Is the infiltration of "integrative medicine" into medicine as relentless as we thought? Maybe not...

If there's one thing about the march of the pseudomedical entity known as "complementary and alternative medicine" (CAM), "integrative medicine," "complementary and integrative medicine" (CIM), "complementary and integrative health" (CIH), it's that over the last 25 years or so its progress towards being mainstreamed has appeared utterly relentless.

I like to paraphrase Kyle Reese, the warrior from the future sent back in time to save Sarah Connor in The Terminator: "Listen, and understand. That terminator is out there. It can’t be bargained with. It can’t be reasoned with. It doesn’t feel pity, or remorse, or fear. And it absolutely will not stop, ever, until science-based medicine is dead."

And sometimes it certainly seems that way. After all, the number of "integrative medicine" programs in academic medical centers has skyrocketed over the last two decades to over 60, and that doesn't count the many more non-academic medical centers. Meanwhile, Andrew Weil has successfully produced an "integrative medicine" residency that has metastasized far and wide throughout medical academia, while major conferences devote major sessions to "integrative oncology" and respected medical journals publish "state of the art reviews" of pseudoscience and "clinical guidelines" written by naturopaths. There's even a board certification in "integrative medicine," although it's not backed by the usual certification mechanism.

These developments have conspired together to produce an illusion of inevitability to the mainstreaming of "integrative medicine." It's an illusion that integrative medicine proponents actively cultivate, the better to paint opponents as crotchety cynics standing in the way of progress to the perfect integration of the "best of both worlds," to the "marriage of equals" (never mind that the pseudoscience "integrated" into medicine by integrative medicine is anything but equal), to the ultimate in "patient-centered" medicine. Certainly, even to those of us who bemoan the integration of quackery into medical academia to produce what I like to refer to as quackademic medicine, the infiltration of pseudomedicine into medicine often seems unstoppable, not unlike the aforementioned Terminator.

As I survey the continuing advance of pseudomedicine, I can't help sometimes thinking of Arnold Schwarzenegger's voice saying "Hasta la vista, baby!"

However, surprisingly, all is not completely rosy in the world of integrative medicine. I don't know how I missed these articles, which are actually all at least two months old, but I did. They're both by John Weeks, that tireless promoter of integrative medicine whom we've discussed on this blog quite a few times before.

In a couple of columns in (where else?) The Huffington Post, Weeks bemoans the disappearance of two behemoths in the world of integrative medicine. First, he noted Mt. Sinai Merger Shuts New York’s Integrative Medicine “Crown Jewel”. Then he wrote about Wayne Jonas, MD and the Closure of the Influential Samueli Institute: Next Steps. Upon seeing these articles, my thought was: Whoa! These closures are both big deals.

The Continuum Center for Health and Healing: Quackery at its "finest"

Let's take a look at Mt. Sinai first, because the Continuum Center for Health and Healing at Beth Israel Medical Center was one of the examples that first demonstrated to me just how low an academic medical center could go. This center was also sometimes referred to as "Urban Zen" because its creation was funded by Donna Karan's Urban Zen Foundation, created after her husband and business partner, Stephan Weiss, died of lung cancer in 2001. Basically, Urban Zen started out as a whole cancer treatment floor being turned over to "combining Eastern and Western healing methods." As the New York Times put it:

Instead of just letting a celebrated donor adopt a hospital wing, renovate it and have her name embossed on a plaque, the Karan-Beth Israel project will have a celebrated donor turn a hospital into a testing ground for a trendy, medically controversial notion: that yoga, meditation and aromatherapy can enhance regimens of chemotherapy and radiation.

And it spread from there, as you will see, to three floors. Some of the center's webpages have been replaced with an announcement of the closure of the center on October 28, 2016, but there's plenty left of the website so that it's possible to see how in its prime the center offered reiki, Rolfing, prayer, Therapeutic Touch, traditional indigenous healing therapies, acupuncture, even that woo of woo, that One Quackery To Rule Them All, homeopathy. To give you a taste of the "science" supported by Urban Zen, let's take a look at what its homeopath was saying about homeopathy:

People tend to believe that generally the higher a dose of any given medicine, the greater its potency, but the opposite is claimed to be true for a homeopathic remedy. Homeopathic solutions can be diluted to the extent that literally no molecules of the original substance remain; yet according to homeopathic philosophy the more diluted it becomes the greater its potency becomes. Samuel Hahnemann based his theory of how homeopathy works only on the results of experiment and observation. He found that remedies could exhibit their healing qualities only after they were homeopathically potentized (diluted and vigorously shaken). Even after the remedy is diluted beyond the Avogadro number, it remains biologically active, but only if it was potentized. The conclusion was that the biological activity of homeopathically prepared remedies involved energy. Hahnemann suggested that during the process of vigorous shaking (called “successions” [sic] in homeopathy) the energy of the original substance was transmitted to the neutral matter (water) in which it was diluted. The dynamic force which causes the illness and the homeopathic healing, was called “vital force” by Hahnemann. Despite certain experimental evidence that high dilutions of biologically active substances can retain activity if they were vigorously shaken during the dilution process, this issue remains controversial. A unique molecular organization of water has been implemented in its potential ability to transmit biological information.

No, the issue does not "remain controversial." Science has shown that homeopathy cannot work. As I like to put it, for homeopathy to "work," not only would huge swaths of well-supported physics, chemistry, and biology have to be wrong, but they'd have to be spectacularly wrong. Yet, here was a standalone center affiliated with Beth Israel, which at the time was affiliated with the Albert Einstein College of Medicine, spouting off about homeopathy on its website as though homeopathy were more than vitalistic pseudoscientific twaddle. Not surprisingly, Mr. Weeks bemoans what has befallen Urban Zen:

The work at the Continuum Center was leading edge. The team fostered a high level of interprofessionalism and team care. They generated an important body of research. They experimented with business models and experienced times of profitability. Yet amidst a larger economic drama of what was called a merger between Continuum Health Partners and the now dominant Mt. Sinai Medical Center, the formerly 32-clinician integrative center, with its 6,000 visits per month, was put on the corporate chopping block last fall.

Basically, Urban Zen was losing money, and, as its director Dr. Ben Kligler put it, he "totally understands how it looks from [Mt. Sinai’s] point of view. We just looked like another practice in a hospital that was losing money." He blames the closure on bad luck and bad timing:

Kligler views the loss of the Center as “just bad luck.” Why? “[Mt. Sinai] came in when we were the most vulnerable.” Had the merger come through a couple of years earlier, it would have been when the center “was booming.” Kligler explains. In 2012, demand exceeded the ability to fulfill on meeting patient interest. The Center was operating profitably and expanded to a third floor. New investment coupled with new practices not yet overflowing added up to a temporal moment of significant red ink. Had the merger come later, in Kligler’s view, the new configuration would have had time to fill out and flourish. Mt. Sinai caught the snapshot of that moment’s performance rather than considering a promising revenue trajectory. Kligler summed up his view: “Honestly, we can’t hold Sinai responsible. It was terrible timing.”

This explanation, of course, sounds very self-serving. Maybe the Center was on a trajectory to profitability, but, really, when viewing a unit that is losing money most businesses (and, of course, hospitals are businesses) consider whether that unit is likely to return to profitability any time soon and how profitable it is likely to be.

Reading between the lines, I sense that Mt. Sinai either didn't see the Center becoming profitable soon enough for its liking and perhaps didn't have enough interest in maintaining an integrative medicine center. Unfortunately, Mt. Sinai isn't abandoning "integrative" care altogether (which would have been a most excellent outcome). Rather, a core of four physicians relocated to a clinic in West Village (where else?) and that group was apparently lobbying to keep some of the non-MD practitioners previously associated with the Continuum Center (i.e., acupuncturists, naturopaths, etc.). The grants held by the Center transferred to the Mt. Sinai Department of Family Medicine, the better to bolster its standing in quackademic medicine.

Don't feel too bad about Dr. Kligler, though. He's landing on his feet. He's now the new National Director of the Integrative Health Coordinating Center at the Veteran’s Health Administration, where he will work closely with Tracy Gaudet, MD, the director of the Office of Patient Centered Care and Cultural Transformation, to continue what Dr. Gaudet started and infuse the medical care of veterans with a healthy dose of pseudoscience and quackery.

I can't help but picture Schwarzenegger as the Terminator, saying, "I'll be back."

Bye, bye Samueli

I've also written about the Samueli Institute many times. In brief, the Samueli Institute was one of the two sugar daddies for funding the integration of pseudoscience into medicine. It was very influential, as influential as the Bravewell Collaborative, which itself shut down two years ago using the reason that it was no longer necessary, or, as Christy Mack, one of Bravewell's founders put it, "...when our principal strategies had achieved our goals, and when integrative medicine had become part of the national conversation on healthcare, our members collectively decided that it was time to sunset the organization." (Given how thoroughly integrative and quackademic medicine has become entrenched at major academic medical centers, that reason was actually believable.)

So learning from Mr. Weeks that the Samueli Institute will be closing in 2017 shocked me as well. Wayne Jonas, the President and CEO of the Samueli Institute, tried to put a happy face on its shuttering in much the same way that Ms. Mack did for Bravewell, by saying it was no longer needed:

The value of that “somewhere” that Congressional appropriations enabled through the Institute is encapsulated in Jonas’ response on why the Institute was ending operations: “When we started out there really wasn’t much complementary and integrative medicine going on in the VA or the military.” The Institute’s research output and military partnerships led to the seminal 2010 Military Medicine report “Total Force Fitness for the 21st Century: A New Paradigm”. Expansive integrative health research, education and practice initiatives are now presently underway in both agencies, due to this ground work, but without the Institute’s direct presence. Added Jonas: “The work we were doing is now going on inside the DoD and the VA. Our work is not so necessary anymore. What we did has worked. It’s not that I won’t be in touch with them. But what we set out to do is done.” Bridge built.

Again, this excuse is somewhat plausible. There is a lot more integrative medicine around now than there was when the Samueli Institute was formed over 15 years ago. On the other hand, it clearly doesn't tell the whole story:

So why the shut-down of the Institute? Jonas offered a response that felt at once both like putting a nice face on a tough situation, and a spot-on reflection of a job well done. The “nice face” is connected to the Institute’s rapidly declining portfolio of government and particularly military research grants, and the staff to fulfill on them. An Obama-era federal policy change limited members’ of Congress ability to appropriate specific funds to specific entities for specific projects. While Congressional “earmarks” may be considered “pork barrel” when they are for bridges to nowhere, the grants to the Samueli Institute sought to bridge the nation’s medical industry from mono-therapeutic management of disease to a whole system focus on health. That’s a “somewhere” that deserves investment in the United States where the medical industry is the 3rd leading cause of death and at least one-third waste.

Translation: The Samueli Institute apparently relied too much on grants that weren't competitively awarded, as NIH grants are. Instead, it appears to have relied on woo-friendly legislators to send money its way via earmarks, the process whereby individual legislators could "earmark" appropriations to favored entities to do work that a legislator reserving an earmark wanted to support. When those grants dried up, Samueli had an increasingly difficult time staying viable. Also, Jonas had apparently become tired of just administering grants, saying, "I’m not sure that focusing on the minutia of administering large grants is the best use of my skills [The Samuelis and I] decided to take a step back. A lot of our best work has been as catalysts. How can we catalyze what we want nationally? I couldn’t do that and run contracts.”

Of course, like Bravewell, Samueli won't entirely die. It transferred $7 million of grants to the Thought Leadership Foundation, whose mission is: "To promote new and innovative thinking that leads to transformative change in the healthcare, education, economic opportunity and environmental arenas by engaging thought leaders in research, writing and program activities to address intractable problems plaguing those communities." On the surface, TLF doesn't look that woo-ful an organization. It supports initiatives in autism; translational medicine’s impact on treating Traumatic Brain Injury (TBI), Lyme disease, HIV/AIDS, other chronic diseases; renewable energy sources; mobile medical care plans; and other environment- and medicine-related projects. There doesn't appear to be much, if anything, about integrative medicine on its website. I rather suspect that that will change, though. Mr. Weeks notes that TLF "saw huge growth with the transfer of the Samueli Institute’s research portfolio, quadrupling TLF’s size." This suggests that Samueli's "integrative medicine" portfolio is taking over TLF.

So basically, the Samueli Institute won't really die either, nor are Jonas and the Samuelis going away:

Serving as a catalyst is the seed of what Jonas will bring forward in his next phase of partnership with the Samuelis. “Dialogue about integrative health care will not be the focus, but integrative health will be at the table, in the mainstream.” (Notably, this was already modeled with in the project that will be carried by IHI, where integrative health representatives served on the steering committee.) Moving forward, their goal will be to “catalyze nationally some of the work we have been doing.” Approaches such as social impact investment may be considered, together with not-for-profit initiatives and other business models. “We are moving,” he said, “toward a more convergent platform. We are thinking about how we can accelerate this movement.”

I'm not sure exactly what that word salad is supposed to mean, other than that Jonas and the Samuelis will use the Samueli money to do something else to promote the integration of quackery into medicine. The Terminator's voice again echoes in my head, "I'll be back."

A fit analogy?

On the surface, the events I've described, the closing of the Continuum Center, of the Samueli Institute, of Bravewell, seem to indicate that maybe integrative medicine isn't the unstoppable juggernaut that we skeptics portray it as. Indeed, these aren't the only examples. In his article about Mt. Sinai, Mr. Weeks notes that other centers had shut down too, while in an article published at the end of 2016, he noted:

To the budgets of the multi-billion juggernauts of the US medical industry inappropriately styled as “healthcare systems,” integrative medicine is - as a colleague suggested recently - a “rounding error.” And as has become clear over the past two decades of multiple shuttering of significant integrative centers, a profound economic misalignment exists between the “volume-based” and technology-driven industry and the mission-and-value orientation of relatively low cost, human-intensive, integrative care. Still it was a shock when word came out - apologies, I am part way into writing this story - that the powerfully influential Continuum Center for Health and Healing no longer fit into the plans of its parent, the $3.5-billion, plus, Mount Sinai Health System. Meantime, when the $7-billion Banner Health took over University of Arizona Medicine they showed no interest in the Phoenix-based Arizona Integrative Health Center where the Andrew Weil-founded Arizona Center for Integrative Medicine anticipated proving integrative health’s business model as a low cost option for chronic disease. Be aware: another shoe is about to drop. Each, notably, was showing patterns of positive outcomes. Are these centers simply a misfit with the industrial focus of the volume based system?

I'm guessing that the "other shoe" to which Mr. Weeks referred at the time was the closing of the Samueli Institute, which hadn't happened yet. Mr. Weeks is, of course, quite attuned to what's going on in the world of integrative medicine; so likely he had inside information that the closure was going to happen. In any case, you get the idea.

Although the pseudoscientific practices in integrative medicine are often perceived as a license to print money (and sometimes they are), because insurance doesn't reimburse for them it can be much harder to build a sustainable business model providing such services than you'd think. That's one reason why integrative medicine advocates lobby so hard to license naturopaths and to have laws passed requiring that services like acupuncture, traditional Chinese medicine, and the like be covered by health insurance plans.

It's why Sen. Tom Harkin inserted a clause in the Affordable Care Act requiring insurance plans sold through federal exchanges to cover the services of specialties licensed by the state, such as naturopathy, chiropractic, and acupuncture. So basically, what integrative medicine practices can bill insurance companies for are the services they provide that are the real medicine into which they are integrating their quackery. The problem, of course, is that those services are not well-reimbursed (as any cash-strapped primary care practice can tell you), and apparently the "cash on the barrelhead" integrative medicine services don't make up the difference, particularly given how one of the main appeals of integrative medicine is how much time practitioners spend with patients, which greatly limits the volume they can see.

Unfortunately, there are those who have figured out how to make money integrating quackery into medicine:

This article is one in a series on significant ups and downs with major centers. We see significant expansion at Jefferson in Philadelphia, a new 17,000 square foot space for the Center for Functional Medicine at the Cleveland Clinic, and system-wide integrative health at Meridian Health. The build-up of integrative health and research in the Veterans Administration with which Kligler is now involved is another bright light.

Yes, the Cleveland Clinic is one such institution, and I've written many times about it. Some have even joked about it. I still think that The Terminator is an excellent analogy for integrative medicine, though. When the Terminator says, "I'll be back," he always does come back. The Terminator is usually destroyed at the end of each movie, but somehow he's always back in one form or another in the next.

I have no doubt that the closure of the Samueli Institute and other major integrative medicine centers will only slow the advance of pseudoscience infiltrating medicine; that is, unless medicine starts to value science over pseudoscience and stops falling for the false narrative that you have to "integrate" quackery in order to take care of the "whole patient" in a patient-centered manner. I'm not holding my breath waiting for that…

“Fear not. I’ll be back…in Terminator 3!”