For many years I have been using Continuing Medical Education (CME) programs offered by the American Academy of Family Physicians (AAFP). The FP Essentials program consists of a monthly monograph with a post-test that can be submitted electronically for 5 hours of CME credit. Over a 9-year cycle, a complete family medicine curriculum is covered to prepare participants for the re-certification board exams. Some examples of typical subjects are skin cancer, hand and wrist injuries, valvular heart disease, and care of the newborn. I rely on these programs to learn, review, and keep up-to-date in my specialty. Imagine my dismay when I opened the latest package to find a monograph on Integrative Medicine.
First it was called various names like folk medicine, quackery, and unproven/untested treatments, then all of those (the less rational right along with the more rational) were lumped together under the umbrella term “Alternative Medicine,” then it became “Complementary and Alternative Medicine” (CAM), and now it has been re-branded as “Integrative Medicine.” The term is designed to make unscientific treatments seem more acceptable to science-based doctors. “Integrative Medicine” is a marketing term, not a meaningful scientific category. It is a euphemism for combining Complementary and Alternative Medicine (CAM) with mainstream medical practice, unproven with proven, magic with science. It has been critiqued many times on this blog. We have stressed that there is only one medicine, and that when a treatment is proven to work by good evidence, it is just “medicine.” When the evidence for a CAM treatment is not good, it essentially amounts to experimental treatments and/or comfort measures. Worse, sometimes CAM even persists in using treatments that have been proven not to work or that are totally implausible, like therapeutic touch or homeopathy.
Integrative Medicine is a shameless thief: it has tried to appropriate aspects of real medicine and pretend that it invented them. Some of the things integrative medicine claims as uniquely its own are clearly not: exercise, diet, prevention, and a holistic approach to the patient are co-opted from good mainstream medical practice. “Integrative Medicine” doesn’t make sense. As Mark Crislip explained:
If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.
When Andrew Weil, the “father of integrative medicine,” was chosen to give the keynote speech at the annual AAFP scientific meeting many people complained, and the Institute for Science in Medicine sent a formal letter of protest to the AAFP. They responded that choosing Weil did not imply any endorsement of his work or products, and said that no continuing medical education credits were attached to his presentation.
While FP Essentials does not represent the official policy of the AAFP, it is an important CME program sponsored by the organization, so the AAFP can no longer deny that it offers CME credit for the kind of faulty thinking epitomized by Weil.
No conflicts of interest are disclosed, but 4 of the 5 authors of the AAFP monograph clearly have a personal interest in promoting integrative medicine. One of them, Tieraona Low Dog, is a Director at Weil’s Arizona Center for Integrative Medicine and she even speaks at seminars that hawk Weil’s “Seasonal Supplements.”
The FP Essentials editor introduces the monograph by saying:
We want to integrate the best and most effective therapies into a patient-centered treatment plan. As part of integrative medicine, CAM therapies are not to be feared, eschewed, or ignored. Rather, they can be integrated successfully into traditional management approaches to fill a treatment gap, reduce adverse effects from traditional remedies, augment traditional therapies, or honor a patient’s wholeness.
I would argue that all those goals can be accomplished within the scope of conventional mainstream medicine, and that if anything in the sphere of CAM were really “the best and most effective therapy,” it would be part of evidence-based medicine and could no longer be designated as CAM.
The stated learning objectives for the monograph are not achieved. Among other things, they include:
- “Discuss the effect of exercise on mental health.” (Exercise is a mainstream recommendation, not an integrative one.)
- Describe the rationale for recommending IM therapies in chronic pain management. (Various IM therapies are discussed, but not the rationale for recommending them over other therapies, and certainly not the rationale against recommending them.)
- Summarize difficulties in conducting and interpreting research focused on IM therapies, for instance finding an appropriate control in acupuncture studies. (That would indeed have been a worthwhile learning objective, but it is not covered at all in the text.)
- Devise an IM treatment plan to improve health after a breast cancer treatment and to prevent recurrent breast cancer. (They present evidence that the kind of health advice offered by mainstream medicine can improve quality of life in breast cancer patients. There is no evidence that IM can prevent cancer recurrence.)
The 5 key practice recommendations they derive from the monograph are pretty skimpy and do nothing to impress me that “integrative” medicine offers any advantages:
- Consider adding folate to selective serotonin reuptake inhibitors. (This is already considered in mainstream medicine.)
- Offer butterbur to patients with migraine. (This is rated as only “Possibly Safe” and “Possibly Effective” by the Natural Medicines Comprehensive Database. And in the text the authors themselves warn that butterbur may contain hepatotoxins and that monitoring liver function would be a good idea.)
- Consider fish oil to lower triglycerides. (Fish oil is already one of the standard recommendations; there is nothing “integrative” about it.)
- Ask patients with cancer if they are using integrative medicine therapies. (This is something every doctor should already be asking patients, especially since we know that certain herbal remedies can interfere with chemotherapy or increase the risk of bleeding after surgery.)
- Consider multiple modalities including massage and acupuncture for cancer patients with pain. (The first is a conventional comfort measure; the second is arguably a placebo. All doctors should suggest comfort measures; it is not ethical to offer placebos.)
The preface tells us that “nontraditional approaches can address pathophysiology in a way that biomedical treatments cannot.” But the text offers no evidence to support that claim.
The monograph is divided into 4 sections, addressing depression, chronic pain, cardiovascular health, and oncology with a focus on breast cancer.
This section starts with a paragraph on the importance of establishing a therapeutic relationship with the patient. That goes without saying: it’s a basic principle of mainstream medicine. They discuss various therapies as adjuncts to prescription antidepressants or as alternatives to them: St. John’s wort, SAMe, Folate, Vitamin B12, Omega-3 fatty acids, exercise, light therapy, music therapy, and mind-body therapies such as mindfulness. They summarize the available evidence. The evidence for mindfulness-based cognitive therapy (MBCT) consists of one recent randomized controlled trial showing that it may be as effectiveas cognitive behavioral therapy.
For migraine: biofeedback, butterbur, dietary modifications, and acupuncture.
For low back pain: acupuncture, manipulation, mind-body therapies, and massage therapy.
For knee osteoarthritis: glucosamine, chondroitin, acupuncture, SAMe, balneotherapy (bathing in hot mineral water), and herbal supplements.
For fibromyalgia: tai chi, magnesium, spa therapy, mind-body therapies.
For spinal manipulation, they cite two Cochrane reviews showing small benefits not superior to other treatments. For mindfulness, they cite a small study that compared a mindfulness meditation class to being in a wait-list control group. For massage, they cite a study showing that massage was as good as acupuncture, but we know that acupuncture only acts through placebo effects. They cite small trials, mixed results, and generally very poor quality evidence, the kind of thing that is routinely seen when advocates design studies that can be predicted to favor their treatments. They cite evidence from pilot studies, pragmatic studies, and preliminary studies, the kind of evidence that is so often overthrown when more rigorous, larger, better-designed studies are done.
As the physician’s comfort level and experience increase, the focus becomes how to integrate these approaches into practice.
In other words, “Try it. The more experience you get, the more you’ll like it. Then instead of asking whether it works, you can just assume it works and figure out how to do more of it.” Sorry, but that’s not how the scientific method works. Remember Mark Crislip’s words of wisdom: “In my experience” are the three most dangerous words in medicine.
For dyslipidemia, they cover fish oil including a prescription fish oil, Lovaza. How could a prescription drug be considered “integrative”?!! They cover niacin, which was a mainstream treatment long before the term “integrative medicine” was coined. For fiber and plant stanols, they cite “cholesterol treatment guidelines” (from mainstream medicine). They cover other therapies like garlic only to say they don’t work.
They cover red yeast rice, saying it effectively lowers cholesterol and is cost-effective. The active ingredient is the same thing that is in prescription Lovastatin in a standardized dosage. They warn that red yeast rice is not standardized and may contain too-high levels of the active ingredient. They apparently don’t realize that by federal mandate the active ingredient has been removed from all red yeast rice products sold in the US.
For treating high blood pressure, they provide some questionable evidence. Dandelion root is listed because it is a diuretic, but there is no evidence that its diuretic effect leads to lower BP, much less to any reduction in cardiovascular events. For hibiscus, they cite a study whose authors concluded that it could not be recommended, but in the table of “Herbals and Supplements for HTN Management” they list hibiscus nevertheless. They even mention lavender aromatherapy, but only to say it doesn’t decrease BP.
Oncology: Breast Cancer
They say integrative medicine is popular. (So what? So is astrology.) Patients use it “to prevent recurrence, to improve and support their immune system, and to manage immediate adverse effects and long-term sequelae from treatment.” But there’s little evidence that it actually does what they use it for. They suggest that energy medicine modalities can be useful, even though the evidence is poor; they say more studies should be done. They cover studies on therapeutic touch without a shred of skepticism. They provide the traditional explanation for acupuncture without questioning the existence of acupuncture points or qi. For hot flushes they cite a Cochrane review showing that the only nonhormonal treatment that works is relaxation therapy. Then they cite a small, uncontrolled study showing that magnesium worked, so they list it as a recommended treatment.
For preventing recurrence of breast cancer, they admit there is no real evidence. But they recommend healthy lifestyle choices that “might” decrease breast cancer recurrence risk. Here they co-opt all the things non-integrative doctors recommend to their patients: not smoking, physical activity, 5 servings a day of fruits and vegetables.
Homeopathy is conspicuous by its absence from this monograph, yet they uncritically mention therapeutic touch and other forms of energy medicine that are equally improbable. One can only wonder what privileges one form of magic over another in their minds.
They conclude that one barrier to the use of integrative medicine therapies is:
The proven efficacy of integrative medicine is not well established, and many therapies are not covered by health insurance.
“Proven efficacy is not well established”? Awkward. Perhaps that’s their way of saying that they think integrative medicine has been proven to work (by their experience and by inferior quackademic standards), but that the scientific community remains unconvinced. I submit that this is a good argument for not advocating it and not making health insurance pay for it.
Conclusion: Quackademic Medicine Strikes Again
Although many studies lack statistical power, certain integrative medicine modalities show promise for improving patient outcomes when used in conjunction with conventional therapies.
This assertion is based on wishful thinking rather than on evidence. It could even be read as science denial. Lots of things “show promise,” but science requires that they be tested to find out whether it is a false promise. This whole monograph is a travesty. It cites questionable low-quality evidence. It epitomizes the reasons we on SBM have objected to “evidence-based medicine” as commonly implemented and it underscores the need for true science-based medicine. The authors seem to think it’s enough to find any supporting study in the literature: they are willing to accept a study’s findings at face value without rigorously considering prior plausibility, pitfalls and flaws in experimental design, or the fact that most research findings are false (as Ioannidis explained). It amounts to a poorly conceived infomercial, marketing their non-rigorous approach to medicine. This kind of thing has no place in a science-based CME program.
This article was originally published in the Science-Based Medicine Blog.