Polarization-Based Medicine : Protests Against the Mayo-NCCIH Pain Guidance Evoke the Bigotry of the Political Season

Antagonism from Three Continents

The article at issue was “Evidence-based evaluation of complementary health approaches for pain management in the United States.” ¹⁰ It was written by a five-person team from the NCCIH led by the agency's chief epidemiologist, Richard Nahin, PhD. The article was prepared as a continuing medical education offering, targeting primary-care doctors. It was one part of a wide-ranging practical series for Mayo Foundation for Clinical Education and Research, and was published in Mayo Clinical Proceedings. The topic sentence of the NCCIH media release on the paper was positive but far short of a ringing endorsement: “A review of evidence from clinical trials shows that a variety of complementary health approaches—including acupuncture, yoga, tai chi, massage therapy, and relaxation techniques—hold promise for helping to manage pain.” ¹¹ This was the synopsis from the 105 U.S.-based randomized controlled trials (RCTs) related to integrative strategies for pain that fit the team's inclusion criterion.

Here is a taste of the response. An Australian medical doctor immediately characterized the synopsis as “one of the most blatant examples of quackacademic confabulation I have seen in ages.” (The pejorative is a favored description of the scientists who are members of the Academic Consortium for Integrative Medicine and Health, and elsewhere around the world, who are integrating complementary and integrative approaches into their research, education, and in some institutions, clinical practices.) The members of the NCCIH team are portrayed by the same writer as “sincerely deluded cranks.” In a separate column, the same USA academically-based surgical oncologist noted above dismisses the NIH's guide from the 105 RCTs as “tooth-fairy science.” He condemns the process by association: two of the NIH's team, each with research doctorates, were separately educated as doctors of chiropractic and naturopathic medicine, respectively. He writes, “If you want to know why NCCIH supports so much pseudoscience, look no further than it having chiropractors and naturopaths in high ranking positions.” He restates his definition of “integrative medicine” as “integrating pseudoscience and quackery into medicine.”

“Quackacademic” Integrative Educators and “Crooked Hillary”

From England, also within days of the NCCIH's publication, a blog post from a medical doctor and former professor who has written for two decades against integrative care was titled: “Why that study about alternative therapies relieving pain is worthless.” ¹² The NIH team is portrayed as “actively misleading” the public with “exaggerations, sloppy research and misleading conclusions.” The name-calling—and particularly the routine attributions of quackery—recall Trump's epithets placed on each of his opponents, for example “Crooked Hillary.” ¹³

On review, some of the items in this writer's case against the NCCIH authors had some merit. Yet, overall, the goal appears to have been to fulfill on his headline rather than scientific give and take. Though the NIH team caveated the limits on safety claims, the writer takes them to task for sharing the safety statements made in the RCTs. He denigrates the team for not knowing the difference between efficacy and effectiveness. This is the fact that the data tables available to the target audience through links in the article separate them out. Though the authors explained their decision to choose only RCTs for the United States because of applicability to their purpose, he suggests that the authors set these parameters to present a more positive case. Yet had the NIH team included, for instance, acupuncture trials from Germany and China, the evidence for acupuncture would have been stronger. He raises questions about the lack of a conflict of interest statement because the whole team “was not NIH staff.” Yet, all five authors are NIH staff, and the CME section includes a conflict of interest statement. ¹⁴ He bluntly dismisses the paper as “lacking critical thinking,” despite the 90 pages of data tables in which they evaluated each trial. The authors are charged with failing to do a quality assessment on each of the trials. This appears to be a reasonable point. The overall pattern, however, is infected with polarizing bias.

Medicine's “Birthers”: Condemnation via Origin and Tribe

An additional reason that the article is deemed “worthless” is particularly resonant with the strategies of candidate Trump. Trump has led “a five-year long smear of the nation's first black president” by questioning the right to office of current president Barack Obama through suggesting—despite hard evidence to the contrary—that Obama wasn't born in the United States. ¹⁵ Here is the echoing language from the British antagonist to the NCCIH: “The article is from the National Center for Complementary and Integrative Health, a part of the NIH which has been criticised repeatedly for being biased in favour of alternative medicine.” By its birth in the NCCIH, the work is damned. Or, as the surgical oncologist suggested, if doctors of chiropractic or naturopathic medicine are involved, it must be worthless. Such logic is akin to racial profiling. Condemnation due to origin or tribe.

This is interesting. The NIH's pronunciations are well known for leaving large swaths of disgruntlement among complementary and integrative health practitioners for portrayals of integrative products, practices, and practitioners that are deemed by these “alternative medicine” practitioners as dismissive. Case in point, spinal manipulation is absent from the short list of treatments in the NCCIH media release that “hold promise for helping to manage pain.” In response to a query, chiropractor and researcher Christine Goertz, DC, PhD, a member of the Board of Governors of the quasi-governmental Patient Centered Outcomes Research Institute and of the Advisory Council to NCCIH, responded, in part: “There were considerably more SM [spinal manipulation] trials available for inclusion in the review than was true for acupuncture and yoga and SM trials tended to have smaller sample sizes. As the authors themselves state ‘small trials are prone to more variability and to false-negative results’” (Christine Goertz, PhD, DC, pers. comm., September 12, 2016).

Challenged on Both Sides

Another leading chiropractor researcher, the founding director of the NCCIH-funded Chiropractic Research Center and current president of Palmer West College of Chiropractic, William Meeker, DC, MPH, chimed in, “I am surely biased. Yet I find it hard to understand the notion that spinal manipulation wouldn't fall into the category of ‘more positive than negative results.’ The preponderance of evidence argument is in manipulation's favor, unless I am interpreting the body of literature all wrong. Perhaps I am” (William Meeker, DC, MPH, pers. comm., September 12, 2016).

Perhaps I am biased. What a welcome, humble perspective! In fact, in a context in which a third of what is done in regular medicine is unnecessary, in which quality science is still attached to but a fraction of what is done, and in which frightening levels of morbidity and mortality are endemic to medical delivery in the United States, such self-questioning serves us all.

A recent exchange between a naturopathic clinician, author and researcher, Michael Traub, ND, DHANP, FABNO, and NCCIH director Josephine Briggs, MD, models our way out of polarization and toward putting the patient first. In July 2016, the NCCIH published a Clinical Digest entitled “Skin conditions and complementary health approaches: what does the science say.” ¹⁶ Dr. Traub, the author of Essentials of Dermatological Diagnosis and Integrative Therapeutics, is a regular speaker on integrative dermatology. He was critical of the document, and provided multiple scientific references to back his case that the NCCIH misled by leaving out what he held was significant supportive science. ¹⁷

A Model Exchange Toward Civil, Scientific Discourse

NCCIH director Josephine Briggs, MD, responded publicly. She explained her office's inclusion criterion, and noted that they would consider some of Dr. Traub's suggestions in a potential rewrite. She further commented favorably on his suggestion that the NIH be transparent about the authors of the Clinical Digests. ¹⁸ In a response, Traub credited the NCCIH director, and offered an additional suggestion. Since “most CAM and integrative clinical treatments have not been studied extensively enough to have been subjected to systematic reviews, meta-analyses and large RCTs, nor have clinical practice guidelines been developed,” perhaps including double-blind placebo controlled trials, such as those he recommended, is warranted. Should the public be led to believe that there is zero evidence for an integrative practice relative to a given condition just because such evidence hasn't crossed the political-economic barriers of large trials or publication in guidelines of conventional organizations? Good question. Civil discourse!

Polarization is an expected part of political life—as it is in behavior of fund-raisers and warmongers. People are more likely to support, activate, donate, and give their lives when the cause is presented as a perfectly clear choice between good and evil. Most issues are more complex than the elevator speech, the 30-second advertisement, or the 750-word blog post. There is one's own kind of people, one's own correct way of seeing, and then there is the Other. Life in silos begets such polarized activity. The separateness may be shaped by one's actual tribe, profession, chosen community, or favored talk show station.

Medical integration challenges us as humans. Achieving the form of justice known as optimal patient-centered care is a delicate balance scientifically, clinically, politically, and economically. Convened are historically separate and unequally resourced professions, guilds, and tribes. We need to bring our best selves to the table. In this diplomacy, we are served to apply the serenity prayer to decide where and how we spend our energies to find the optimal common ground. Wisdom leads us to the place that my colleague, at the top of this article, suggested I go, which was to not write this column. British poet Robert Graves provides us guidance: “Hark how they roar, but never turn your head/Nothing can change them, let them not change you.”

Now then, back to the challenging work of engaging and publishing the research that will best support us in “making use of all appropriate therapeutic and lifestyle approaches, healthcare professionals and disciplines to achieve optimal health and healing.” ¹⁹