The growth of integrative medicine in academic institutions

The Atlantic published an article about the growth of quackademic medicine in our teaching institutions and it’s celebratory more than critical. It profiles the integrative medicine clinic of Dr. Brian Berman. That’s right, this Dr. Berman. I blogged about him four years ago and it seems his clinic at the University of Maryland is still going strong. Stronger, apparently.

The article, like integrative medicine itself, is a mixture of quackery and general distortion with a little science and pseudo skepticism thrown in. A central premise is that no matter how nutty the idea, you can’t call it quackery if it carries the imprimatur of a respected academic institution: “Concerns of outright malpractice or naked hucksterism seem grossly misplaced when applied to a clinic like Berman’s.”

Below are a few more of the distortions contained in the article:

The false dichotomy between the conventional medicine approach and “healing.”

The claim that conventional medicine ignores prevention.

The notion that the principles of conventional medical science are obsolete because they originated in the era when acute infectious diseases were the leading killers.

The idea that medical science has failed to make significant advances in the care of chronic diseases. (Tom Sullivan debunks that popular canard.)

By and large the purported benefits of integrative medicine, as illustrated by the numerous testimonials in the article, are the result of the placebo effect and the generous time and personal attention lavished on the patients who attend. So, some might ask, what’s the problem? Aren’t those reasons enough to justify integrative medicine?

Not when those benefits are attributed to a quacky intervention. It’s just unethical. As Steve Novella, interviewed for the piece, said:

Novella is a highly respected Yale neurologist, and the editor of Science-Based Medicine, an influential blog that has tirelessly gone after alternative medicine. I met with him in his home outside New Haven, Connecticut, where he argued that claims about the practitioner-patient relationship are only intended to draw attention away from the fact that randomized trials have by and large failed to show that alternative treatments work better than placebos. And while he concedes that sham treatments can give patients a more positive attitude, which can confer real health benefits, he is adamant that providing sham treatments at all—essentially fooling patients into believing they’re being helped—is highly unethical. “Alternative practitioners have a big advantage,” says Novella. “They can lie to patients. I can’t.”

Aside from the ethical considerations cited by Novella the argument raises another false dichotomy: that spending lots of time with patients and approaching them as whole persons is somehow uniquely inherent to integrative medicine and foreign to conventional medicine. For many counter-examples to that argument just read DB’s many posts on the true nature of mainstream internal medicine or my post where I cite the example of the late Thomas Brittinghamas the exemplar.

No, it’s not the pure notion of the whole person or spending time with patients that’s unique to integrative medicine. So what is integrative medicine’s uniqueness? I would submit that, in part, it’s the fact that it makes quacky claims that are so appealing and sensational to the uncritical public that patients are willing to pay handsomely for it out of pocket. That eliminates some of the time pressure that exists under the reimbursement system for conventional medicine.

The article additionally points out the alarming degree to which quackademics are infiltrating the renowned Mayo Clinic, to a greater degree than even I was aware. Even the dean of the medical school is on board.

Some of the Mayo doctors quoted in the article are in favor of integrative medicine but their arguments are mainly sophistry. Though superficially appealing the defects and half-truths in their statements become apparent once a little critical thought is applied.

Robert Donnell is a hospitalist who blogs at Notes from Dr. RW.

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  • David Hanson

    My wife has a chronic condition — an autoimmune disease of the connective tissues.  She has seen many specialists at Mayo Clinic in Jacksonville.  Not one of them has ever talked to her about diet or exercise or any other lifestyle issue.  Each specialist is pretty much only interested in their part of the body — NOT the whole person.

    Dr. Donnell doesn’t seem to understand what is going on in the doctor’s offices.  From what I have seen, doctors have become test ordering and pill prescribing machines.  And, of course, the main purpose of the family doctor is to turn the patient over to the specialist. 

    In my opinion, there is so much that can be done with diet change and exercise for so many health problems.  Dr. Sanjay Gupta of CNN predicts that there would be no more heart attacks if people ate a healthy diet, for example.  He did a recent medical series on CNN discussing this.  So WHY aren’t the doctors pushing for a radical change in diet and lifestyle?  Why are they as meek as mice about these changes — that could greatly help the health of the patients?   Do they not know themselves because they have been educated so badly?  Or, I hate to say it, do they want their patients sick?

  • Anonymous

    I have several chronic conditions.

    Most of my “primary care” is provided by PA’s and NP’s.  They deal with acute problems…have never discussed the long term issues faced by my conditions.  My PCP doesn’t really know who I am, and does not provide “whole person care.”  None of these providers have spent any significant time with me, nor have they considered “lifestyle” issues beyond the standard vague diet and exercise advice.

    Several years ago I saw a integrative specialist mostly because I didn’t feel well and the doctors I was seeing seemed to think everything was fine because I followed treatment recommendations.  With the integrative specialist, dietary issues were considered…is food sensitivity quackery?  My feeling were discussed…that never happens in an MD’s office.

    Of course, the MD’s all criticize alternative care while they continue to perform back treatments, use stents and a host of other unproven treatments.  When conventional medicine gets all it’s ducks in a row, then I will take your quackery comments seriously.

    • Anonymous

      Unfortunately, not all PCP’s have committed to the micropractice system, but the ones that have would try to get to know their patients as well as offer what advice they can. I would suggest seeing one who operates a micropractice in your area, rather than one that operates in a large clinic, for more informative and rounded care (however, if integrative medicine is working for you, that is fine as well). However, this does fall under the problems of the under-appreciated and insufficient primary care system – people expect specialists to give primary-care/integrative type treatment when they are unable to dedicate the energy or time to it, and believe that PCP’s do nothing but turn away work. Most simply, patients sometimes forget their doctors are humans, not givers of panaceas.

      Stents are not part of an unproven treatment; in fact they are part of better proven treatments. But, many doctors do disagree on what methods are valid, especially in the light of contradictory evidence. It is unlikely we will ever have a perfect system that everyone will be satisfied with. Integrative/Alternative medicine tends to lack the ability to undergo rigorous scientific testing, which dissatisfies those who prefer evidence-based methods over “worked by chance/luck/miracle.” Moreover, doctors would wonder why patients would pay possibly a large sum of money for “unproven” cures – it’s no better than asking an exorcist to drive out evil spirits, or asking a witch for healing potions. But not all such treatments may be “quackery” – as far as you have explained, I would venture to say that concern about your dietary sensitivity may be well-placed, but what treatment did they offer? If they said change your diet, a nutritionist/dietician could have done the same, and it is a viable treatment. If they had offered acupuncture for this however, that would most likely not have alleviated diet issues.

      I don’t believe, however, that all integrative medicine is quackery or just sophistry- some things, such as massage therapy (alleviate stress) and yoga (alleviate stress and calm the spirit), can alleviate symptoms possibly associated with stress/other factors that induce illness without the necessity of pills. These things, however, should be taken with a grain of salt – they probably will not treat major problems, such as Type I Diabetes (needing insulin) or cystic fibrosis as well.   

      • Anonymous

        So you think I should have gone to a nutritionist with my problems?   Is it less valuable advice because an integrative medical provider suggested it?  Isn’t the point that my PCP should have been the one to consider what lifestyle changes I could make to feel better?

        The elimination diet was inexpensive and non-invasive.  While the test was negative, eliminating a particular food would not require a nutritionist.  I actually enjoyed trying new foods.  My point is conventional medicine did not even consider a milk allergy or a gluten sensitivity. 

        Aren’t my options at this point to feel like sh*t or try different approaches?  This is what you do when science fails you.  Many of us that use alternative treatments are not trying to avoid conventional treatment, but find something that treats illness so we can live fulfilling lives.  The ten minute drive-by PCP appointment, many of them with a mid-level really hasn’t been helpful at all.  I currently see a naturpath (insert more accusations of quackery here) and am always skeptical of the supplements she recommends.  But since my PCP has no ideas, should I take the herbs?  What have I lost by taking them?  What have I lost if the herbs are actually a placebo?

        As for stents:

        How well was the efficacy and safety of the stent understood before it was used on millions of people?  If I needed a stent and did my research, I wouldn’t find rock solid science.  Quack quack.

  • http://pulse.yahoo.com/_FC7AQ3ZT3QBKEGP27XGO7TTD3U anne

    Speaking as a patient who has recently moved to a fabulous Integrative Medicine Doctor (Dr.Ehrlich / Beth Israel Hospital, NYC) I have to respond with an explanation of why I changed.
    At 62 I’ve had plenty of experience with Doctors. ( a melanoma, a Cesarean, an adrenal gland removal, a salivary gland removal, and guiding my mother through hospitals and medical care in her old age). In each of these experiences I never felt that I or my mother was being treated – the Doctors treated a diagnosis and often incorrectly diagnosed symptoms and test results:
                          My 78 year old Christian Scientist oriented mother was put on hospitalized bed rest after a fall and then after a few days of no walking was diagnosed with DVT. Her Doctor brought her to court and forced her to have a vena cava implanted because she didn’t want to take Coumadin as it’s also a rat poison – she wanted herbal medicine. Prior to this hospitalization she never had DVT.
                          32 years ago I had a biopsy of a mole and had to remind the Dr to get the results – when I went for results he told me I had to be hospitalized immediately or he could not guarantee my life due to a melanoma (NY Hospital). I got a 2nd opinion (NYU Hosp.) – stage 1 and no rush for removal – 3rd opinion (Sloan-Kettering) nothing there. The 2nd and 3rd consulted and agreed I needed to have it removed but I could wait a few months. I did and 32 years later still wonder which opinion was correct and what would have happened had I gone with the 1st Doctor’s demand.
                         More recently I was prescribed an antibiotic, Clindamycin, by a dentist to
    “prevent” against infection. He told me not to take yogurt and I wound
    up with a c.diff infection. Calling my Integrative Dr. resulted in a
    recommendation for the probiotics Culturelle and Floraster until I could
    travel to his office. They ended the symptoms and pain immediately.
    After a culture, I did have to take 2 rounds of another antibiotic but
    we were both sure of why I was taking it. I was annoyed that the Dentist
    didn’t know(?) to advise a support of probiotics with the antibiotic.
    My pharmacist said Clindamycin is a favorite of dentists but the letters
    at The People’s Pharmacy indicate it has very serious side effects:
    http://www.peoplespharmacy.com/2011/01/26/clindamycin-can-cause-disastrous-diarrhea/

    I remember Dr’s who made house calls and lowered bills for patients or let them pay as they could without interest. They were friends who would explain illnesses give preventive tips and more natural remedies before pharmaceuticals.
    Then a lot of lobbying allowed pharmaceutical companies to advertise and produce nocebo’s* that created a run on anti-depressants and other harmful drugs. I can’t believe my ears when an anti-depressant is advertised on tv and the side effect of “suicidal thoughts” is mentioned as they hurry through the side effects.                                                      
    Dr’s now prescribe drugs rather than discuss causes and non-pharmaceutical interventions perhaps because of the many incentives for writing the prescriptions. Dr’s are overburdened with loans and insurance fees that have to be passed on so I empathize to a degree but am also aware that people were being cured by natural methods for thousands of years. Over a billion Chinese people are proof of that. Our conventional Dr’s are leaving behind the years of accumulated natural knowledge gained and we are all losing in so many ways – I’m sure Hippocrates would be disappointed to say the least.

    I consider Integrative Doctors as practitioners who consider the whole person in making a diagnosis and as per Dr.Weil: Integrative medicine is healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative:  http://www.drweil.com/drw/u/ART02054/Andrew-Weil-Integrative-Medicine.html
    People are turning to Integrative medicine because they can perceive the medical tunnel vision in the rush of a conventional Dr.’s office, the reliance on unnecessary testing, the focus on the symptom not the patient, and the over-prescribed pharmaceuticals.
    Integrative Doctors look for the right solution using many different options instead of just relying on drugs with negative side effects. Seems like an intelligent, thoughtful, and balanced approach to me!

    *(from Latin, from the infinitive nocere, “to do harm.” – A nocebo
    response occurs when the suggestion of a negative effect leads to an
    actual negative outcome)

  • Anonymous

    I’m so tired of the vitriolic and disgruntled patients with an internet soapbox painting their doctors like the enemy.

    Good God.

    And, no I’m not a doctor.

    But, wake up. They’re not fixing cars. It’s not an oil change. They’re not perfect. And neither are you.

    If you hate doctors so much, don’t go to them when you’re sick. Just stick with integrative practitioners and acupuncturists and masseuses who make you feel special and then use Google MD for everything else. Seriously. See how that works for you. Do the rest of us (who have had their lives saved or changed because of a doctor) a favor.

    And do you really think they want you to be sick? Did you really just write that? Un-freaking-believable.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    As physicians if it works and if it is reproducible by independent researchers in well designed studies it should not be considered alternative or complimentary medicine. If major university centers are recognizing that there are areas outside our traditional areas of medicine that might work and are applying the scientific method to these areas to test their efficacy then more power to them.  If they are not testing the untested or if they are promoting unproven remedies for financial gain only ( for them and their institution) then the snake oil sales should be stopped. 

    • Anonymous

      Doctors recommend treatments that are not scientifically proven.  It was recommended by a surgeon that I take large quantities of vitamin E to soften a breast lump.  My doctor currently recommends I take large quantities of vitamin D.  Where’s the scientific proof that taking large quantities of vitamin D are helpful and not harmful?  I”ve also been prescribed melatonin by an MD.  

      My doctor recommends meditation.  Are you saying that the ancient practice of meditation is now considered conventional medicine?

  • Anonymous

    I can see the appeal of integrative medicine – many doctors have insufficient time, insufficient resources, and no comprehensive knowledge of alternative treatments and supplements. However, as the child of a wonderful primary care physician (MD, internal medicine) who spends a some-would-say-ridiculously long period of time with each of her patients, and a current third-year medial student, I have to add that not every physician is a walking, talking science book who couldn’t care less about your feelings.

    The problem is, if you go to a nephrologist/pulmonologist/cardiologist, of course they are going to concentrate on your kidneys/lungs/heart, that is what they are there for! They are not therapists or naturalists or whoever else — their specialty and training is All About Their Organ Of Interest. You probably don’t want them to talk about your feelings, and you wouldn’t want your herbalist to try to cure your end-stage renal disease. There is a place for each.

    Primary care, on the other hand, should care about your feelings, because that impacts your overall health. Sure, there are some primary care docs who spend 15 minutes with you and send you on your way, but certainly not all. I know a number of primary care physicians personally who spend a long time talking to their patients about diet, exercise, how they are feeling overall, and things of that nature. You just have to keep looking until you can find one who you feel comfortable with. This might take a minute, because spending time with patients brings in a lot less money from insurance companies than running tests does. And I Really mean it doesn’t pay well – I’ve done billing for primary care offices, and while I will not go into detail, there are times when these MDs makes less than minimum wage, after taking into account staff salaries and office expenses.

    An auto-mechanic will not talk to you about riding bikes, because they don’t work with bikes – doesn’t mean that bikes aren’t a good way to get around, it just means that you should probably ask someone else about them. Similarly, physicians usually can’t recommend herbs/homeopathy/etc because they have no experience with or knowledge about them (this is a generalization, I am sure many MDs have some personal experience in this field). However, the two can be used at the same time, as long as both sides (natural vs. medical) are aware and take the time to look up possible interactions (since many herbs/natural remedies do have pharmacological actions, in ways that can significantly and sometimes dangerously impact the effects of pharmaceuticals). It doesn’t have to be one or the other. My mother has done this with many of her patients, and this has been successful – many dangerous situations have been avoided! If your PCP is not willing to look into the interactions of your herbs after you ask hir to, you may want to consider a new PCP. 

    Finally, regarding the placebo effect – if the placebo effect works, then placebo all the way! At the end of the day, if someone’s indigestion/depression/pain is cured via meditation, ~magic energy water~ and a jogging regimen, is their indigestion/depression/pain any less cured? For some things, like infection, cancer, and things that can be proven via imaging, pathology, and microbiology, this is less applicable, but for conditions that are more symptomatic than histologic in nature, I don’t see why treatment via placebo effect is less “real” than treatment with drugs, etc.

    • Anonymous

      I disagree that feelings about illness and the proposed treatment plan are unimportant for the specialist.  They are essential to finding the right course of action.

      While my bicycle and my car are separate entities, my lungs, my heart, and my kidneys and my feelings are not.  If we felt that a specialist only had to know one organ, why do we bother to have them do rotations in different fields?

      • Anonymous

        I didn’t mean feelings about the proposed treatment plan, I meant feelings in general. Of course feelings about the treatment plan and illness are important, because that influences whether or not the patient goes through with the treatment plan, and is important with regards to learning about how the treatment plan is affecting the patient on other levels. However, other aspects of emotional well-being are not the specialist’s field – they are not trained in having “feelings talks,” and are generally not as proficient in coordinating multi-specialty care as, for example, general practitioner or internist is. Similarly, a general practitioner is probably not as good at nephrology as a nephrologist.

        • Anonymous

          Clearly, if treatment is needed for emotional issues, a specialist in mental health is the right person to talk to, not primary care.  My PCP has never had that talk except for the cursory depression evaluation.

          I coordinate my own care.  It’s not so hard.

  • Anonymous

    When I read hyperbolic denunciations of either integrative or mainstream medicine, I am mistrustful of the writer’s knowledge and objectivity. Rants of any kind only kindle like-minded hysteria (e.g., Congress), they do not inform nor do they persuade intellectually. They merely sound angry and defensive, which makes me wonder what is being so vigorously defended against. Perhaps the writer doesn’t even know. (Yes, I’m a psychodynamic psychotherapist.)

  • Anonymous

    When I read hyperbolic denunciations of either alternative or convention medicine, I feel mistrustful of the writer’s knowledge and objectivity. Rants mainly polarize by stirring up hysteria (e.g., Congress); they neither inform nor do they persuade intellectually. They function defensively. I always wonder what must be so vigorously defended against that moderation and reason are dispensed with. I wonder if the writer even knows. As neuroscience is discovering, our minds, like our bodies, function mostly unconsciously. And as Jung observed in a language very different from that of neuroscience, if we don’t work to make the unconscious conscious (to the extent that we can), we will project our own shadow onto others and thereby create our worst fears.