Respectful Insolence

I’ve discussed the evolution of “integrative” medicine on many occasions. To make the long story discussed over many posts short, medicine based on prescientific and/or unscientific ideas was once, appropriately, referred to as quackery, and those practicing it, appropriately, as quacks or charlatans—or other derogatory terms. Then, beginning sometime around the 1960s and 1970s, such quackery became known as “alternative” medicine. This was a less derogatory term than what used to be used, but still unsavory. As I put it, alternative medicine was (and is) medicine that does not fit into the current scientific paradigm, a term used to describe medical practices that were not supported by evidence, were ineffective and potentially harmful, and were used instead of effective therapies. Physicians understood that modalities such as homeopathy, reflexology and various “energy healing” (i.e., faith healing) methodologies were based either on prescientific vitalism, magical thinking, and/or on science that was at best incorrect or grossly distorted and weren’t afraid to say so.

So around 25 years or so ago, “alternative medicine” morphed into “complementary and alternative medicine” (CAM). This term ha the advantage of eliminating the main concern about alternative medicine, that it was being used instead of effective, science-based medicine. Instead, it was to be used as a “complement” to real medicine. Over time, the name change had its intended effect. No longer did most physicians automatically view modalities that were once considered quackery, later considered “alternative,” and now considered “CAM” as quackery. Modalities such as homeopathy, reiki, various energy healing methods, and even reflexology were no longer dismissed, no matter how pseudoscientific or mystical the modality.

Then, beginning maybe 10-15 years ago, CAM morphed into “integrative” medicine. Why? Because being “complementary” wasn’t enough. It implied a subsidiary position of the woo being promoted to science-based medicine, which was the “real” medicine. It’s much better to “integrate” such medicine as a a seeming equal to science-based medicine. It’s the “best of both worlds!” Of course, as I like to point out, the only thing that “integrative medicine” brings to oncology (my specialty) or to medicine in general is pseudoscience and mysticism. In essence, “integrative” medicine “integrates” quackery with real medicine. Unfortunately, the rebranding is working; so believers in “integrative” medicine are taking it further.

For example, listen to Dr. Hal Gunn, co-founder and CEO of InspireHealth, a Canadian nonprofit integrative cancer care organization, do something else that promoters of unscientific medicine are good at, co-opting the term “personalized” medicine:

You may have heard terms like “patient-centered” or “personalized” medicine. These buzz words are being used by the medical community to recognize that the ‘one-size fits all’ approach to patient care is quickly changing. Enter integrative medicine.

See the not-so-subtle message, the implication that in order to provide truly “patient-centered” or “personalized” medicine, you have to embrace the pseudoscience of the modalities, of which CAM or “integrative medicine” or whatever you want to call it. It’s the same false dichotomy that I’ve been harping on, lo these many years, just a slightly different take. The false dichotomy I usually discuss is the same idea, just applied to “wholistic” medicine. The message being sold in service of “integrative medicine” is that, to be a truly “wholistic doctor,” to take care of the “whole patient,” you have to embrace quackery. Again, it’s a dichotomy that I reject, as it is not necessary to embrace quackery like traditional Chinese medicine, “energy medicine,” acupuncture, and the like in order to take care of the “whole” patient. If the problem, as we are often told, is that conventional doctors do not listen to patient concerns or are under pressure to provide drug therapy rather than do the hard work of helping patients embrace healthy lifestyle changes, the answer is not to embrace quackery. It’s to empower physicians, giving them the time and means, to do what needs to be done and help their patients change their lifestyles.

Of course, I’ve always been a bit skeptical of the term “patient-centered” medicine. Personally, I find the term mor ethan a little Orwellian in that it can mean so many things. Basically, it’s a lot like Humpty Dumpty when he says to Alice, “When I use a word, it means just what I choose it to mean — neither more nor less.” So it is with “patient-centered care.” It’s such a wonderfully–shall we say?–flexible term.As I have pointed out, the whole concept of “patient-centered” care, as worthy as it is in theory, is all too often in practice co-opted by promoters of unscientific, pseusocientific, and faith-based health care modalities to justify quackery. At the very least, it’s all too easily used as an excuse to do whatever the patient wants regardless of whether it’s science- and evidence-based or not.

I wrote about this a couple of years ago when I commented on a series of articles that appeared in the New England Journal of Medicine (NEJM), one of which discussed a woman who, after attending an “integrative medicine” exhibition, was persuaded to undergo testing for circulating tumor cells. Her test was positive, and she was told that she had advanced small cell lung cancer. Treatment was recommended (of course!) even though the significance of “circulating tumor cells” in an asymptomatic woman was unknown and the test was unvalidated. The integrative practitioner insisted that she needed to undergo a 12-week course of intravenous high dose vitamin C, even though, as I’ve described multiple times before, vitamin C, if it has any anticancer activity at all, has such minimal anticancer activity that it’s almost certainly not worth the effort. Certainly it’s no “miracle cure.” On the other hand, the woman in the anecdote, having only “circulating tumor cells” detected using a dubious test, most likely would have done fine, allowing the “integrative medicine” practitioner to declare victory: We’ve caught the tumor early! You’re cured! Hallelujah!

You should read the rest of the story, of course, because that one little pebble started by the woman undergoing an unnecessary and dubious test started an avalanche. A skeptical friend suggested a chest X-ray and a scan. Her cousin, who happened to be a doctor, ordered it. The scan showed “two tiny nodules, 2 mm each in diameter,” leading to that most dreaded of dreaded radiologist statements, “Clinical correlation is recommended in the context of a smoking history.” We see these tiny “incidentaloma” nodules on scans all the time. Most of the time, they’re nothing, and the followup is a repeat scan in six months. but they cause endless patient worry and physician hair-pulling. A PET scan (negative) followed. Nothing reassured the patient, who was still convinced that she had a deadly cancer lurking in her body that would kill her and couldn’t believe the author of the article, an oncologist, wouldn’t go full tilt investigating and treating her for lung cancer.

Certainly many “integrative” practitioners have wholeheartedly embraced the concept of patient-centered care. However, they have done so more out of a desire to be able to justify placebo medicine. If it makes the patient feel better, it must be better. “Patient-centered care” is easy when it devolves into giving the patient what she wants without consideration of science. Real patient-centered care is hard and must contend with situations where what the patient wants is unrealistic or impossible. As I’ve pointed out before, integrative medicine is far more about keeping the customer satisfied that it is about providing superior science-based care. It can’t be said enough times: In terms of medical care, patient satisfaction does not equal quality. To bastardize The Rolling Stones, giving the patient what she wants often keeps her from getting what she needs.

Integrative oncology as a specialty (or integrative medicine in general) is far more about giving the patient what she wants than giving her what she needs. Unfortunately, it seems to be catching on. I came across another article touting CAM for cancer on the up and up. Unfortunately, I can’t read the whole article because I am not a licensed physician in Australia, and to register for the site requires that. I also can’t read the study referenced in the article, Prevalence of complementary and alternative therapy use by cancer patients undergoing radiation therapy. It’s an observational study that looks at CAM use among cancer patients in a radiation oncology clinic between December 2011 and July 2012. It found:

There were 464 (72.6%) men and 175 (27.4%) women, with a mean age of 69.9 years (range 27–94 years). Prostate cancer was the predominant diagnosis (53.1%), followed by breast cancer (17.5%) and skin cancer (14.7%). Of these, 530 patients (82.9%) had used at least one therapy. Of the 530 patients using CAT, the most quoted reasons for use were to improve quality of life (42.6%), to boost the immune system and general health (33.6%), to increase energy levels (32.6%) and to live longer (28.9%). Of the 530 users, only 112 patients (21.1%) took CAT to help cure their cancer. Women were significantly more likely to use CAT, as were patients with breast cancer.

The use of CAT in patients with cancer is prevalent and more frequent in our population than in other published studies. Few patients use CAT to improve their cancer cure, but rather use CAT for other reasons.

“CAT,” by the way, is the term used in the article for “complementary and alternative therapies.” I’ve never seen that abbreviation before, to be honest. Be that as it may, not being able to get the article without waiting for interlibrary loan, I can’t tell if this study suffers from the same issue most studies of this type do, namely defining “CAT” (or “CAM” or whatever you want to call it) so broadly as to include science-based medicine modalities, such as nutrition and exercise, or religious practices, such as spirituality and prayer, that, in this country at least, the vast majority of people participate in regardless of whether they’re ill or not. Whatever the case, this and other studies suggest that integrative oncology is becoming more and more popular, driven by doctors like Hal Gunn. The same is true about “integrative medicine,” keeping the customer satisfied, if not necessarily well cared for.

Unfortunately, I saw evidence of that on display at the American Society of Clinical Oncology (ASCO) meeting this week, but that’s a topic for another post, either here and/or on my not-so-super-secret other blog. As I said before, all “integrative oncology” adds to oncology is pseudoscience and mysticism, but it’s showing up even at the largest and most general oncology meeting in the country, if not the world.

Comments

  1. #1 Newcoaster
    June 6, 2014

    Dang. When I saw Hal Gunns name, I was hoping you were going to give him a heapin helpin of some classic Orac insolence.

    Being a family doc near to Vancouver , I’m well aware of this media whore. I’ve written to him and Inspire Health a few times asking for evidence any of the treatments they offer are supported by robust science. I only got standard boiler plate responses, and that since their “research” is underway they couldn’t divulge it before it is published.

    There was another puff piece in The Vancouver Sun this week, who seem to have a soft spot for this tool. It was to announce a research project studying high dose vitamin D in colorectal cancer. The study itself sounds like it’s going to be useless, they only have 12 of a desired 50 patients for an unblinded RCT.

  2. #2 Chris Hickie
    June 6, 2014

    Stephen Salzberg put up a good column last week on Forbes re-iterating how patient satisfaction does not equal quality (http://www.forbes.com/sites/stevensalzberg/2014/05/26/dr-house-was-right-give-patients-what-they-need-not-what-they-want/).

  3. #3 Militant Agnostic
    June 6, 2014

    For “Patient Centered”, substitute “Customer Centered” – tell them what they want to hear so you can sell them whatever it is you have for sale.

  4. #4 Nanea Taylor
    53.5°N, 10°E
    June 6, 2014

    “believers in “integrative” medicine are taking it further.”

    They’re even taking it as far as the university hospital in my hometown, sadly: Classical homeopathy in the treatment of cancer patients – a prospective observational study of two independent cohorts The lead author is now part of the team at the local cancer center, he’s the consultant for naturopathy and complementary medicine. This is making me sad and angry at the same time, because the center itself has a very good reputation for their research and high success rates in treating even complicated cases.

  5. #5 RobRN
    June 6, 2014

    This whole “Personalized health care” paradigm bothers me to no end. It all boils down to how “Nice” the altie provider is and how much time they spend with their patient (client). I’d rather have my provider be SMART, QUALIFIED and COMPETANT!

  6. #6 Dorothy
    June 6, 2014

    @ RobRN

    CompetEnt–can’t resist pedantry when the word in question is COMPETENT, but I completely agree with your comment!

  7. #7 Leigh Jackson
    June 7, 2014

    A report by the NIH in 2005 – CAM in the USA – said that conventional and CAM treatments should be held to the same evidence-based standards for demonstrating clinical effectiveness. Everyone knows that homeopathy fails to meet this standard. Why is this non-evidence supported treatment found within integrative medicine?
    Acupuncture also fails to measure up. Take a classic example: its use as an adjunct to anti-emetic drugs to treat side effects of chemotherapy for cancer. It was first touted back in 1999 by a NIH consensus report on the basis of two small, poor quality, electro-acupuncture trials.
    A Cochrane Review (2006) pooled the results of those two early studies with a larger electroacupuncture study and one manual acupuncture study. Although the pooled results showed a reduction in the rate of vomiting the study was circumspect in its conclusions.
    The review noted that the manual acupuncture study showed no statistical difference between acupuncture and sham; 5-HT3 anti-emetic drugs in the manual acupuncture study looked to have been far more effective than the earlier generation of anti-emetic drugs used in the large electro-acupuncture study (18% v 82% event rate); there was also a dramatic difference in the history of vomiting in the control arms of the two studies (manual 46% v electro 84% & 62%). The review recommended that electro-acupuncture must be compared with state-of-the-art anti-emetic drugs. As it stood the study raised more questions than answers.
    Where do we stand today?
    A systematic review of acupuncture in cancer care, published last year in the Journal of Clinical Oncology, could only find one RCT with low risk of bias, showing positive benefit of acupuncture for cancer symptoms. That RCT happens to be the same electro-acupuncture trial found to be inconclusive by the Cochrane SR.
    The safest acupuncture study, in terms of bias, known to date, in the field of cancer symptomology relief, was found wanting in terms of clinical meaningfulness, 7 years ago. We still await an HQ trial of adjunct acupuncture of any kind to show benefits greater than modern anti-emetic drugs for chemotherapy induced nausea-vomiting. All these years after the NIH report.
    Why is this non-evidence supported treatment found within integrative medicine?

  8. #8 Narad
    June 8, 2014

    Then, beginning sometime around the 1960s and 1970s, such quackery became known as “alternative” medicine.

    Lazy attestations here.

  9. #9 Narad
    June 8, 2014

    This, I’m sorry to say, is probably too much to hope for as a locus.

  10. #10 AnnB
    June 10, 2014

    I’ve always taken the term patient-centered to be doublespeak. If they were really concerned with a patient’s health, they wouldn’t have to use a term like that.

  11. #11 ChrisL
    June 12, 2014

    @ Newcoaster

    The InspireHealth vitamin D study is listed on ClinicalTrials.gov: http://clinicaltrials.gov/ct2/show/NCT01150877.

    It isn’t clear from what is posted what they are really expecting to show.

  12. #12 Doug
    Australia
    June 12, 2014

    Spoiler. I’m a member of the Chiropractic profession so everyone can make their assumptions now…… Ok I’ll get on with it. Personally I and my immediate collegues try not to hold beliefs which are unsubstantiated. Technically we diagnose and conservatively manage spine related disorders which in practice means we act as part of potential health care team with respect to the patient. As such we commonly refer for medical opinions in advanced imaging, neurosurgery, etc. I have to lead in with this because I am a vociferous critic of my profession and also strongly disagree with the assertion that the problem is CAM. The false dichotomy is that there is medicine which works and medicine that doesn’t. This would mean that all the patients of every profession outside of medical practice don’t ‘work’. For a start it belittles the field of psychology. Let me now state that Integrative medicine is similarly bullshit. The accurate description is that an approach either strives to meet the standards of logic, reason and evidence or it does not. The false dichotomy is medicine vs ‘umbrella term’ (whatever we emotively feel deserves to go here based upon my latest poorly thought through ideas). Clearly bullshit is everywhere albeit more highly concentrated in some areas (mine for example and the integrative med folks) up to complete rubbish such as reiki and homeopathy which are supported by the evidence base of ‘I like it’. No it’s way too easy to get caught up in ridicule and forget Hitchens antidote to hubris – to doubt more that which if true would suit me. My wife uses that before she signs off on medico legal reports for neuropsychological opinion. It works well.

  13. #13 AdamG
    June 13, 2014

    The false dichotomy is that there is medicine which works and medicine that doesn’t.

    The false dichotomy is medicine vs ‘umbrella term’

    Clearly bullshit is everywhere

    Haven’t you just swapped one ‘umbrella term’ for another?

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