Respectful Insolence

Quackery invades another once science-based journal

The editorial staff at The BMJ contemplate their next systematic review.

Surprisingly, I made it through an entire three day weekend without posting anything to the blog. Believe it or not, this is a good thing. It means that I actually worked on my grant that’s due at the end of the week. Still, a blogger’s gotta blog; so I can’t just shut down until the end of the week. So, hwere we go.

I’ve long lamented the creeping infiltration of quackery into medical academia in which modalities once considered quackery, such as acupuncture, reiki, naturopathy, homeopathy, and various other dubious treatments, have found their way into what should be bastions of science-based medicine (SBM). Over the years, I’ve noted the proliferation of “integrative medicine” programs and residencies in medical academia, and professional conferences, the credulous teaching of “complementary and alternative medicine” (CAM) modalities as part of the normal medical school curriculum. (Georgetown University even had a program where acupuncture meridians and points were taught during gross anatomy.) Basically, CAM has been a Trojan horse for quackery in which appeals to more “humanistic” medicine and emphasis on diet and exercise have lured medical schools to bring the giant horse in, after the doors on the bellies of the Trojan horses opened to disgorge quackery such as naturopathy, homeopathy, acupuncture, reiki, and even anthroposophy.

Besides the enthusiastic embrace of quackery by large, respected academic institutions like the Cleveland Clinic and Memorial Sloan-Kettering Cancer Center, this “integration” of quackery with medicine has manifested itself in medical journals. Once hard-nosed, science-based medical journals have, unfortunately, started publishing what can only be described as credulous endorsements of quackery. Indeed, I’ve documented many examples of this shameful phenomena over the years, but I’m about to document a whopper of an example now in, of all places, The BMJ, which has recently published two “state of the art reviews” on “integrative medicine” that can only be described as fully buying into the false paradigm that quackery needs to be “integrated” with medicine. The first “state of the art review is about the management of chronic pain using complementary and integrative medicine by Lucy Chen from the Massachusetts General Hospital Center for Translational Pain Research and Andreas Michalsen from the Institute for Social Medicine, Epidemiology and Health Economics and Immanuel Hospital in Berlin. The second is about complementary and integrative medicine in the management of headache by Denise Millstine, Christina Y Chen, and Brent Bauer, all from the Mayo Clinic. Sadly, both Harvard and the Mayo Clinic have become bastions of quackademic medicine.

The evolving language of “integrative medicine”—or whatever they’re calling it this week

One of the most striking things about both of these articles is the term their authors chose to use to describe what was once “CAM” or “integrative medicine”: “complementary and integrative medicine” (CIM). It’s an odd choice that seems a bit out of sync with what is going on in quackademic medicine these days, as I will describe. But first, let’s take a look at what I’m referring to.

Chen and Michalsen describe it thusly:

The concept of complementary and integrative medicine (CIM) encompasses both Western-style medicine and complementary health approaches as a new combined approach to treat a variety of clinical conditions. CIM may have a unique role in chronic pain management because the multidimensional nature of the pain experience requires a multimodality treatment approach. Recent advances in basic science and clinical research on CIM have substantially increased patients’ awareness about the potential therapeutic use of CIM.

Note the false dichotomy, in which “Western” (i.e., European) tradition is presented as scientific, reductionistic, and lacking in humanism, compared to “CIM,” which is the opposite.

I’ve been noticing a new step in the evolution of language about CAM, and this is another part of it. It first struck me when the National Center for Complementary and Alternative Medicine (NCCAM) first proposed renaming itself to the National Center for Research on Complementary and Integrative Health. The actual name NCCAM took, as we all know now, was the National Center for Complementary and Integrative Health (NCCIH). This is just the latest iteration of rebranding quackery to try to make it respectable by calling it something else, and the BMJ articles contribute to this rebranding. Let’s look a bit at the history.

Around a quarter century or so ago, as part of a conscious effort to make quackery respectable, the term alternative medicine morphed into “complementary and alternative medicine” (CAM). The process continued, such that around 15 years or so ago, the term “CAM” then “evolved” into “integrative medicine.” Each name change was an intentional use of language that served two purposes. First and foremost, the goal of CAM advocates has been for their pseudoscientific treatments like acupuncture, reiki, “functional medicine,” and the like to come to be seen by physicians and the public as legitimate medicine, rather than the rank quackery that many of them are. Second, such terms have facilitated the co-optation of real, science-based treatments (such as those involving dietary manipulation and exercise) as somehow being “alternative” or “integrative.” The reason, whether acknowledged or not, for lumping such treatments together with quackery is because “lifestyle” treatments (such as diet and weight loss for early type II diabetes) can be science-based and can work. They thus provide a patina of respectability to all the other nonsense that gets lumped together with them as “complementary” or “integrative.”

It’s telling to note how the terms evolved. I’ve discussed this in detail on several occasions over the years, but it’s worth a brief recap. Way back in the mists of time (say, the 1980s) there was alternative medicine. Alternative medicine was (and, when the term is used, still 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. Instead of giving up therapies without evidence to support them, however, alternative medicine practitioners rebranded them as “complementary and alternative medicine” (CAM). Over a relatively brief period of time, the name change had its intended effect. No longer did many physicians automatically view modalities that were once considered quackery, later considered “alternative,” and now considered “CAM” as quackery, and those who still did were dismissed as close-minded, stubborn, and dogmatic, relics who were trying to stop what was clearly the future of medicine. The term “complementary”, however, soon became a problem.

Thus, back in the mists of time (say around the late 1990s to early 2000s) was born a new term: “integrative medicine.” No longer were CAM practitioners content to have their favorite quackery be “complementary” to real medicine. After all, “complementary” implied a subsidiary position. Medicine was the cake, and their wares were just the icing. That wasn’t good enough. They craved respect. They wanted to be co-equals with physicians and science- and evidence-based medicine. The term “integrative medicine” (IM) served their purpose perfectly. No longer were their treatments merely “complementary” to real medicine. The very intentional implication, was that alternative medicine was now co-equal to science- and evidence-based medicine, an equal partner in the “integrating,” and that “integrative medicine” combined the “best of both worlds” (Cue the Locutus of Borg jokes). Of course, I like to refer to such “integration” of pseudoscience into medical academia as “quackademic” medicine.

Then came the NCCIH, which broadened the term to gauzy near-meaninglessness. “Integrative health”? Just what the heck is that? Why get rid of the word “medicine”? Obviously, the intent was to expand the meaning to encompass nearly anything health-related and to further blunt any concerns that pseudoscience is being used instead of SBM (although, contrary to what CAM promoters claim, it is). Indeed, I’ve started noticing the term “integrative health” popping up more and more, supplanting “integrative medicine.”

All of this is why I found the choice of the term “CIM” to be so odd. Thus far, every step in the evolution of nomenclature for CAM or “integrative medicine” (or whatever you want to call it) has been to make it more and more indistinguishable from real medicine, to lessen its dependence on real medicine, to sell the pseudoscientific modalities embraced by integrative medicine as being co-equal with real SBM. As part of that messaging and rebranding, CAM has positioned itself as a means of “nonpharmacologically managing” pain and a large part of any potential solution to the opioid addiction epidemic, messaging that’s been going on at least five years, is part of the NCCIH’s strategic plan, and has been so successful that even the FDA is buying into it. Going from “integrative medicine” to “complementary and integrative medicine” would seem to be a step backward, a step back towards terminology in which SBM is the real medicine and “CIM” is just the icing on the cake.

Millstine et al explain it this way:

Conventional treatments, particularly drugs, are often effective in resolving acute headaches and reducing the frequency of chronic or recurrent headaches. However, many patients turn to complementary and alternative medicine (CAM) for greater improvement. CAM has evolved over time but it generally includes treatments that are not typically considered part of conventional medicine. Examples include massage therapy, acupuncture, mind-body medicine, and the use of botanicals and supplements. The distinction between CAM and conventional medicine, however, is not always clear, as is the case with several over the counter supplements now commonly recommended by conventionally trained providers, such as magnesium supplements in migraine.

However, partly as a result of research support by organizations such as the National Center for Complementary and Integrative Health (NCCIH), a growing body of literature has shown that many CAM therapies are effective when used in conjunction with conventional care.3 This has led to the use of the more appropriate term, complementary and integrative medicine (CIM), reflecting the fact that evidence based CAM therapies are increasingly being incorporated into conventional care. The Academic Consortium for Integrative Medicine and Health notes that integrative medicine “reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, healthcare professionals and disciplines to achieve optimal health and healing.”

My head hurts after reading that. After all, the term “CAM” was originally coined to assuage the doubts of doctors who feared that alternative medicine was being used instead of conventional SBM. That was the very purpose of the term. One of the references the authors cite is an NCCIH web page entitled “Complementary Health Approaches for Chronic Pain: What the Science Says.” Let’s just say that it doesn’t really provide compelling evidence that “many CAM therapies are effective when used in conjunction with conventional care.” Even if it did, the renaming is still…curious. In essence, it does what we have been doing all along here and equates the word “integrative” with “alternative.” In essence, it almost admits to the linguistic prestidigitation that turned “complementary and alternative” to “integrative” medicine. One wonders if a lone science-based holdout editor at the BMJ forced the authors to use this term as a subtle joke. Whatever the reason for the term CIM, Edzard Ernst agrees with me that “CIM” is a nonsensical term.

But what do the articles say?

One more time: Nonpharmacologic treatments for pain ≠ CAM, CIM, or whatever it’s called

The article by Chen and Michalsen on CIM for pain is long. It clocks in at well over 18 pages, although over five of those pages are references, which brings up something that Ernst also mentioned, namely how much the authors strive to give the appearance of scholarship. After all, a lengthy references section equals strong scholarship, right? Wrong. To cite an extreme example, I can point to antivaxers who write articles with dozens of references. Indeed, one of them, Ginger Taylor, likes to list well over 100 references that supposedly support her view that vaccines cause autism. They don’t, as the articles she cites as supporting a causative role for vaccines in autism do nothing of the sort and the ones that she cites that do support a causal role are uniformly crap. No, I’m not saying that Chen and Michaelsen were that bad. I only chose the example I did as a very extreme example. I mean only to point out that quantity of references do not equal high quality science and to reinforce Ernst’s point that this article left out a whole lot of negative studies, cherry picking “only evidence for the efficacy of the treatments they promote.”

One thing that struck me about this review is that it was weighted very heavily towards either rheumatoid arthritis or studies of back or neck pain, which is not entirely unreasonable given that back and neck pain are very common. Another thing that struck me about this article right away is that it is how heavily weighted towards acupuncture it appears, with a large table of studies that supposedly establish efficacy of acupuncture for pain. Fortunately, I just wrote about acupuncture last week and a couple of weeks before that, so I don’t have to go into much detail as to why the evidence cited does not support the efficacy of acupuncture for pain. Basically, the larger and better designed the clinical trial, the less likely it is to show an effect of acupuncture above placebo. Acupuncture is theatrical placebo.

None of this stops Chen and Michalsen from enthusiastically embracing it, even buying into the multiple odd ways that acupuncturists combine acupuncture with other “treatments,” from potentially science based (electroacupuncture, which is really just transcutaneous electrical nerve stimulation, or TENS, with needles) to bee venom:

Bee venom acupuncture falls into the category of herbal acupuncture, which combines the effect of bioactive compounds isolated from bee venom with acupuncture stimulation. Several meta-analyses found limited evidence assessing its effectiveness. Pain was lowered significantly more with bee venom acupuncture than saline acupuncture (n=112; weighted mean difference on 100 mm visual analog scale 14.0, 95% confidence interval 9.5 to 18.6, mm; P<0.001). However, the limited number, low quality, and small size of the RCTs make drawing conclusions difficult.73‑75

This is basically a very silly and unreliable way of administering a potentially pharmacologically active compound.

Another section of the review covers “mind-body” therapies. I always find this category problematic, because, as is the case with much “CIM,” it lumps together techniques that could be science-based, such as exercise, with other modalities that are probably not. Inevitably, the “body” part of mind-body modalities always emphasizes “exotic” forms of exercise, such as tai chi, quigong or yoga, over more mundane forms, such as walking or gentle aerobic exercise. For instance, early mobilization is recommended in the treatment of back pain now, and these forms of exercise are just more “sexy” ways of achieving that. In any event, the best that Chen and Michalsen could conclude is that yoga and tai chi might be beneficial, while the evidence for qigong was more conflicting.

Chen and Michalsen are also very much taken with supplements, herbal medicines, and dietary manipulations. For instance, they recommend the Mediterranean diet, citing a small randomized controlled trial and a larger nonrandomized controlled trial as evidence of its efficacy, both of which were thin-gruel indeed, scientifically speaking. Unfortunately, they also included a dubious dietary intervention, elimination diets:

Among a broad variety of food and nutrients that are associated with increases in disease activity, meat, milk and dairy products, wheat gluten, citrus fruit, alcohol, and coffee are ranking high.172 173 Doctors may encourage patients to find individual associations and try individual elimination after confirmation by re-challenging. Clinical research in elimination diets is difficult and complex to perform. So far, only one RCT with 53 patients has examined the concept of an elimination diet with a complex study design, including an initial washout period and specific responder analyses.188 Foods least likely to cause intolerance were reintroduced first in a stepwise manner, and any foods inducing symptoms of rheumatoid arthritis were removed from the diet. There was a significant reduction in pain with the diet in both groups during the dietary elimination phase, but differences between groups were not reported.

Elimination diets are a favorite of naturopaths who like to think that all disease is traceable to diet or various food “allergies.” It’s at best dubious and at worst quackery. (Let’s just put it this way; Gwyneth Paltrow is a fan.) Elimination diets are rarely based on properly conducted allergy testing. Indeed, the testing used to determine what foods to “eliminate” is not scientifically supported.

If you want an idea of how credulous Chen and Michalsen are, look no further than this passage:

This treatment was evaluated in a cohort study and a further prospective non-randomized comparative study. The comparative study included 86 patients with back pain and compared a complex anthroposophical therapy with the standard approach, finding comparable improvements in both groups after six and 12 months for pain, function, and quality of life.214 A longer term cohort study that assessed effects of anthroposophical medicine in 75 patients with chronic back pain found sustained benefits after two years.215 Future randomized trials are warranted.

Anthroposophic medicine is mystical hooey created by Rudolf Steiner. It’s a medical “system” (if you can call it that) that is at the bottom of a lot of quackery and antivaccine beliefs. It also encompasses biodynamic farming, which involves actions like stuffing cow manure into the horn of a cow and burying it in the autumn, leaving it to decompose during the winter, and taking crushed powdered quartz and stuffing it into a horn of a cow to bury in the spring until autumn, supposedly to control fungal diseases. You get the idea. No wonder I was so depressed when anthroposophic medicine showed up at my old alma mater.

Any review that takes anthroposophic medicine seriously is not a serious review.

All this woo is giving me a headache

The second review, by Millstine et al. suffers from many of the same issues as Chen and Michalsen’s review. For instance, it is very much as acupuncture-heavy and credulous. It even goes into auricular acupuncture, explaining it thusly:

Hand, ear, and scalp acupuncture can be more accessible than traditional acupuncture in various clinical settings. The ear holds a microsystem of the body, where stimulation of specific points on the external surface of the ear may provide therapeutic relief of symptoms that are connected to the body system (fig 2).28 Ear acupuncture, for example, can be performed quickly with the patient sitting upright and fully clothed. An RCT of 94 women with migraine without aura compared ear acupuncture in a therapeutic area with treatment in an area deemed unlikely to be beneficial. VAS was significantly reduced 10 minutes after needle insertion time and the effect lasted for two hours (P<0.001).29 Another RCT compared ear acupuncture with traditional acupuncture in 35 patients with migraine without aura. The severity of pain (using the migraine index) was reduced after eight weeks of weekly treatments; it was significantly improved from baseline and both groups were comparable after treatment and three months later (residual pain 54.83% and 63.43% for somatic and ear acupuncture, respectively). After six months residual pain was 16.80% and 48.83% for somatic and ear acupuncture, respectively (P=0.038). These results were confirmed by the visual analog scale test and by the evaluation of pain threshold.30

My brain tuned out after I read the part about the ear holding “a microsystem of the body” and how “stimulation of specific points on the external surface of the ear may provide therapeutic relief of symptoms that are connected to the body system.” Actually, my brain didn’t tune out enough not to notice that the trial cited appears to have had no sham control group and compared regular acupuncture to auricular acupuncture. I don’t have online access to the journal in which the article was published, but it also appears not to have been double-blinded. Placebo effects are therefore highly suspected as the reason for the results. (Yes, this appears to have been a comparative effectiveness trial.) Back to the silliness of ear acupuncture. Remember, auricular acupuncture basically assumes a homunculus on the ear whose parts map to organs and other body parts. It is just as scientific as reflexology, and reflexology is utter pseudoscience. Millstine et al. leave out the homunculus, but they do include an illustration of an ear that shows parts of the ear mapping to the same parts that the traditionally drawn homunculus does. Despite its utter pseudoscience, unfortunately there are military advocates who are successfully integrating auricular acupuncture into the treatment of wounded soldiers and veterans in general as “battlefield acupuncture.” It’s been a wildly successful effort, unfortunately.

The rest of the review reads very much like that of Chen and Michalsen, listing “mind-body” interventions, botanicals, diet, and the like, with very little compelling evidence presented for efficacy and no mention at all of the extreme implausibility of so many of the treatments. In doing so, Millstine et al. propagate the idea that there’s something about diet and exercise that is somehow “integrative” or “complementary” when dietary interventions and exercise, when used in a manner supported by sound science and evidence, are just medicine.

None of this stops Millstine et al. from concluding:

The use of CIM therapies has the potential to empower patients and help them take an active role in their care.90 91 Many CIM modalities, including mind-body therapies, are both self selected and self administered after an education period. This, coupled with patients’ increased desire to incorporate integrative medicine, should prompt healthcare providers to consider and discuss its inclusion in the overall management strategy.

Wait a minute. The evidence base for CIM strategies for migraine is low quality, but providers should recommend it because they “empower” patients and help them take an active role in their care? What a false dichotomy! Empowering patients and getting them to take a more active role in their own care do not require prescribing unscientific treatments with no compelling evidence for their efficacy. In other words, accepting quackery does not equal “patient-centered” care or “empowering” patients. These desirable outcomes can and should be achieved while recommending science-based medicine.

Count The BMJ among the fallen

With the increasing infiltration of quackery into medicine in the form of CAM, or “integrative medicine,” or “CIM,” or whatever you want to call it, we are seeing more and more journals succumb to the temptation to publish nonsense like these two review articles that appeared in The BMJ. In this case, it’s particularly puzzling, given how The BMJ has a history of publishing articles decrying the overhyping of acupuncture and warning about acupuncture-transmitted infections and potentially serious adverse events. It’s also published articles with titles like “The scam of integrative medicine“, “Integrative medicine and the point of credulity“, and “Doctors warn of dangers of complementary medicine for children.” It has also published credulous articles as well, but seldom, as far as I can tell, as “systematic reviews” as obviously biased as these two are.

Prof. Ernst is justifiably unhappy. As he says, The BMJ used to be a good journal. What is happening? Sadly, I think I know. The tide of pseudoscience that has been rising over the last quarter century has simply engulfed The BMJ too. At least in this case there has been some pushback, but I fear it will be short lived. In the meantime, I eagerly await The BMJ‘s next systematic review on the use of CIM to treat patients with a vague sense of unease or a touch of the nerves or even just more money than sense. I’m sure it will be equally positive as the reviews by Chen and Michalsen and Millstine et al.