a sugar pill in testing!

    The magic energy talk is pretty much a cultural embarrassment, though.

  23. #23 Ms. S
    November 14, 2007

    It’s a bit off topic, but – there was an ABC news story on tonight about the schools of Prince George’s County, Maryland. Currently 2300 students are barred from attending the schools because they are not vaccinated. They even tried offering free vaccines, to no avail. I almost hate to mention it as I’m sure it will draw the usual trolls… but here is the link. Sorry, I don’t know how to HTML it. Anyway, thought it might be of interest. http://www.washingtonpost.com/wp-dyn/content/article/2007/11/13/AR2007111301408.html

  24. #24 The Crack Emcee
    November 15, 2007

    I’m still really interested in thoughts on the credentials working for the Lynx Collaborative Care Network,…like:

    Sally J. Hartshorn, RN, MS, has degrees in Environment Design, Nursing, and Health Care Administration, and has worked many areas including long term care, youth corrections, and adult medicine. Before relocating to Colorado in 1993, she worked at Children’s Hospital in Boston. In addition, she has worked in hospital planning, hospital architecture and labor relations, consulted on medical malpractice issues, and created, directed, and trained nurses in a behavior management program in a large corporation.

    Ms. Hartshorn has been committed to studying alternative healing modalities since she was a young woman. In the 1970s, she studied with Guru Amrit Desai (founder of Kripalu Yoga) and studied Buddhism in the 1980s. She has had a therapeutic touch practice and periodically teaches courses on adapting to change.

    Or listed under Lynx Case Researcher

    Adam Kay is a Ph.D. candidate in Modern and Medieval Languages at the University of Cambridge (UK). He has received scholarships, grants, and awards in several areas, including creative writing and anthropological research in Tibet. For nearly a decade, he has worked as a freelance editor for a wide range of material, from professional psychological papers to original screenplays. He has published articles on shamanism and the meaning of dreams.

    Anyone?

  25. #25 Abel Pharmboy
    November 15, 2007

    Speaking of “clubs,” Miki, here is the integrative medicine club: The Consortium of Academic Health Centers for Integrative Medicine

  26. #26 PJ
    November 15, 2007

    In the UK we have the disgraceful University of Greenwich that offers (of all things) a Batchelor of Science degree in Complementary Therapies

  27. #27 Annie
    November 15, 2007

    @ Crack Emcee:

    Regarding nursing v. medicine territory fighting and credentialing, you might be interested in the stylings of the Universal Health blog on WordPress. There was plenty of blogging about the educational nightmare maze that is in nursing, and also writing which addressed the need to bolster credentials across that profession.

    As to the Lynx faculty credentials: they aren’t applicable to the “therapy” that is being referenced. Caveat emptor.

  28. #28 The Crack Emcee
    November 15, 2007

    Annie,

    “Caveat emptor.”

    “Let the buyer beware.” (I looked it up) Well that’s my point exactly: My friend isn’t a “buyer” but a (financially) poor guy, with a serious kidney problem, being pressured by a bunch of creepy parasites, working as a group, just-outside of the hospital setting, that he has no choice but to rely on.

    Questions arise like, if he continues to resist their efforts, will his level of care decrease, maybe, because of selective bias? If he’s getting the Reiki sales pitch, what are other patients getting? Has anyone resisted getting care because of the pressure?

    Is the actual buyer (the hospital and/or the city) aware of what’s going on and, considering the acceptance of woo in medicine, do they approve? Since the credentials of the practitioners “aren’t applicable to the ‘therapy’ that is being referenced”, isn’t there a chance of all-kinds-of-problems going undetected? Is this nightmare the future of medicine?

  29. #29 Alecto
    November 15, 2007

    I have a med school interview at one of those institutions on Monday. I’ll have to ask the students how the CAM material is taught.

    It’s my top choice, too. *sigh*

  30. #30 Paul
    November 15, 2007

    @ Bruce McNeely

    I’m currently a student at UBC, and the thought of students training in dispensing small expensive doses of clean water under the mistaken belief that it actually does anything more then a placebo concerns me. I think I’m going to contact them by email.

    And if they envoke Quantum Mechanics, well, I’m currently working in the Physics department and I actually have taken courses in QM.

  31. #31 jen_m
    November 15, 2007

    Crack Emcee – I made it through a BSN at a nursing school on that list without ever being exposed to “therapeutic touch” or “energy fields.” One of our instructors was very fond of therapeutic breathing techniques, but she stumped up some papers as evidence in the face of student skepticism. “Nursing theory” is definitely more broadly used than this Rogerian whatnot, which I’ve never encountered before.

    Because the field is up in arms about what exactly nursing is, as I’ve encountered it, nursing theory is an effort to assemble a coherent philosophy of nursing based on the existing evidence for nursing interventions and the evolving role of the nurse. (That is, as I’ve encountered it, it’s the philosophical rather than the scientific term “theory.”)

    My school was very, very into evidence-based nursing. The nursing journals aren’t as rigorous as the biomedical ones, yet, but they’re getting better, slowly. (Full disclosure: I’m an epidemiologist now. I opted not to get my PhD in nursing because I didn’t want to do nursing research as such – too limiting.)

    Side-note: what a shame the term “therapeutic touch” has been applied to describe aura wiggling! Certainly there is something to the idea that simple touch can comfort and help heal.

  32. #32 Dr. Val
    November 15, 2007

    Orac and Sid – I confess that I used to be laissez faire about CAM. I thought it was mostly silly, figured it was also largely harmless, and really didn’t think too critically about it. But when our tax dollars are being shifted away from life-saving treatments for lymphoma patients and towards analyzing whether or not water has memory… my blood starts to boil. And over the past couple of years (and in large part to your excellent and entertaining blog) I have realized that passivity amongst physicians like me is enabling this shift away from good care to foolishness – even at our own academic centers that should be the defenders of science and reason! Are we too burned out from working in this broken healthcare system to stand up for cancer patients whose treatment funding is being siphoned off to line the pockets of energy healers? I think it’s time for us to take a stand. I shall do so on my blog and any chance I get. :) Yours in the struggle – Dr. Val

  33. #33 HCN
    November 15, 2007

    Miki,

    I know of that naturopathic school… I actually lived down the street from it when it was leasing the old MacDonald school in the Green Lake/Wallingford area, before it moved to its present spot at an old seminary.

    I learned what homeopathy was in the early 1990s when there was a TV news spot announcing that Bastyr was going to do a definite study on homeopathy. They had some talking head from the school explain it, and I was flabbergasted at the amounts of dilution. That study should have been completed over the last 15+ years, but I have been unable to find any results (1989-90 is too far back to be in any news feed archive, I tried to find it). Can someone you know find out what might have happened to that study?

    Also, is it your epidemiology department that has been posting requests for test subjects in local community centers to research “homeopathic teething tablets”?

    Personally, I know there are lots of good medical professionals from the UW who do not give an credence to the woo, even if there are one of two persons who buy into it (like Henry Lai, http://www.drclark.net/en/therapists/articles/wormwood.php ), like our family doc, dentist, kid cardiologist and neurologist.

  34. #34 HCN
    November 15, 2007

    I’m sorry, I should be more clear: the medical professionals we had to deal with from the UW do not seem to subscribe to woo. Even my family doctor called the Dr. Sears a bit nutty (Dr. Sears was a big child care advice giver in the early 1990s, and recently I saw him mentioned here: http://www.nytimes.com/2007/11/14/health/14vaccine.html?ref=us … sorry registration required, but he is described as “And Dr. Robert W. Sears, an Orange County, Calif., pediatrician who writes popular medicine books for parents, including a new one on vaccines, said the study showed “one of the very positive aspects of vaccination.””)

  35. #35 Aggravated DocSurg
    November 15, 2007

    I thought I’d Google my alma mater with the phrase “complementary medicine,” and found that it is included as an available elective during the first and second years of medical school. Dr. Seldin is still alive and active there, so he can’t be spinning in his grave…..but his head must be about to explode.

  36. #36 Felix Kasza
    November 15, 2007

    What is the problem with reflexology? I thought it was a wonderful treatment for fibromyalgia — an imaginary treatment for an inexistent disease, and the only concrete evidence left behind by the whole thing is maintained by the banks :-)

    Cheers,
    Felix.

  37. #37 The Crack Emcee
    November 16, 2007

    jen_m,

    Orac has mentioned something I’ve noticed too: the willingness of New Agers to go “under the radar” to achieve their ends (I think Orac says they “insinuate” themselves into the curriculum – anyway:) I’ve read that TT and the like is taught at over 800 nursing schools but, unfortunately, I’m not writing from my own computer so I can’t supply any links.

    Dr. Val,

    Glad you’ve joined the fight. And I want to add one more reason for people to stop this: the “collateral damage” of these beliefs. Just as the believers don’t pay doctors any mind in their rush to make the unreal real, they also don’t pay anyone else any mind as well – friends, family, and other concerned people in their lives. This stuff destroys society.

    To me, fighting this isn’t just about saving medicine, but about re-establishing reason as the foundation of a better world.

  38. #38 DuWayne
    November 16, 2007

    The inclusion of these modalities as first choices in “centers of integrative medicine” is not surprising, as 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. Moreover, among CAM therapies, although I find it weak and unconvincing, there is some evidence that acupuncture might do…well, something.

    Efficacy by association. I commented on this at Abel’s not so long ago. It is much like the common use of the word homeopathy, to describe everything CAM. I am not sure how prevalent this is in other locales, but here at the heart of CAM country, it is used in the CAM centers themselves.

    To research a print article I am working on, I have visited a few of the CAM schools, here in Portland. When I start asking rather uncomfortable questions, there are inevitable attempts to shift the focus to more conventional treatments being taught. This is what I actualnbly find the most frightening, especially since I have gotten to interviewing students. Keeping in mind that thus far, I have focused on non-affiliated schools (If I don’t get put off again, I will be heading up the hill to OHSU after Thanksgiving), so I am dealing with serious woo schools.

    What I have found is that while the administrators (also mostly instructors) are keen on playing bait and switch, the students are very open to discussing what is actually focused on. Rieki and homeopathy, are put on the same plane as nutrition and plant medicines. There is also a strong admix of crossover therapies, plant based medicines that are refined and approved by the FDA for a particular treatment. Under the auspices of CAM, such drugs may be used for a variety of non-approved uses. Colchecine, which motivated me to write the article I am working on, is just one of many. It’s frightening the number of uses they put chelation to, as an example.

    The nutrition education itself is a mishmash of the conventional and woo. Orac will appreciate the orange juice diet for cancer treatment. This is not quite limited to oj, but might as well be. It also includes soy, lots of soy. That in itself isn’t much of a problem. But when you take into account the amount of soy that is used as filler in all sorts of supplements that the cancer patient is taking, the results can be rather counterintuitive. They also push a lot of dubious, high doses of various vitamins and minerals.

    The quackery within the more conventional “treatments” aside, the running theme is to associate CAM with EBM, without jumping through the hoops of actually developing evidence for efficacy. The more that I learn about this, the scarier it gets. While the savvy amongst those running these schools are less prone to make stronger claims of efficacy to people asking hard questions, the less savvy are quick to make fairly outrageous claims of efficacy, for a host of treatments.

    I have to give them this much, I have made no bones about the thrust and intent of the article I am working on. Yet most of the people I have dealt with have been quite gracious and cooperative.

  39. #39 Sastra
    November 16, 2007

    The Crack Emcee wrote:

    To me, fighting this isn’t just about saving medicine, but about re-establishing reason as the foundation of a better world.

    Well put.

    When I talk to people who advocate or practice So-Called Alternative Medicine, I get the same impression I get when I talk to Creationists: it makes no sense to them that there can be two equally valid “ways of knowing” — science and faith — which come up with two different kinds of answers to describe the only world they know. When I point out the poor science and lack of evidence behind Energy Healing, homeopathy, or a 6,000 year old earth I get “but God exists, and science can’t prove that to your level of satisfaction, either.”

    Can’t prove it, perhaps, but surely science can indicate the existence of magic, can’t it? It has to, or their faith is wrong, and they know it’s not. So science must support an enchanted universe, where intention and thought have real power and integrating the “spirit” with the “mind and body” in medicine will show how faith and personal experience are better than all the controlled studies in the world.

    I think fighting woo is fighting religion — a religion which is bewildered by the modern insistence that it needs to keep itself in a separate, watertight compartment called “morals and meaning” and not be taken seriously, as a real force with the real power to do things directly.

    How many times do we read the word “spiritual” on these websites? Arguing with reiki enthusiasts is like arguing against the devout.

  40. #40 The Crack Emcee
    November 17, 2007

    Sastra,

    I’ve tried to make that exact same point, over and over, here and elsewhere, only to be laughed into isolation as a nutcase. The people who will go all-out to fight the Creationists refuse to see woo as a “spiritual movement” that must be dealt with in the same manner – it’s a joke to them. Meanwhile, with the same furious passion as Creationists, the New Agers are working to advance their goals, moving into science, medicine, and even religion.

    It’s incredible for me to watch it unfold as it is, with so many smart people being played for suckers, because they think of themselves as too intelligent to be taken by a bunch of “woos”. They deny the power these people are accumilating. And this as they acknowledge how the woos are doing it: working in an underhanded manner, hiding their tracks, changing definitions, etc. Is it a cult or a bunch of cults? No, it’s just a bunch of “stupid” or “ignorant” people, is all.

    Panda Bear, MD is the only blogging doctor I know of who calls a spade a spade in this regard. Everyone else is tripping. This has good points and (very big) bad ones. A good point is that, by having everyone looking at a different aspect of the phenomena, I can learn about various specific parts – in detail – without having to do the research myself (like what Orac did with this post). The very-bad part is that as long as people (yea, like Orac – sorry, dude) don’t acknowledge that we’re dealing with cults here, we’re never gonna beat them: They’re counting on reasonable people to discount, and underestimate, them – that’s their trump card. They need an equally strong, ruthless, and united force to confront them – it’s all they respect: View woos as nice, harmless, and unorganised (sp?) and reason is dead. Check this out (Orac, you look to) and tell me if it doesn’t make more sense, considering the one-track-mind behavior of believers – professional or otherwise – than the other theories people are advancing (like a mere desire for money, etc.):

    http://www.angelfire.com/mb2/quinine/cult.html

    C’mon, you guys – we’re, all, dealing with cults – and they’re on the march.

  41. #41 Chris and Vic
    November 25, 2007

    I find it hard to believe that this discussion has gone on at length, with not a single dissenter. You guys are a closed circle, and a new idea–perhaps any alternative modality that was not taught in med school as pure science–won’t be considered by you. With this kind of attitude, I don’t see how medicine–or science, for that matter–can advance.

    In the same way that “pain” is what the patient says it is, so “healing,” “feeling better,” and “relief” is what the patient says it is. If people with pain, discomfort, chronic illness and injury say that some modality helps them, then it does. For that individual, it is so. We are bound, ethically, to believe the patient, to take them seriously. And no, that is not pure science, but it is still our duty as healthcare professionals.

    Established medicine does NOT have all the answers. When I asked my own surgeon recently why my knee still hurts here and here, he said “Everybody reacts differently to surgery”. That is not pure science. That is vague. That is debatable. So in the clinical setting, there are plenty of establishment docs giving answers and treating in ways that are not pure science—and you-all know this to be true.

    Stop being so arrogant–you don’t know all the answers. There is no such thing as PURE science. All the facts are not in–on anything. Rather, listen to your patients. They are finding their own ways to feeling better. You need to hear about their journeys.

    Chris, MSN, RN

  42. #42 Orac
    November 25, 2007

    Established medicine does NOT have all the answers…Stop being so arrogant–you don’t know all the answers.

    Straw man. I never said we in academic medicine did have all the answers. However, not having all the answers does not mean that we have to embrace unscientific or even antiscientific ideas. That’s a false dichotomy. Moreover, embracing such nonsense as reiki or homeopathy risks degrading the quality of the science we already do do, something we really don’t need, given how questionable a lot of the studies published already are. We need more rigor, not more woo.

  43. #43 Chris
    November 26, 2007

    Orac, if it is true that all the facts aren’t in, and all the available data isn’t rigorous enough, that is all the more reason to be open to other possibilities.

    But even more importantly, listen to the patient even moreso than to pure science/good studies. The patient is telling you his/her truth and what is reality for him/herself. We need to learn from the patients as much or moreso than from pure science (or pure logic).

    Chris, MSN, RN

  44. #44 Zach Alexander
    November 26, 2007

    Chris,
    You can be open to new possibilities by, e.g., doing a well-designed study of a poorly understood therapy. That’s a wonderful thing to do. But ignoring disconfirming evidence isn’t being “open” — it’s being closed-minded. Are you open-minded to the possibility that many CAM therapies are just the placebo effect?

    I think you have a certain point about listening to the patient; if the patient thinks something works, it works. But if it’s no better than a placebo, then we must conclude that that’s what it is.

    And hell, maybe there’s a place somewhere in society for taking advantage of the placebo effect! (when there aren’t alternatives at least). But there should be no place for medical schools pretending a placebo is a real treatment.

  45. #45 Chris
    November 29, 2007

    Yes, I am open to the placebo effect. It is a near relative, to my way of analzying things, to your health care provider saying “We don’t know if this works–some people say they feel better–but we can try it. No guarantees, you understand, but we want to say we’ve tried all the options, proven and unproven.”

    Chris, MSN, RN

  46. #46 bob koepp
    November 29, 2007

    Chris -
    A “patient-centered” approach where the patient is viewed and treated as a person is important for the practice of humane medicine. And this means recognizing and dealing straightforwardly with the subjective, experiential aspects of medical conditions. But to claim as you do that “healing” is “what the patient says it is” is going way, way too far. In what respects and to what degree a particular patient is healthy or visited by pathology is a matter of objective fact, regardless of the what the patient says.

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