Respectful Insolence

Oh, goody. NCCAM has a blog.

Oh, goody.

I don’t know how I’ve missed this, given that it’s been in existence now for over a month now, but I have. Regular readers (and even fairly recent readers, given that I write about this topic relatively frequently) know that I’m not a big fan of the National Center for Complementary and Alternative Medicine (NCCAM). Just search this blog for “NCCAM” if you don’t believe me. I’ve explained the reasons many times, but the CliffsNotes version is that NCCAM is an enormous waste of taxpayer money, dedicated as it is to the study of modalities that are at best highly implausible and at worst break well-established laws of physics (i.e., “energy healing”). Yes, it’s true that, since the latest NCCAM director, Dr. Josephine Briggs, took over, there has been a noticeable attempt to bring more scientific rigor to NCCAM, and to some extent Dr. Briggs has succeeded. At the very least she is a legitimate scientist with an impressive pre-NCCAM track record, and I do fear who will succeed her when she moves on or retires given that there is enormous pressure from the CAM community to appoint one of their own as director.

Unfortunately, as rigorous a scientist as Dr. Briggs was in her former life, since coming to NCCAM she has gradually been assimilated into the culture of the place. Indeed, although it is good that NCCAM has backed away from studying woo like homeopathy and distance healing, the co-optation of science-based modalities such as exercise, diet, and natural products pharmacology has continued apace. Worse, the recently released five year strategic plan for NCCAM admitted that the science funded by NCCAM in the past was crap and, in essence, promised to do some real science for a change. That’s why I’ve jokingly said that we should take off and nuke NCCAM from orbit. It’s the only way to be sure. On the other hand, no doubt someone would think I seriously mean that we should nuke NCCAM. Of course, I’d never advocate that. NCCAM is located right smack dab in the middle of the NIH campus. The collateral damage would be unacceptable.

I keed. I keed. I’m not kidding, though, when I ask why NCCAM still exists.

But back to the new initiative by NCCAM that I started out the post with. I’m referring to the new NCCAM researchblog. Thus far, it seems to be basically the director’s blog, because all the posts thus far were written by Dr. Briggs, who welcomes readers to the blog in the first post:

Like all of the NIH, our mission is to conduct the highest quality biomedical research to improve the health of the Nation. NCCAM’s special charge is to bring rigorous science to the broad array of health practices that have arisen from outside of mainstream medicine. This covers a lot of tough territory! Not surprisingly the conversation about complementary and alternative health practices has often become polarized, with competing views about what makes good sense. I hope to use this blog as a place for a conversation about these challenges.

Sounds like a plan! It’s also one reason why I encourage my readers to take part in that conversation, both here and on the NCCAM blog (although you should note that the comments on the NCCAM blog are moderated) and thank Dr. Briggs for providing me with additional blogging material. In particular, I’d like to join the discussion of the word, “integrative,” which Dr. Briggs discusses in her second blog post, “Integrative” — What Is in a Word? A very good question. What is in the word “integrative”? I’ve discussed the use of this word many times before, but before we get to my blather, let’s take a look at Dr. Briggs’ blather. First, she tries to have it both ways, being a good skeptic but still accepting the CAM framing of science and language:

That seems simple enough but there are a lot of rough edges at the interface between conventional medicine on the one hand and use of complementary/alternative health approaches on the other, and “integrative” can get caught in a highly polarized debate. From one end, “integrative medicine” offers a holistic, gentle, patient-centered approach that will solve many our Nation’s most pressing health care problems. At another end, “integrative care” represents an evasive rebranding of modern equivalents of “snake oil” by practitioners who raise unrealistic hopes and promote approaches that are not sensible, supported by evidence, or proven safe.

This is the classic false equivalency. Notice how Dr. Briggs characterizes “integrative medicine” on the one hand as being all soft and fuzzy, the equivalent of mom and apple pie. Who could argue with “holistic, gentle, patient-centered” approaches? Well, actually, I can, because the word “holistic” is meaningless in this context. A good science-based primary care doctor is “holistic.” You don’t need to buy into woo to be a holistic doctor. Similarly, you don’t need to buy into woo to be patient-centered in your approach. In addition, as I’ve pointed out before, “patient-centered” is a wonderfully flexible term that can mean so many things to so many people, and the woo-meisters have certainly taken advantage of that in order to promote the idea that patient-centered care necessarily involves their favored quackery.

Now here’s the false equivalency. Dr. Briggs equates the above wonderfully Orwellian verbal prestidigitation that describes CAM (or “integrative medicine” or whatever you want to call it) as the path to holistic care with skeptics who point out that integrating quackery with real medicine makes no sense. As Mark Crislip so famously put it, “If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.”

And if you “integrate” pseudoscience with science, it does not make the science more rigorous. If you mix quackery with real medicine, you do not make the real medicine better—or even more “holistic.” Much of “integrative medicine” represents, more than anything else, a return to pre-scientific beliefs, such as vitalism, miasmas, and illnesses being caused and cured by, in essence spirits or gods or magic. After all, reiki is nothing more than a form of faith healing, and most energy medicine is nothing more than magic, the belief that if you wish for something really, really hard, you can bend the universe to do your bidding and provide you with that thing, in this case, healing.

One notes that Dr. Briggs emphasizes multiple times “nonpharmacological approaches” to pain management. No doubt this is because pain management is where placebo effects are most common, and I’ll have to keep an eye on the blog for what Dr. Briggs says. Not only am I always on the lookout for new material, but I note that she’s already produced one post on pain management. I’m not sure whether to take it on later this week or wait to see what she comes up with next. In any case, it’s clear to me that I need to add the NCCAM blog to my RSS feeds. In the meantime, I also note that in her post about the word “integrative” Dr. Briggs then asserts three “very well documented facts.” Unfortunately, none of these facts are unequivocally true—or even that particularly well documented. I’ll show you what I mean.

Here’s “fact” one:

Individuals, their health care providers, and their health care systems are all, on a large scale, incorporating various practices which have origins outside of mainstream medicine into multi-pronged treatment and health promotion approaches.

Well, yes and no. First the no. As I’ve explained many times, the evidence for this assertion is weak at best. Most surveys of CAM use include spirituality and prayer, which artificially inflates the numbers. It also includes exercise and meditation, both of which are arguably not from “outside the mainstream.” As I’ve pointed out before, when you look at the hardcore woo, such as homeopathy and the like, the numbers of people who use them are actually quite small and haven’t changed that much over the last decade. Now the yes. It is true that quackademic medicine has infiltrated medical schools and that many hospitals whose leaders should know better have embraced it.

Now here’s “fact” two:

This “integrative” trend among providers and health care systems is growing. Driving factors include perceived benefit in health or well-being, emerging evidence in at least some cases that perceived benefits of integrative are real and/or meaningful (e.g., management of chronic pain), and marketing of “integrative care” by health care providers to consumers.

OK, I’ll give her this one—partially, anyway. The reason, however, is because Dr. Briggs cleverly worded it. Note how she refers to “perceived” benefit rather than actual benefits. She’s also right that the marketing of “integrative care” plays a large role in its current popularity. As I’ve pointed out before as well, “integrative medicine” is a marketing term, not a term that describes anything real. It’s a sham. It’s also quite arguable whether in the case of the management of chronic pain the perceived benefits of “integrative care” are real or meaningful. Indeed, some “integrative” modalities touted as effective are in fact science-based treatments, such as exercise and lifestyle interventions.

This leads to “fact” three:

With few exceptions, data to guide evidence-based decision making about safety and efficacy are at best preliminary.

No, no, no, no. With few, if any exceptions, data to guide science-based decision making about CAM or “integrative medicine” are negative. They do not work, by and large. As Kimball Atwood so famously described CAM modalities:

A spectrum of implausible beliefs and claims about health and disease. These range from the untestable and absurd to the possible but not very intriguing. In all cases the enthusiasm of advocates vastly exceeds the scientific promise.

Unfortunately, Dr. Briggs remains inordinately impressed with the concept of “integrative” medicine, calling it “simple” and “pragmatic” while declaring it a “very useful construct” that “focuses on major trends in 21st century health care.” In actuality, most CAM modalities focus on major trends in 17th or 18th century health care or even earlier. They are modalities steeped in prescientific beliefs because they have their origins in a time before we understood enough about how the body works and how health and disease occur not to attribute disease and health to mystical concepts. That is the reality of what CAM “integrates” with science-based medicine.

Comments

  1. #1 Todd W.
    http://harpocratesspeaks.com
    June 20, 2012

    Left the following comment over there. Hopefully it will be posted:

    It’s great to see NCCAM putting up a blog like this to create a forum for discussion. This post, in particular, gives a very good opportunity to talk about terminology. It would be incredibly helpful, and speak well of NCCAM, if an effort were made to bring terminology more in line with reality. For example, the term “conventional medicine” should really be dispensed with. There is, in reality, only “medicine”. In other words, medicine includes those things which have been shown, with an abundance of quality evidence, to actually work. Anything else (e.g., the majority of CAM) is either not yet proven to work or proven not to work and should not yet be called “medicine”.

    When it comes to “integrative”, it would be particularly helpful and beneficial to patients to make clear that when CAM proponents talk about “integrative medicine”, what they are really saying is that they wish to integrate the unproven or the disproven with medicine.

  2. #2 Ren
    40.7142° N, 74.0064° W
    June 20, 2012

    I remember being in High School and having a teacher talk to us about careers in medicine. (I already knew I wanted to be a lab tech, by the way.) She then spent about an hour talking about “holistic” medicine and how “western medicine” didn’t take all of the patient’s life into account. They just give you a pill and send you away to die, I think she said. It seemed a little weird to me, but I wasn’t too well tuned to the stuff of woo.

    Years later I heard she started pushing homeopathy and pushing to have medicine-oriented students do rotations with homeopaths and faith healers. I checked in this morning, and she is not teaching there anymore. But that’s all it takes, really… Some well-intentioned person (as I’m sure she was) to push this stuff on High School kids looking to a career in medicine. Blogs and social media are, in my opinion, one step toward that.

    Maybe.

  3. #3 Denice Walter
    June 20, 2012

    ” A good science-based primary care doctor is ‘holistic'”

    Because they understand the patient’s psychological needs and reactions that relate to the physical illness and treatments (-btw- it’s all physical, really) as well as other issues in the patient’s life that affect health

    I think that using slippery words like ‘spiritual’ is a weasley way of avoiding the simplest explanation- emotions are real and can help or harm patients’ recovery: they can interfere with treatment . Another issue involves sociological factors that affect lifestyle and attitudes: their cultural background and education affect how they conceptualise medicai intervention.

    A good doctor is also a good educator and hospitals may provide informational services. But I don’t necessarily believe that hospitals should become venues for accessing spa treatments. I think that salons and retreat destinations already do that well.

  4. #4 Karl Withakay
    http://Blog.CordialDeconmstruction.com
    June 20, 2012

    “From one end, “integrative medicine” offers a holistic, gentle, patient-centered approach that will solve many our Nation’s most pressing health care problems.”

    Assuming the unstated (and unsupported) premise that current healthcare is not holistic, gentle, &/or patient-centered, how would such an revolutionary approach control costs, our current biggest problem? Consider that here she is referring to one end of a spectrum of CAM belief (whether that end actually exists or not), the end that doesn’t espouse miracle cures and silver bullets/golden BBs to cure and prevent all/most disease and is supposedly only concerned with an approach to the practice of health care.

    “With few exceptions, data to guide evidence-based decision making about safety and efficacy are at best preliminary.”

    If this were, in fact, the case, that would mean that these things are not ready for integration into legitimate medical practice. What would her position be if such a statement were made about a new drug being widely used by doctors to treat patients?

  5. #5 Chemmomo
    the 21st century
    June 20, 2012

    Orac quoted

    From one end, “integrative medicine” offers a holistic, gentle, patient-centered approach that will solve many our Nation’s most pressing health care problems.

    But why do we need “integrative medicine” for that? I get the same thing from my primary care doctor paid for by my HMO.

  6. #6 BA
    At JoeMamas
    June 20, 2012

    I read the title in the voice of Boromir in the mines of Moria, “they have a cave troll.”

  7. #7 Mephistopheles O'Brien
    June 20, 2012

    Is it wrong to think that a holistic, gentle, patient-centered approach to health care is, well, nursing?

  8. #8 Infuriatingly Moderate
    June 20, 2012

    I just keep thinking back to what a former manager told me: it doesn’t matter how you get things done. What matters is being consistent. It’s uncertainty that drives people crazy.

  9. #9 Sastra
    June 20, 2012

    Philosopher Daniel Dennett coined the term “deepity” to refer to a profound-seeming word, phrase, or statement which has two meanings — one of them true but trivial (i.e. not contra science), the other one extraordinary but false. The deepity then trades shamelessly on the resemblance, dancing around somewhere in the area between and shifting as needed.

    “Spirituality” and “holistic” are good examples. So is “we can change reality with our intentions.” You can interpret that in ways that make sense — and in a way that does not. Fuzzy thinkers like to promote the use of these deepities in hopes that the bait ‘n switch won’t be noticed, or will cease to exist if you slide back and forth enough.

    When “alternative medicine” starts trying to co-opt pharmacognosy, exercise, diet, nutrition, massage, and a sympathetic and attentive approach, it reveals itself as another deepity.

  10. #10 Denice Walter
    June 20, 2012

    @ Sastra:

    I like that! Plus, ‘deepity’ looks as though it might be derived from ‘Deepak’ who exemplifies the concept.

  11. #11 Infuriatingly Moderate
    June 20, 2012

    Sorry, I managed to hit post before finishing the thought….

    I’m just an ordinary schmuck, but just adding even more “stuff” like CAM to what’s already an impenetrable health-care maze just drives me nuts. Get the feeling it’s yet another wrong answer to the right problem.

  12. #12 meg
    the looney bin
    June 20, 2012

    I’m always sceptical of ny blog that has it’s comment’s moderated. Sure, it could be to guard against trolls, but I’ve seen plenty of blogs (here included) deal with that fairly well. It just strikes me as censorship.

    I sometimes think about going to a homeopath to see what they tell me. I was recently diagnosed with epilepsy – a very mild form, that I’ve probably had all my life, (I can track the seizures, all partial simple ones, back 10 years). I’ve never had a complex seizure. The MRI suggests either a low grade tumour or that the cells in that part of the brain just didn’t grow right (can never remember the medical name, dammit!). The docs (neurologist and neurosurgeon) aren’t worried. They won’t do a biopsy, cause you may as well remove the ‘tumour’ given it’s location, and surgery’s pointless unless it grows, or the seizures get worse. The medication they’ve given me has stopped the seizures altogether. Though given me weird dreams. . .

    I’m honestly curious – how would a homeopath treat this? Given ‘like cures like’ how can they treat me when it seems most likely I was simply born with this. I’m really tempted just to go and see what they say, then play with their minds a little. . .

    Is that wrong?

  13. #13 Autismum
    http://autismum.com/
    June 20, 2012

    @Meg
    I have mild epilepsy or Elvislepsy as I call it. I get a taste/aroma of white pepper and then get a facial “twitch” like the Elvis lip curl. My DH says he can tell if one’s coming on cos I talk bollox for a few minutes before – not sure how that differs from usual though.

  14. #14 GRichard
    June 20, 2012

    I read her post and don’t see a whole lot wrong with the basic message of it. Some of the wording is a bit suspect, but saying things like “perceived benefit” almost sounds to me like saying, “We know this is BS, but some of it makes patients feel better, even if they aren’t actually getting better.”

    I don’t think you can take a position as the head of an organization and then just rip it a new one immediately. Sure, it might be a waste of money, but suppose some well designed studies get performed that conclusively silence some crazy treatments. Hell, suppose 1% of the treatments they review are found to have decent supporting evidence and get incorporated into our medical toolkit.

    Maybe I’m naive, but I still like to think the glass is half full…

  15. #15 meg
    June 20, 2012

    @autismum

    Mine shut me up! Start as feeling like a panic attack – shortness of breath, panicked feeling, then result in me not being able to understand what’s being said, or being able to speak. Lasts about 30-60 seconds. The impressive bit is that I hid them for so long – I’d fake a coughing fit, or pretend to be distracted by something. I thought they were anxiety attacks, and didn’t want to tell anyone. The docs laughed at that one – if they had been, I wouldn’t have been thinking clearly enough to cover them up! The brain is a weird thing. But officially being able to say I have an abnormal one is now the current family joke.

  16. #16 Quokka
    June 20, 2012

    Meg and Autismum I have partial complex epilepsy as well. A naturopath friend tried to convince me to reduce my epilepsy meds and take some supplement that she would happily sell instead. she said I would eventually be able to stop taking evil chemicals altogehter if I followed her advice. I gave her the name of my neurologist and said if she could convince him I would do it. she is no longer a friend.

  17. #17 LindaRosaRN
    http://www.scienceinmedicine.org
    June 29, 2012

    Todd W. wrote some excellent posts to the new NCCAM blog. I hope that many more of Orac’s readers will follow suit.

  18. […] I tell ya. I ought to send Dr. Josephine Briggs, the director of NCCAM, a thank you note for the amount of blogging material she’s been providing me lately through that blog. This time around, though, it’s both […]

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