McGill University: Integrative Medicine's Latest Casualty | The Body of Evidence

McGill University: Integrative Medicine's Latest Casualty

Banner for the Symposium

It gives me no pleasure to report that one of my almae matres, McGill University, has fallen for the siren song of integrative medicine (IM). In the last decade, we have been witness to many laudable academic institutions embracing the woo in the name of open-mindedness: Harvard, the Mayo Clinic, MD Anderson, the University of Toronto.

The Complementary Health Symposium, held at McGill on June 3rd, 2016, with the support of the university's own Departments of Medicine and Family Medicine, reveals that a lack of critical thinking has claimed another institutional victim.

The full-day event showcased IM institute and research directors affiliated to universities such as Harvard and the University of Arizona. These speakers were selected by the local organizing committee, comprised of the chair of the Department of Family Medicine at McGill and professors researching pain management, preventative health measures, and muscle wasting in cancer, among other topics. A quick look at the biographies of the members of this local committee did not reveal obvious adopters of quackery.

The sole exception may be Dr. Adam Gavsie who, while an assistant professor at McGill, is also listed as a medical practitioner at the Montreal Centre for Integrative Medicine, which offers services such as homeopathy and acupuncture according to its website. Dr. Gavsie completed a fellowship in integrative medicine at the University of Arizona in Tucson, a program which will be mentioned below in the context of one of the presentations. While I do not know whose idea it was to organize this symposium, my money is on Dr. Gavsie.

I did not attend the event (which cost in the neighbourhood of 200$ if I remember correctly), but the slides from each presentation are available on the event website. I will offer my thoughts on each talk below based on the slides, but you can skip to my concluding thoughts by scrolling all the way down.

Introduction, Opening Remarks, and Mindfulness Meditation

The symposium opened with an introduction by Dr. Gavsie of the Montreal Centre for Integrative Medicine and Dr. Mark Ware, who investigates the use of cannabinoids in pain management. The chair of the department of Family Medicine, Dr. Howard Bergman, made opening remarks. A ten-minute block called "mindfulness meditation" probably refers to an actual meditation session, led by Dr. Patricia Dobkin, whose students have reported that she does conduct meditation during her classes.

Talk 1: "Framework and attitudes towards Complementary Health and Integrative Medicine - Taking the pulse at McGill University" by Adam Gavsie

Dr. Gavsie defines integrative medicine as a philosophy that does not "accept alternative therapies uncritically". He goes on to characterize one of its principles as the "recognition that good medicine should be based in good science, be inquiry driven, and be open to new paradigms."

This discourse is emblematic: we are told that IM encourages an open mind to critically evaluate the evidence for a treatment before its adoption. In practice, the adoption precedes the critical evaluation, and the latter is usually dismissed when its results fail to distinguish a particular brand of magic from a placebo response. Meanwhile, homeopathy, chiropractic, and acupuncture are not known for their openness to new paradigms.

While true medicine improves over time, alternative therapies cannot, for they are rooted in dogma, some of which, like D.D. Palmer's chiropractic, is simply made up.

Dr. Gavsie continues his sales pitch by showing he knows his audience: Sir William Osler, a former McGill physician who left a strong imprint on medicine, learned acupuncture and was himself using it in the late 1800s! This argument from authority joins a preceding argument from popularity ("91% of adult cancer patients at St. Mary's Hospital use complementary and alternative medicine!") in foregoing evidence while attempting to convince the audience of the worth of IM. This appeal to insubstantial arguments will repeat in later talks. More worrying is his slide entitled "McGill Complementary Health Educational Overview", which seems to reveal elective courses in IM available to McGill medical students. Gotta get 'em while they're young.

Talk 2: "Integrative Medicine Undergraduate Medical Education and Lessons from the Consortium of Academic Health Centers for Integrative Medicine" by Benjamin Kligler

Dr. Kligler, from the Albert Einstein College of Medicine in the Bronx, begins to share his perspective on IM with the following: "Almost 40% of the population routinely uses complementary and integrative approaches; over 60% if prayer is included." Keep in mind that he is a medical doctor addressing a room full of academics and pointing out that including prayer as an approach to health means his numbers look better.

He goes on to correctly point out that physicians must be mindful of the potential interactions between natural medicine approaches and pharmaceutical drugs. Indeed, these interactions do happen, and when a) the patient does not disclose they are taking an herb and/or b) the physician does not know anything about the herb, problems can arise. This is a valid reason for physicians to learn about complementary therapies but not to embrace them and refer patients to their practitioners if they do not work, as is so often the case.

Dr. Kligler mentions that, as part of the Albert Einstein program in integrative medicine, required curriculum activities include workshops on hypnosis and Chinese medicine, while elective activities can be a mini-course on Reiki (AKA magic) and an exchange program with the Pacific College of Oriental Medicine. He writes that their program focuses on making their medical students physically and psychologically healthier--a noble goal, but waving your hands over someone's body while pretending to manipulate energy fields is probably not the way, not if you are paying 46,000$ for your degree.

Talk 3: "Integrative Medicine in Residency - Experience at University of Arizona and Throughout North America" by Dr. Patricia Lebensohn

Dr. Lebensohn is the director of "integrative medicine in residency" at the Arizona Center for Integrative Medicine, one of two symposium speakers who hail from the Center that is directed by Dr. Andrew Weil, infamous in skeptic circles and a rock star in the field of alternative medicine.

This Center offers a two-year, one-thousand-hour fellowship in IM to medical graduates which is primarily taught online using, the slide indicates, "evidence-based education", a phrase that has lost all meaning. Under "Challenges", Dr. Lebensohn writes that the fellowship is an "elective", probably implying that she would like it to become required for all medical residents at the University of Arizona.

Courses in the fellowship address topics such as nutrition, sleep, and physical activity. Someone needs to remind IM proponents that eating well, exercising, and getting a good night's sleep are not foreign concepts in medicine. This fellowship was the subject of a pilot study using three cohorts of residents (and control sites! Go science!), generating data that will no doubt be used to convince people that "it works". Of course, the study did not address whether or not what was taught was grounded in solid evidence; rather, the measured outcomes were knowledge of IM, a confidence in IM self-assessment, course completion, and a course evaluation survey. You will be astonished to learn that IM fellows knew more about IM that those who did not go through the program. We can also teach medical residents about astrology and test their knowledge on succedent houses in the night sky, but that will not prove that astrology works.

One of the tactics hinted at by Lebensohn and used liberally by IM proponents is akin to a Trojan horse. She mentions wellness and lifestyle behaviours that are being taught to physicians through the Arizona Center for Integrative Medicine. These are: exercising, eating fruits and vegetables, meditating, praying, spending time outdoors, having nurturing relationships, sleeping well, controlling your alcohol intake, and doing yoga/Tai Chi/Qigong. How many of these are "alternatives" to medicine? Once again, eating well and being well rested are not alternative medicine approaches. Yet this is their strategy: introduce the outside of the Trojan horse for validation that IM is legit--because we can all agree that nutrition is important--then let out the prescientific beliefs like energy healing when no one is paying attention anymore.

Talk 4: "Lessons from Establishing the Centre for Integrative Medicine at the University of Toronto" by Dr. Lynda Balneaves

Closer to home, Dr. Balneaves speaks about their experience setting up an IM centre in Toronto. On a slide ironically titled "cutting-edge research", she writes about their "rigorous clinical research on the efficacy and cost-effectiveness of promising CAM [complementary and alternative medicine] therapies", such as, I suppose, Dr. Heather Boon's clinical trial at the University of Toronto on using impossibly dilute homeopathic herbs to treat attention deficit/hyperactivity disorder in children and adolescents. Yes, the University of Toronto is doing "cutting-edge research" into a prescientific system of beliefs that includes the notion that the more you dilute a poison, the stronger it becomes.

Balneaves' slides are the only ones that mention people on the other side of the fence, i.e. "the skeptics". She pastes a screenshot of a Globe & Mail article entitled "Are we being served by the regulation of naturopaths? Not if patients are still being misled". Indeed. Dr. Balneaves actually uses  the word "allopathic" on her slide, a shibboleth of ardent believers in naturopathy, certainly a term that has no place in a serious discussion about medicine.

She admits on a slide that there is "limited evidence for some therapies vs. EBM [evidence-based medicine]" and reports numerous challenges to spreading the good news about IM: there has apparently been a "shift in priorities" at the University of Toronto due to new leadership; they have lost "key champions" in their fight for legitimacy; there has been a "healthcare system restructuring" in the Greater Toronto Area; and they find it difficult to integrate fee-for-service CAM practitioners inside a publicly-funded institution. She writes that it is important to "ensure champions are persuasive with the powers that be (need to include MDs and key administrators".

Finally, they are seeking a visiting scholar in traditional Chinese medicine and are maintaining student exchanges with the Chinese University of Hong Kong. Mao Zedong is probably smiling in his mausoleum at how gullible Westerners are of his creation.

Talk 5: "Harvard's Osher Program in Integrative Medicine and Acupuncture Research" by Dr. Helene Langevin

This presentation seemed focus on the role of the connective tissue in pain and scar formation, with graphs and images taken from various published studies. It lacks a clear story and would require either audio from the presentation or a deep dive in all the papers quoted to reassemble the original story. I will mention the cute slide that opened the talk: a picture of two seemingly distinct icebergs--one labelled "alternative", the other, "conventional"--which shows that they are actually the same underwater. They are not.

Talk 6: "The Impact of Place on Health and Well Being" by Dr. Esther Sternberg

I will be kind to this talk because, while it is based on a false premise, I agree with its conclusions. Dr. Sternberg argues that certain sounds and sights will affect how you heal, and that stress-reducing elements (such as green spaces) should be incorporated into hospital and overall urban design. We need more green spaces, biodiversity, walkability, and areas for social interactions. Having worked in a hospital for seven years, I can vouch for the depressing effect of pastel paint and impressionistic paintings of flowers. If rigorous studies indeed show that patients benefit from making hospitals look less like pre-mortuaries, and if hospitals have funds for transformational change (or realize they would save money by investing in this), please go ahead. Both my thumbs are raised high in the air. The false premise? How is this "alternative medicine"?

Talk 7: "Research in the World of Complementary and Integrative Medicine" by Dr. Sunita Vohra

There is now a special place in my heart for this last speaker, Dr. Sunita Vohra. She is the director of the Integrative Health Institute at the University of Alberta, the very same institute that had planned an all-too serious workshop on bending spoons with the power of the mind for academics and clinicians. When fellow professor Timothy Caulfield caught wind of this, he unleashed the poster onto social media, whose skeptics ridiculed the event. Traditional media outlets picked up the story, and the workshop was cancelled.

In her McGill talk, she thankfully starts by mentioning the elephant in the room: "why clinicians worry?" They are not knowledgeable in IM; there is a heterogeneity to the alternative treatments; there is a known lack of quality control for natural health products; there are possible herb-drug interactions; patients who believe in CAM may delay actual medical treatment and relay on unproven therapies instead; and, she ends, "lack of evidence?". Yes. Is there really a lack of evidence, she seems to say.

She cites a 2005 paper, declaring that the "quality of RCTs [randomized controlled trials] of complementary therapies [is] as good as conventional therapies". And moves on to the question of whether or not these therapies are safe. Hold on. The authors of the 2005 paper do not claim that these RCTs demonstrate there is good evidence behind complementary therapies. What they did is look at 612 RCTs and determined if they had the features of a good trial: double blinding, randomized assignment to the multiple arms of the trial, size of the sample. In other words, there are good quality trials on the effectiveness of complementary therapies... but this study says nothing about the results of these trials. 

Dr. Vohra moves on to talk about a study called SONAR in which 20 community-based pharmacies were recruited to do "active surveillance" of natural health product and drug interactions and their adverse effects. Her study showed that 7.4% of patients who went through these pharmacies had experienced an adverse event due to the use of natural health products, "which represents a 4000x increase in AE [adverse events] reporting compared to passive surveillance". This is important. Herbs contain active drugs which can interact with medication. I am all for active surveillance, but her solution seems to be to embrace the woo, as demonstrated by #SpoonGate.

She ends by saying that there are "many different ways of achieving health and healing" and advocates for "culturally competent care". This has the stench of cultural relativism, which dictates that the medicine of every people is equally valid and must be considered. To paraphrase Tim Minchin (and many others), there is medicine that works and medicine that does not. A "way of achieving healing" that demonstrably works becomes medicine. There is no need to look beyond that. Relativism is the enemy of critical thinking, and integrative medicine is the relativistic arrow that has been shot in the heart of healthcare.

Concluding Thoughts

While McGill University is not apparently part of any integrative medicine consortium at the moment, its collective intellectual rigour is showing symptoms of negligence.

Signs of this erosion might have been visible in the past. Certainly, I have written about a chiropractor, André Bussières, who holds a faculty position as assistant professor at McGill's School of Physical and Occupational Therapy. But this symposium cements in my mind the slippery slope McGill is navigating.

If there is push-back on this piece, the central argument will be that we don't know what works and what doesn't, so we need to do more research. The blog Science-Based Medicine contains a slew of counter-arguments, covering the evidence against acupuncture, chiropractic, energy medicine, and pretty much any alternative therapy adopted by IM proponents. There is no reason to continue researching homeopathy, a silly counterfactual dogma that claims water has memory when you shake it a certain way. Nor is there any reason to pursue research into Reiki, when a child can demonstrate that its believers can't even feel the energy fields they claim to detect.

When rigorous trials show no difference between a CAM practice and placebo, its defenders now say this means the practice works. They say we need to conduct elaborate theatrical performances which carry risks (needle contamination and accidental perforations, arterial dissection, natural health product contamination), all the while lying to the patient, in order to foster a temporary feeling of wellness that simply masks the underlying illness.

Lest I appear cold-hearted, I am not advocating neglecting the problems the symposium speakers believe can be answered through integrative medicine. Adverse events created by the concurrent taking of drugs and natural health products is a real problem. Likewise, I recognize (from personal experience as well as from empathy) that chronic pain forces some patients and physicians to look outside the science box. Stress is a real thing, and physician burnout and suicide ideation are not desirable outcomes. But the solution to any of these problems cannot be magic.

We find ourselves in a troubling time, where cultural relativism seems to foster the reconsideration among academics of prescientific ideas. Homeopathy is the notion that water can cure illness. Chiropractic is the idea that invisible misalignments in the spine are at the root of every disease. Reiki is the belief that non-existent energy fields can be manipulated by hand gestures to promote wellness. These exact wishful thoughts are part of the baggage of IM, were discussed at McGill University in front of clinicians and researchers, and will now slowly contaminate its medical faculty, as they have major medical schools in North America and elsewhere.

The argument made my multiple speakers at the symposium--that IM is popular--is a dangerous reversal of scientific education. It used to be that scientists would gain knowledge and subsequently educate the public. IM proponents suggest the public knows best and should educate the scientists. I am all for a two-way dialogue, but it must be guided by robust evidence, not customer choices.

The plural of anecdotes is not data. Do I, of all people, need to remind the McGill Faculty of Medicine?

 

(For more on the topic, you can watch my video on integrative medicine here)