Monday, March 16, 2009

The Institute of Medicine’s Summit on Integrative Medicine

---was recently held in Washington, D.C. I couldn’t be there (not that I wanted to) so I did the next best thing by viewing all the available Power Point slides and watching about half the speaker videos. A few observations follow.

Overview: Although the conference promoted woo, the IOM promotes woo and the whole thing was supported by the woo promoting Bravewell Collaborative, many of the talks were not blatantly, directly about woo. That’s good, you say? Not really. The generous portion of non-woo merely gave the real woo behind the effort a greater air of legitimacy. Worse, it helped conference organizers obfuscate the meaning of integrative medicine by confusing the integration of pseudoscience into mainstream medicine with integration as a model of health care delivery systems, the latter being the topic of many of the speakers. No distinction in meaning was attempted and the confusion permeated the conference. Given the massive publicity and influence of the IOM, this confusion is sure to spill over into public discussions and increase the effectiveness of “integrative medicine” as (to borrow a term from Orac) a Trojan Horse by which real woo can sneak into education and public policy. A lot of Kool-Aid was served at this meeting, in woo and other flavors, of which I strongly suspect, given the influence of the IOM, the public and the Obama administration will imbibe deeply. Don’t expect the NCCAM to be defunded anytime soon. A few good points were mixed in with the load of BS, which I’ll try and cite as I go along.

The whole person, hygiene, preventive medicine, genomics, and the interaction of genes and environment--- all concepts which conventional medicine embraces. Yet, explicitly or implicitly (using terms like reductionism and allopathic) the speakers hijacked these ideas for their own promotional use by accusing the mainstream of ignoring them.

A more fluid concept of evidence: David L. Katz, MD, a professor at Yale, thinks the evidentiary standards by which mainstream medicine evaluates treatments are too rigid. He advocated for a “more fluid concept of evidence” (background here). He illustrated this fluid concept with a testimonial about treatment of abdominal adhesions with acupuncture and homeopathy.

Don Berwick speaks: Even without regard to what he had to say it’s significant enough that Donald Berwick, M.D., CEO of the prestigious and (up to now!) very mainstream Institute for Healthcare Improvement, lent his good name to this woo fest. But what he had to say was rich. After introductory remarks about how happy and honored he was to be there he mentioned homeopathy and acupuncture, not to criticize them as health claims, but only to warn that they shouldn’t compete with each other, or with other modalities, for limited health care resources. In other words, let’s stop fighting and work together. (Groan). He praised the IOM for its contributions to the design of health care, starting (now get this) with “traditional, allopathic and curative care and now migrating into this distinguished and important new arena.”

But here’s the bomb. Berwick, who seems to believe that healthcare should be like any consumer industry, said that quality is defined by patients’ perceptions. This is his idea of patient centered care which he defines as the patient having all the control. The IHI’s metric for quality, he said, is (watch this, now, emphasis mine) “…give me exactly the help I need and want exactly when I need and want it.”

Think about that for a moment. The woosters and quackademicians of the world point to surveys like these which show that patients, in large numbers, really seem to want woo. They support their unscientific promotions by saying that because so many patients seek it out it must be valid. Adherents of science based medicine often point out the silliness of such thinking. Now, though, this argumentum ad populum is given new life and legitimacy because the Institute of Medicine and the Institute for Health Care Improvement endorse it!

As an aside, it’s ironic that Berwick leans toward single payer health care. His radical “I want what I want when I want it” model of patient centeredness could never function in any conceivable form of single payer care in the U.S.

Dean Ornish speaks: Dean Ornish, M.D. is president and founder of the Preventive Medicine Research Institute and Clinical Professor of Medicine at UCSF. His talk had all the trappings of basic science and a deceptive sprinkling of clinical non-woo. Don’t be fooled. Go and read Orac’s analysis. Nuff said.

On a less negative note: There was some appropriate emphasis on the fact that true individualization of care will one day be enabled by genomic medicine. The tools of genomic medicine will be available for prime time in a decade or so, making much of the one size fits all comparative effectiveness research obsolete just as the government’s $1.1 billion is finally spent.

Conclusion: Pseudoscience has been invading mainstream medicine in the areas of education, research, public policy and clinical practice for the past 20 years. The Summit on Integrative Medicine which has just taken place is a watershed event because it legitimizes this invasion like never before. Pseudoscience is winning. Two of the most influential think tanks in all of medicine now publicly support it. Leaders in science based medicine need to unite and smack it down. Hard. And soon.

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