Terra Sigillata

Over the last several days, Dr. RW, Orac, and Joseph (Corpus Callosum) have been discussing the virtues, or lack thereof, of a national medical student association espousing the coverage of integrative, complementary and alternative medicine (ICAM) modalities in the medical curriculum.

Our SciBling, Joseph, raised the interesting point that CAM education might improve the one aspect of medicine that administrators and health insurance companies are trying to drive from medicine: the doctor-patient relationship. I would say that none of the MD bloggers disagree that time constraints in the practice setting are interfering with the doctor-patient relationship. But Orac disagrees strongly that the introduction of CAM coursework is the proper way to enhance this time-honored aspect of medicine. I’m the only non-MD in this discussion thus far who has any interest in the alternative medicine discussion, so here are my thoughts – and they extend far beyond what is taught in medical schools but, rather, what is occurring in clinics on medical school campuses.

Most certainly, formerly conventional medical patients cite loss of time/communication with their physicians as one of the primary reasons for pursuing alternative therapies. In some practice settings, physicians and medical systems have recognized this; I was recently quite pleased to have almost an hour of history and consultation time with my pulmonologist when working up the management of my allergic asthma. As I understand though, my experience was an exception.

So, someone like me who feels a doctor doesn’t have time for them might approach any one of the growing number of integrative medicine centers within our nation’s top academic medical centers (or a similar practice setting in the community). Will such a person be met by a trained MD or some questionably-credentialled “professional?” This point is the single greatest threat to the use of CAM within conventional medicine. Will they be told that their asthma is the result of unprocessed grief, or problem with the flow of their Qi, or that a simple mindfulness-based meditation program can help resolve their asthma?

So, I am torn – an asthma patient like me should be evaluated with the best pulmonary function testing and given state-of-the-art pharmacotherapy, but I have no problem with also being prescribed several cups of thyme tea daily. My greatest concern is that the less effective modalities will be prescribed by those practitioners least likely, or not licensed, to prescribe prescription medicines. So, my concerns extend beyond whether medical students learn any alternative medicine in their curricula. My concerns are that the inclusion of CAM coursework in medical schools brings into the academic medical system practitioners who, alone, lack the qualifications for comprehensive care of serious and potentially fatal diseases.

If my colleague, Orac, really wants to get into a lather, let’s all take a look at the Consortium of Academic of Academic Health Centers for Integrative Medicine. Take a gander at the member institutions. Examine the mission of this consortium. And who is behind this movement? Something called the Bravewell Collaborative, a collection of individuals at academic institutions, many of whom are million-dollar-earning authors of wellness books. (Clarification: The Bravewell Collaboration is based on an operating foundation of philanthropists who espouse their Declaration for a New Medicine and offer to donate at least $150,000 over a three year period; each year; the Bravewell Leadership Award is then given to a membership-associated academic leader – clever, eh?). Even their page on evidence-based integrative medicine includes not one single link to a peer-reviewed research manuscript (although there are plenty of links to white papers and television programs.).

Yes, friends, modern integrative medicine is a public relations and marketing campaign.

Further, this organization is just one example that confirms my suspicion that integrative medicine is intended to be only for the rich and famous.

If it does exist for the benefit of patients, it does so at the expense of those patients’ dollars lining the pockets of these “visionaries.”

With very, very few exceptions, most of the leaders of this field are pseudoexperts - a term that is not mine but, rather, that of Dr Edzard Ernst, a physician who has dedicated his career to the study of complementary and alternative medicine at the University of Exeter, UK. Dr Ernst edits a review journal on CAM that is widely-distributed in Europe, but less so in the US, called Focus on Alternative and Complementary Therapies (FACT). So even-handed is Ernst that the journal has earned the grudging endorsement of Quackwatch’s, Dr Stephen Barrett.

Here’s how Dr Ernst views the academic CAM vultures:

I have to admit, I occasionally get irritated by some of the so-called CAM ‘experts’ that so vociferously dominate our field, but more often these people amuse me. Virtually all fields of medicine are driven by healthcare professionals and scientists, but CAM is different – it is an area that is driven by consumers. It also is an area where, relative to mainstream medicine, scientific knowledge is still in its early infancy. These important differences have many far-reaching implications, and one of them is that almost everyone seems to be an ‘expert’ in CAM…

…in order to qualify as an expert, one has to have a reasonably long history of dealing with the subject. In CAM, such common sense is often suspended. Here people seem to become ‘experts’ virtually overnight….

…As already mentioned, with pseudoexperts there is no real history of having studied CAM in any depth. They have therefore little or nothing to show for themselves by way of publications. Search for their name in Medline, for instance, and you will find no more than two or three citations (in all likelihood, however, you will find none). As they lack factual knowledge of CAM, pseudeoexperts normally don’t bother with the all-important fine detail; they often pretend to be visionaries capable of ‘seeing the bigger picture’. As soon as you put them on the spot, however, you find that their ‘vision’ fades into shallow speculation…

Mind you, this characterization comes from a strong proponent of complementary and alternative medicine.

The personality of the pseudoexpert merits detailed psychological analysis. It helps, I think, not to be too intelligent. This makes it easier for the pseudoexpert to fall victim to his or her own powers of persuasion. The result is often an almost religious belief of the pseudoexpert in the correctness of his or her assertions. One cannot readily disprove a religion and those pseudoexperts who mistake CAM for a religion cannot even conceive the possibility of being wrong. Not all pseudoexperts, however, are true believers nor are all of them stupid. Some are highly motivated by strong self-interest. These are the ones who tend to be addicted to the limelight of public interest. If you read the Sunday papers and follow how some health writers promote certain treatments, you probably understand what I mean. One does not need to do an awful lot of research to find that some of these pseudoexperts are motivated by financial rewards. [emphasis mine]. For others the attraction lies in the prospect of fame or power. Attractive positions and distinctions wait for those who loudly and unscientifically promote what the government of the day or other VIPs want to hear.

In time, I predict that a major US academic medical center will be sued for malpractice as a result of the practices of CAM renegades in their midst. Until then, I recommend vigilance, both by medical students and medical faculty. Again, Ernst:

The proliferation of CAM pseudoexperts is perhaps not surprising and in many instances it is a highly entertaining phenomenon. Yet it is also regrettable for several reasons. Pseudoexperts misdirect decision makers. They can also produce more tangible harm, e.g. by misleading patients into using the wrong type of CAM or the right type wrongly. Finally they jeopardise the potential that CAM has in certain areas. And this is a lasting disservice to our field.

Comments

  1. #1 Orac
    November 17, 2006

    If my colleague, Orac, really wants to get into a lather, let’s all take a look at the Consortium of Academic of Academic Health Centers for Integrative Medicine. Take a gander at the member institutions. Examine the mission of this consortium. And who is behind this movement? Something called the Bravewell Collaborative, a collection of individuals at academic institutions, many of whom are million-dollar-earning authors of wellness books. Even their page on evidence-based integrative medicine includes not one single link to a peer-reviewed research manuscript (although there are plenty of links to white papers and television programs.)

    Aggh!

    That’s really bad. I had no idea…

    However, I have one that may be even worse (if that’s possible), which I plan on blogging about next week (plug, plug).

  2. #2 Robin Peters
    November 17, 2006

    The impression that I got from reading this entry was that CAM is “driven by” consumers. This underscores a point I have been making repeatedly in recent comments – that people want individual attention, and they’re driven to CAM practitioners because patients feel they don’t get that individual attention from those who practice conventional medicine. You’re right to note that insurers often dictate how much time a physician can spend with each patient, and if the physician is allowed very little time to spend with each individual patient, the patient feels neglected and ignored.

    I consider myself fortunate in the sense that my current physicians do not rush me hurriedly out of the examining room in an attempt to pack as many patients into their calendar as they can. However, I have talked of my problems with protocol-based medicine (in which everyone with the same medical problem gets treated according to a strict protocol irrespective of individual differences). Being treated according to a strict protocol, without acknowledging individual differences, is little better than being rushed out of the examining room because the physician wants as much insurance money as possible. The patient ends up the loser, either way.

  3. #3 UK Community Pharmacist
    November 17, 2006

    From the work I’ve read Dr Ernst seems very even handed with regards to CAM, looking for evidence and evaluating it in those cases where it is available. He had an interesting series of articles in the Pharmaceutical Journal in 2004-05. The complete series is at http://www.pjonline.com/noticeboard/series/complementarymedicine.html

  4. #4 Tanta
    November 18, 2006

    Oh, dear. I find that the university medical center at which I am being treated for cancer is a member of the Consortium you link to. Having not (yet, at least) been exposed to much in the way of woo there, except for a recommendation (which I ignored) to take high-dose vitamin E to treat hot flashes (this may or may not be woo but it sounds iffy to me), I spent some time checking out my institution’s website. I found this in the homeopathy section:

    “An initial visit to the homeopath can take from 1 to 1 and a half hours. Because homeopaths treat the person rather than the illness, the practitioner interviews the person at length, asking many questions and observing personality traits as well as unusual behavioral and physical symptoms. Determining the person’s condition also includes a physical examination and possibly laboratory work.” [Emphasis added]

    I confess I’m amused by the missing “merely” in front of the words “the illness,” but mostly I’m outraged. If you take the boldface phrase out of this sentence, it passes for an “objective” description of what homeopaths do. With the editorializing added, it becomes a hook for those of us who aren’t attracted to woo but who are frustrated by the seven-minute office visit with highly competent docs who are poor communicators. I have suspected for some time that this “treat the person, not just the disease” business was going to end up being worse than the problem it pretends to solve, and this just clinches it. The worst part of it from my personal perspective is that cancer patients can certainly use all the sensitive support they can get, but if this means referral to a freaking homeopath, count me out. Now I’m even more determined than usual to edit my responses on the “depression questionnaire” I have to fill out at each doctor visit. I used to be worried that they’d just sic the psychiatric social worker on me and we’d spend an hour determining that yes, having cancer is a bummer; now I have to worry about someone siccing the homeopath on me, which would do unto my blood pressure what it doesn’t need to be done unto.

    It turns out, by the way, that the whole “CAM” section of my university medical center’s website is provided by this outfit:

    http://www.adam.com/

    I browsed their site this morning. Among other things, I saw their Q3 earnings report. I struggle to understand medicine and pharmacology issues (because I have to these days), but honey, I can read financial statements in my sleep. Are you shocked to discover that they use the dreaded “Non-GAAP” measures of revenue? (GAAP = Generally Accepted Accounting Principles. Non-GAAP = the CAM of the financial world.) They may be pulling in what looks like the big bucks for pitching woo, but they look to me like a financial flame-out waiting to happen. I suppose if your pension fund doesn’t own shares of this dog, it might strike you as some of that old-time karmic justice. It strikes me as a double-dip kind of fleece, since I suspect those most likely to buy the product are those most likely to buy the shares. In any case, I wouldn’t be so quick to distinguish between the “true believers” and the “self-interested.” If ADAM, Inc. is representative of the breed, they’re as credulous with a business plan as they are with folk medicine.

  5. #5 cobbler
    December 4, 2007

    I know this is an older post but I just came across a recent article by Lisa Emrich that seems to support your notion.

    Is Alternative Medicine Complementary in the Pursuit of Health & Wellness?

    I was told that my pH was completely neutral which needed to be addressed and that the elevated leukocyte level indicated a possible urinary tract infection. The first thing I asked was “what is a normal pH level for a regular person and then what is a normal pH level for someone who takes the medications I do?” It was at this point that the doctor looked down at my forms and replied, “Oh, you are taking a lot of medications. What are these for?” The red flag began to rise.

  6. #6 coracle
    December 5, 2007

    Sounds like excellent reading. Along similar lines is John Diamond’s Snake Oil. The author was a non-science journalist writing consumer articles for The Times when he was diagnosed with cancer. The book looks at how various alternative therapies fail to add up. The book is tragically short due to the authors death, although there are some of his newspaper columns included to supplement the bulk of the text.