The Society for Integrative Oncology (SIO) doesn’t like me much. I understand. I haven’t exactly been supportive of the group’s mission or activities. So it wasn’t surprising that SIO wrote letters trying to rebut a Perspectives article on “integrative oncology” that I published in Nature Reviews Cancer two years ago. What depressed me about that encounter was that one of the complaints the SIO had about my article was that it spent too much verbiage discussing homeopathy as one pseudoscientific treatment that “integrative” oncology “integrates” with science-based medicine and no one uses homeopathy. This led me to point out in my response that the SIO includes naturopaths as prominent members, including as co-authors of its guidelines for breast cancer supportive care. It also led me to point out that you can’t have naturopathy without homeopathy because naturopathy schools teach homeopathy, which makes up a prominent section of the NPLEX, the test naturopaths have to take to be licensed in states that license them. It further depressed me that apparently the doctors in the SIO who responded to my article didn’t realize that one of the naturopaths who was a co-author of the breast cancer guidelines was at the time actually running a clinical trial of homeopathy.
That incident, more than any other, convinced me that most “integrative medicine” MDs, even prominent ones and particularly ones who work with naturopaths, have no clue about the level of pseudoscience and quackery that they’ve embraced. No clue at all. They realize at some level that homeopathy is complete and utter quackery, with no basis in science, which is why they reacted so badly to my discussion of homeopathy. (Ironically, the homeopathy discussion in the first submission of the paper was much shorter, but I was forced to expand it because of comments from one of the peer reviewers.) However, they do not realize that all naturopaths are trained in homeopathy, most naturopaths use it, and that naturopaths used many treatments equally quacky. It’s not just naturopathy, either. Integrative medicine MDs have the same blind spot for traditional Chinese medicine (TCM), which they fail to recognize as a prescientific medical system based on religious and mystical beliefs that was in essence created by Chairman Mao through the “integration” of many Chinese folk medicine traditions because at the time Mao couldn’t bring science-based medicine to enough of his people.
I relate that story not because this post is about naturopathy or TCM, but rather to set the stage for a point that I want to make, illustrating it with the Chief of the Integrative Medicine Service at one of the most prestigious cancer centers in the world, Memorial Sloan-Kettering Cancer Center (MSKCC). On its website, there is an interview with Dr. Jun Mao, who is the Chief of the Integrative Medicine Service. It’s an interview chock full of the sorts of fallacies and what Kimball Atwood used to call the “weasel words of woo” that have facilitated the infiltration of pseudoscience and quackery into halls of medical academia as hallowed as those of MSKCC.
The first question was simple, basically about whether Dr. Mao always envisioned his career “bridging Eastern and Western medicine.” Of course, I hate the whole “Eastern medicine” construct. I view it as a racist term because it implies that those inscrutable Asians are all “holistic” and “natural,” in contrast to those “Western” (and white) doctors, who are all scientific and reductionist. Be that as it may, here’s Dr. Mao’s response:
I’m always interested in the system as a whole, while paying attention to the parts. If you look at a human being in that way, you can see cancer in the context of the entire body. As I pursued Western medicine training, it felt like some of that was missing —sometimes we focus so much on figuring out the exact parts of the body that we sort of forget the whole.
That led me to turn to Eastern medicine. Being the Chief of Integrative Medicine is my dream job. The goal is really to bring the best of conventional medicine together with therapeutics that originate from other cultures and traditions and apply scientific method to research them and eventually disseminate them into clinical practice. Ultimately, we want to allow cancer patients and their family members to have more tools available to them to deal with the physical, emotional, and spiritual impacts of cancer.
On the surface, this sounds reasonable, but you don’t have to dig too deeply or analyze too hard to see the problems with this view. First:
Seeing the body’s “system as a whole” ≠ TCM.
Think about it. TCM is based on the idea that disease is a result of imbalance in the five elements and various other permutations. For instance, some diseases are due to imbalances between damp and dry, heat and cold, and various other opposites. In its basic concept, TCM resembles ancient “Western” medicine; i.e., the humoral theory of medicine in which disease was thought to be a result of imbalances in the four humors. Also, it does no good to “see the whole system” if the lense through which you see that system is basically a kaleidoscope of pseudoscience that distorts everything you look at. That’s what TCM does as a prescientific medical system.
Dr. Mao goes on:
My research in acupuncture has shown that when used for these women, it can help reduce joint pain, decrease hot flashes and anxiety, and improve sleep. By combining Eastern and Western approaches, we allow them to have the best symptom control, hopefully adhere to their lifesaving drugs, and improve their longevity.
Another way to think about it may be that conventional drugs are more about targeting the disease and integrative medicine focuses more on healing the whole person.
This, I’m afraid, is utter and complete bullshit. There’s just no other accurate way to describe it. Unfortunately, it is the fallacy at the heart of so much rationalization of integrating quackery into medicine by advocates like Dr. Mao. Consider this aspect of TCM. TCM practitioners often use something they call “tongue diagnosis. What this involves is looking at the tongue and making diagnoses. So what’s the problem? After all, doctors look at the tongue all the time and can tell all sorts of things about the patient by doing so. Yes, that is true, but in TCM, tongue diagnosis functions a lot like reflexology, with different parts of the tongue thought to map to different organs and body parts. Also, TCM is based on prescientific vitalism, the idea that there is a “life energy” that flows through the body. After all, that’s what acupuncture is supposed to be affecting, the flow of this “life energy.” Let’s just put it this way. Basing treatment on pseudoscience and prescientific belief systems might be “taking care of the whole patient,” but it isn’t taking care of the whole patient correctly. My retort to this argument is that you don’t have to embrace pseudoscience and quackery to take care of the whole patient.
As for acupuncture, Dr. Mao is just plain wrong. It doesn’t help above placebo for pain, hot flashes, or anything else. It’s not as though I haven’t blogged about some of the very studies that Mao uses to support his belief in acupuncture.
Next up is my favorite: What’s the difference between alternative and integrative medicine? Dr. Mao’s happy to answer:
Unlike alternative medicine, integrative medicine focuses on using research to inform evidence-based practice of complementary therapies. Integrative medicine is also better integrated into patients’ treatment and survivorship care plans to help them adhere to conventional treatments while augmenting their symptom control and improving their quality of life through other means, such as yoga, acupuncture, or meditation.
As President of the Society for Integrative Oncology, I help lead our group to advocate for scientific research to understand both the safety and the efficacy of complementary therapies. There’s a continually emerging body of literature that suggests many of the therapeutics we use, such as massage, acupuncture, meditation, and yoga, have beneficial effects for psychological distress, insomnia, pain, and fatigue. And those are very common in cancer patients.
Alternative medicine often completely operates on empirical experience. In some contexts, there are people who take advantage of that and make unsubstantiated claims that some herbs or substance can cure cancer without scientific proof. And that’s really why integrative medicine tries to separate itself from alternative medicine.
Sigh. Yes, practitioners of “integrative medicine,” especially the ones at quackademic medical centers, take great umbrage if you mention alternative medicine and imply that what they do is in any way like it. They pull themselves up and say something along the lines of, “Oh, no, we don’t do that. We use only evidence-based treatments.” Then they go on about acupuncture, herbs that don’t work, and other aspects of TCM, mixing it with potentially real evidence-based modalities like exercise or massage. It is basically the central message of “integrative medicine,” and unfortunately it’s effective, a large reason why integrative medicine has infiltrated institutions like MSKCC.
It is rather interesting, however, to see what Dr. Mao says about skeptics:
I think skepticism is a healthy thing. Just like for a lot of conventional cancer treatment, there’s always skepticism, and that helps us to push the envelope more. Clinicians are always asking whether a therapy is working or whether it’s safe. I actually don’t think we should have a blind acceptance of everything.
In terms of people being concerned about a placebo effect, it’s a really great question. I am very intrigued and actually studying that.
Think about placebo effect as a mind-body effect: If you actively engage your mind in wanting a specific outcome, you achieve the outcome. I think the way we are answering whether acupuncture or other types of therapies are better than placebo is by trying to understand the mechanisms underlying the pain, depression, anxiety, and distress that people are experiencing, whether a lot of that is driven by the mind-body effect.
Ugh. This borders on what I like to refer to as the central dogma of alternative medicine, which is that thinking makes it so. It’s also combined with the fallback position that more and more advocates of “integrative medicine” have fallen back on as study after study have failed to find an effect due to their woo that is detectably different from placebo effects. That narrative is that, sure, something like acupuncture doesn’t do anything detectably better than placebo, but it’s the placebo effect that’s invoked that’s “healing.” Add a dash of Cartesian dualism to that, with the hole invocation of “mind-body” effects, as though the mind were somehow separate from the body when it is not, and you have a recipe to thoroughly depress me reading such words coming from a high ranking faculty member of an institution like MSKCC.
Sadly, SIO and the integrative medicine service at MSKCC are just two examples of all too many. All over the US—the world, even—once rigorously science-based institutions are embracing pseudoscience. Unfortunately, the reasons they give are the same all over the world and just as deluded.
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" If you actively engage your mind in wanting a specific outcome, you achieve the outcome."
And yet I keep not winning the lottery. :(
And, as any double-blind study will show, it's something* which is obtained by giving no real treatment to the patient.
So, Dr Mao, riddle me this: why should I pay you to stick needles into me if I can obtain the same effect with a nice herbal tea and a positive attitude?
* assuming the placebo effect is "something", instead of just the wax and wane periods of a condition, or naturally-occurring healing (i.e. the one your body was going to do anyway).
"That incident, more than any other, convinced me that most “integrative medicine” MDs, even prominent ones and particularly ones who work with naturopaths, have no clue about the level of pseudoscience and quackery that they’ve embraced. No clue at all."
Yes David, no one has an utter clue but you, a cut-rate surgeon who blogs more than he treats patients. Have you ever heard the phrase "delusions of grandeur"? Its a common malady among PhDs. Unfortunately there is no cure, but there are treatments, but none that have been validated with an RCT :(
If they are willing to do trials on homeopathic remedies, I thought you would applaud that. Finally, you'll be vindicated when it turns out they don't work. Except you don't want that to occur. I wonder why...
You've probably all seen this one before. Posted for truth. Take it away Dara O'Briain.
"There’s a continually emerging body of literature that suggests many of the therapeutics we use, such as massage, acupuncture, meditation, and yoga..."
A large bowel movement from a severely constipated patient is also "continually emerging" and like Dr. Mao's integrative medicine stinks and deserves flushing. Also both are massive piles of fecal matter that usually need morcellation into more easily disposable waste as you so adroitly do with integrative medicine when it inspissates our medical institutions, Orac.
Sigh. It looks like Robyn Roberts is doing a report on "integrative" medicine, and that's the reason for the big publicity push from MSKCC. Its Twitter feed this morning is full of promotion of its integrative medicine services. Sigh.
One reason these institutions are getting into the game is that more money is becoming available from some private foundations to investigate CAM. Some of them are front groups funded by supplement manufacturers. In veterinary medicine, you are almost compelled to use crackpot non-medicine even if you don't believe in it, or you're not eligible for membership in some of the main groups. Supposedly that is being changed, but I know several honest vets who will privately tell you they resent having to endorse and promote these things. And of course there will always be those who are merely profiting from the credulous.
How the mighty have fallen. So sad.
I trained there for two years, and I cannot count the number of times I walked through that entrance pictured above.
I am also a patient there. Fortunately, everyone I have had contact with must have known not to try to push nonsense on me. This stuff was never mentioned. Or perhaps it is not as important as Dr. Mao thinks it is.
Dr. Mao: "As President of the Society for Integrative Oncology, I help lead our group to advocate for scientific research to understand both the safety and the efficacy of complementary therapies....If you actively engage your mind in wanting a specific outcome, you achieve the outcome.”
Well, there you go. All Dr. Mao's group has to do to get an alt med treatment validated by research is to want it badly enough.
This may qualify as extreme measures, but maybe you should send them to this essay by John Scalzi and tell them that the same analogy applies to them. The original essay compares Trump voters who claim not to be racist to people who, in order to subscribe to HBO, get a package that includes Cinemax and then claim not to be Cinemax subscribers. They knew, or should have known, that Cinemax was part of the package (the cable company does not conceal this detail) and that some of the subscription fee is paid to Cinemax. Likewise, Trump never concealed his racism, and Trump voters knew, or should have known, that they were supporting that racism. The same thing applies here: people who are into "integrative medicine", especially but not limited to naturopaths, make no secret that they practice homeopathy, so if you encourage the practice of "integrative medicine" in your medical center, you know or should know that you are actively promoting homeopathy, and they deserve just as much respect (i.e., none whatsoever) as a homeopath.
"If you actively engage your mind in wanting a specific outcome, you achieve the outcome.”
Damn! Why did no one tell me this before? I'm off now to actively engage my mind in wanting to be able to put weight on my right hip and stand up and sit down without yelping in pain. I'm sure that after I've actively engaged my mind, I'll be able to skip down the street singing, and farting rainbows!
In the photo of MSK that accompanies the article, is that guy on the right hailing a cab or chastising Laetrile supporters?
And the woman with what looks like really puffy lower extremities - might those actually be the legendary goodie bags MSK sends patients home with, stuffed with pharma drugs and GMO cookies?
Homeopathic remedies will now have to "prove" they work:
That is just her weekly supply of supplements she just bought.
Let's take this statement "If you actively engage your mind in wanting a specific outcome, you achieve the outcome." and flip it around - if you don't achieve the outcome you want, it is because you did not actively engage your mind. Or to put it more bluntly - it's your fault that you have cancer and the treatment didn't work.
What the hell, Dr Mao. Do you have any idea how cruel you are?
Lester @3: I'm going to answer you directly, in case you don't understand why there are not more RCT of homeopathy.
Basically the answer is ethics. An ethical study requires many things, including prior plausibility (is there any data to suggest that the treatment will work?) and equipoise (is there data to support that this treatment is better or safer than the existing treatment?).
Homeopathy has no prior plausibility (it requires violations of the laws of physics), and therefore cannot achieve equipoise. Thus it would be unethical to study homeopathy.
Well, Mao didn't totally trash the PRC's medical system, he largely did, but later managed to repair it to a degree.
As one example, due to his insistence on reviewing ancient herbal treatments, we now have Artemisinin and its semi-synthetic derivatives to help treat malaria, which is becoming increasingly drug resistant.
Of course, had he not bothered with that cultural revolution purge, he'd have not had that much to repair.
Oh well, the broken clock is right twice a day.
As for ”If you actively engage your mind in wanting a specific outcome, you achieve the outcome.”, I'm still waiting, like #1, for that bloody winning lottery ticket to appear on my dining room table. Thus far, the laws of thermodynamics remain quite firmly in effect in my house. ;)
I also am an advocate for homeopathic IV infusions, to be used in capital punishment instances. ;)
That'd avoid the possibility of executing a wrongfully convicted prisoner and help put another nail in homeopathy's virtual coffin.
I wonder how this is supposed to work in cases of mental illness, where the illness affects your thinking; I suppose you just will yourself to "think positive" (my brother) and get over it.
Lester: "If they are willing to do trials on homeopathic remedies, I thought you would applaud that."
It is not ethical to lie to patients. Homeopathy is literally nothing, so claiming it works for anything is lying.
Now, you are quite welcome to do an animal study on homeopathy. Andre Saine claims homeopathy works better for rabies than the modern vaccine. So go and do that study with rodents. Have three groups: one that is vaccinated for rabies and two that are not. Infect all three with rabies and treat one group of unvaccinated rodents with homeopathy. Compare how all three do.
Come back after you publish your results in a PubMed indexed journal.
Seems to me they are doing sound studies on homeopathy to show irrefutably that it is junk. Use RCT and rigorous methodology to end this pointlessness, right? What other reason is there to spend money on this? But you cannot show confirmation bias at the outset: yes,we know this is garbage, but we just want to settle the question once and for all. This new indulgence of studying what's known to be useless is a response to a few decades of someone always whining about some fault or other with debunking studies. Do it right, show clear results, and move on to more important issues. Let the champions of woo cook up some reason why good studies showed their nonsense is nonsense.
"The goal is really to bring the best of conventional medicine together with therapeutics that originate from other cultures and traditions and apply scientific method to research them and eventually disseminate them into clinical practice."
"As President of the Society for Integrative Oncology, I help lead our group to advocate for scientific research to understand both the safety and the efficacy of complementary therapies."
And I thought the point of research was to find out IF a treatment worked, not to assume it does work. Sigh.
Sara: "Seems to me they are doing sound studies on homeopathy to show irrefutably that it is junk."
Who is "they"? If it is the naturopaths doing a clinical trial with homeopathy and breast cancer you will see that there are often very serious problems with the methods, etc. There have been some examples discussed on this blog.
I really want someone to do that rodent study of the efficacy of homeopathy to treat rabies. I have challenged many defenders of homeopathy about that kind of study starting when Andre Saine made his claim in a debate:
No, actively wanting an outcome is not enough. Or do you think that Hillary Clinton, Bernie Sanders, Ted Cruz and everyone else who ran for president in the last two years didn't want to be elected? Does only one baseball team a year actively want to win the World Series, and only one jockey want his horse to win the Kentucky Derby?
Chris @22: The study you propose might well be declared unethical by any university IACUC, for the same reason that a human study would be ruled out: there is no evidence that it would work, and you would cause pain and suffering as well as death to the animals. (No matter what the animal rights activists say, people who do research on animals are bound by ethical considerations.)
""I really want someone to do that rodent study of the efficacy of homeopathy to treat rabies.
Ouch. Since those with rabies exibit hydrophobia, one would have to handle the little vectors to forcefully administer the treatment.
Rodents pretty much don't carry rabies:
"It is not ethical to lie to patients. Homeopathy is literally nothing, so claiming it works for anything is lying."
Obviously there is no need to lie. Patients don't know whether they are getting placebo or the remedy, so your point is moot. Nice try though, really. I like the circular reasoning part of your argument where you make an assumption "Homeopathy is nothing" to justify not doing an RCT to find out if it is actually nothing. That would usually work on the dim-witted. Ditto the ethical gambit.
Wow. I thought Sloan Kettering would be the last people to embrace this stuff!
If, by any chance, you can perform the study you want, your manuscript will be evaluated by "experts". "Experts" in this field are homeopaths. They will criticize your lack of expertise in the field, the choice of your animal model, the way you did your dilutions, the time when you gave the treatment, and so on...
You are expecting too much from experiments and peer review, and not enough from knowledge, logic, and judgment. We don't have to do anything to prove that homeopathy is bllsht. Homeopathy interests me because it shows how much the knowledge industry is corrupted. MDs that are co-authors with homeopaths can be referees for journals. What do you think it means in terms of evaluation?
Corcos, the study would get more legs by someone who actually believes homeopathy actually works.
Also, it serves to just shut them up.
Lester: "Obviously there is no need to lie. Patients don’t know whether they are getting placebo or the remedy, so your point is moot."
That is the definition of lying.
They will never give up, like astrologists or believers. If they were able to change their mind in the face of evidence, homeopathy would be a science.
Corcos, the joy in the rabies challenge for homeopathy is that they actively avoid dealing with the question, and lurkers see the pure idiocy of the entire concept.
Mercy me. You're all taking Dr. Mao's "If you actively engage your mind in wanting a specific outcome, you achieve the outcome" out of context. He's not offering that as a pronouncement of metaphysics. He's describing placebo effects. What is placebo if not people engaging their mind in wanting to better, and thus achieving the 'outcome' of feeling better? And he's not just wooey-cheerful about the mind games that effect mood 'outcomes'. He identifies the 'mind-body effect' – the mind tricking itself about body conditions – as a source of the "depression, anxiety, and distress" experienced by cancer patients.
Orac privileges 'science' first and foremost, measures any IM thing against the ideals of high scientific rigor, and condemns it all as a result. Here anyway, I'm going to privilege patient well-being, and apply a more pragmatic standard. In that, I start with things as they are, and in the case of IM I see central problem as the conflation of physiological health and physiological effect in every way with psychological health and psychological effect. That's not just enabling for bad physiological medicine, but bad dealing with psychological health as well. Compared to IM pooh-bahs like Andrew Weil, Mark Hyman and (gag) John Weeks, it sounds to me like Dr. Mao is trying to move the IM needle in a positive direction. Is it perfect? No. But what change does not occur one step at a time.
At least Dr, Mao recognizes that cancer patients, especially those on chemo, face serious issues with "depression, anxiety, and distress", and is trying to do something about it.
As someone who has had enough "depression, anxiety, and distress" to make the phrase "quality of life" sound like a sick joke, my position is "if something gets you further from the bottom of the pit, far be it from me to be critical'. If somebody stuck a bunch of needles in my 'acupoints' I'm pretty sure I'd just get more "depression, anxiety, and distress". But it does seem there's evidence some folks get the opposite effect, and, well, good for them.
Actually, when I first read "If you actively engage your mind in wanting a specific outcome, you achieve the outcome," my first thought wasn't 'placebo' but 'that just sounds like CBT'. as it happens, CBT also just increases my depression anxiety and ditress, but, again I won't knock it sui generis since it does seem to help other people.
JP asked how Mao's approach "is supposed to work in cases of mental illness, where the illness affects your thinking; I suppose you just will yourself to “think positive” and get over it." And that's CBT in a nutshell. And yeah, JustaTech, if you're in CBT, and "you don’t achieve the outcome you want, it is because you did not actively engage your mind. Or to put it more bluntly – it’s your fault that the treatment didn’t work."
But here's the thing: Dr. Mao is just trying to explain some stuff to a couple 'journalists' from MSKCC's internal publications unit, not talking to patients. The patients have cancer. If Dr. Mao prescribes yoga for those who can do it and aren't turned off by it, and it lifts their spirits some and helps them cope, they will probably credit the yoga. If it doesn't, they'll chalk that up to the cancer and/or the chemo, don'cha think?
Finally, did it occur to any of you that MSKCC might be concerned with patients who have declined treatment there or left treatment there because fear of chemo or experience with the ravages of chemo has led them into the arms of cancer quacks? Well, it seems that Dr. Mao might be thinking about that, since he frames the value of "complementary therapies" to patients as "help them adhere to conventional treatments while augmenting their symptom control and improving their quality of life."
On that count, I'll ask of the conventional medicine standard-of-care: What does it offer to deal with "depression, anxiety, and distress"?
sadmar @35: "On that count, I’ll ask of the conventional medicine standard-of-care: What does it offer to deal with “depression, anxiety, and distress”?"
CBT, talk therapy, anti-depressants, group therapy, social workers, religious personnel, art therapy, music therapy, massage, occupational therapy, honesty.
You beat me to it.
Yes, sadmar clearly doesn't understand and in so doing falls exactly into the trap laid by advocates of "integrative medicine" and in the process once again mischaracterizing skeptics' views. We do not have objections to yoga, exercise, music, etc., for cancer patients. These used to be called supportive care or patient activities, the sorts of things long used to lift patient's spirits. And, as I've quoted Kimball Atwood about massage, it just feels good; so we don't have an objection.
What we do have a problem with is advocating using these modalities to treat specific conditions without evidence, which is a lot of what's going on in integrative medicine. Worse, as I've discussed before in my Nature Reviews Cancer perspective piece (which I really should send a copy of to sadmar, as it explains all this in nauseating detail), I find these modalities problematic because they medicalize exercise, diet, music, etc. Also, re: acupuncture. It is unethical to use a modality that has no real benefits and is, in fact, all risk and no benefits, even if the risks are very small.
"lift patient’s spirits"
The beauty of these therapies is you don't need to be a patient to feel better. Illness is not a prerequisite.