Is Integrative Medicine the Future? Relman-Weil debate focuses on scientific evidence issues

Edited by: Steve Bunk Arnold S. RelmanAndrew Weil Integrative medicine, the combining of alternative and conventional medical methods, was the subject of a debate held recently at the University of Arizona (UA) College of Medicine. The opponents were Arnold S. Relman, editor-in-chief emeritus of the New England Journal of Medicine and professor emeritus of medicine and social medicine at Harvard Medical School, and Andrew Weil, director of the UA program in integrative medicine and best-selling author of eight books that have made the Harvard-educated physician a leading advocate of integrative medicine. Last December, an article by Relman appeared in The New Republic that sharply attacked Weil's writings.1 Their subsequent debate consisted of opening remarks, rebuttals, questions, and closing remarks that have been edited in the following text. Sentences and paragraphs have been deleted or transposed where appropriate. Relman: Integrating alternative medicine with mainstream medicine, as things stand now, would not be an advance, but a return to the past, an interruption of the remarkable progress achieved by science-based medicine over the past century. I can't see how such integration, even if it were possible, would improve medical care or further the cause of human health. Most alternative systems of treatment are based on irrational or fanciful thinking, and false or unproven factual claims. Their theories often violate basic scientific principles and are at odds, not only with each other, but with modern knowledge of the structure and function of the human body as now taught in our medical schools. It could not be woven into the fabric of the medical curriculum without confusion, contradiction, and an undermining of the scientific foundation upon which modern medicine rests. Weil: In this country and throughout the world, patients in unprecedented numbers are going outside of conventional medicine to look for help. Why are people doing this? Clearly, there is dissatisfaction with conventional medicine. There is a large and growing gulf in this country between what patients expect of doctors and what medical schools are training them to do. Patients want physicians who can take the time to sit down with them and listen and explain to them, in language they can understand, the nature of their problem; who are aware of nutritional influences on health; who will not push just drugs and surgery as the only approach to treating illness; who can answer intelligently questions about dietary supplements; who are sensitive to mind-body interactions; who will not laugh in your face if you ask questions about Chinese medicine; who are willing to look at you as more than just a physical body. I think those are very reasonable requests. Relman: What do consumers want? They want, I believe, doctors whom they can trust, who are going to be honest with them and tell them the truth. And if the truth is that alternative methods have not been adequately tested, and we don't know whether they can work or not, doctors should sympathetically and compassionately explain that to patients, and not simply be indifferent to the fact that there is no evidence to support these methods. Weil: I don't agree at all that there is no data to support this. There is a great deal of data scattered in far-flung places, and one of the first tasks is to bring this together in a form that our physicians can look at and decide whether they want to use it, and to evaluate it. That's exactly the mission of the program in integrative medicine here. We are trying to go through this and sort it all out, and separate what is nonsensical and what is possibly harmful from what is potentially useful, and to teach both doctors and patients to do that. Relman: How would the proposed new integrative curriculum deal with this wide, philosophical gulf between alternative and conventional medicine? Here is just a small, but representative example of the many unproven, and often highly unlikely claims made by practitioners of alternative medicine, led, most notably, by Dr. Weil. One: Improper breathing is a common cause of ill health, and breathing exercises will cure disease and promote good health. Two: Massive doses of intravenous vitamin C speed the healing of surgical wounds. Three: Guided imagery, meditation, or hypnotherapy will reduce the frequency of recurrent attacks of herpes simplex. Four: Topical application of human urine is effective treatment for athlete's foot. Five: Two tablespoons of ground flaxseed daily reduces the risk of breast cancer. Six: Cutting down on sugar intake decreases the frequency of urinary tract infection in nondiabetic women. Seven: Therapeutic touch and other forms of so-called energy medicine can heal disease through the manual transmission or adjustment of types of energy, so-called, that are simply too subtle to be detectable by instruments. And, eight: Belief alone, without any physical intervention, can cure organic disease. Weil: In my experience--and I know this is a phrase that Dr. Relman doesn't like, but I consider experience to be one valuable source of data--many patients use alternative methods because they find that they work. And if a patient has tried a method and found that it works, that patient needs no further proof, does not need to read the reports of a randomized, double-blind, controlled trial in a medical journal to be convinced of the efficacy of treatment. Relman: The history of medicine is full of people who say, "My experience tells me this, that, or the other," and when put to the test, the numbers are collected, the measurements are made, and statistics are gathered, it isn't so, it doesn't stand up. The only way to know whether someone's opinion is right or not is to put it to the test. Weil: I am all for refining our medical practice and making it more consistent with scientific evidence, but as Dr. Relman himself has pointed out in an editorial in the New England Journal, medicine constantly operates in areas of uncertainty, where the evidence has not yet come in. As a researcher, you have the luxury of insisting on rigorous scientific testing, and you have the leisure to wait for results to come in. As a practitioner, you are in the trenches, working with patients who have medical needs. And you often have to guess, and you have to make use of your best medical judgment in the absence of definitive evidence. The Office of Technology Assessment of the U.S. Congress has estimated that fewer than 30 percent of procedures currently used in conventional medicine have been rigorously tested. Relman: It is true that in medicine we often try things that have not yet passed the gold standard of controlled, randomized clinical trials. But usually, when we do, there is good, plausible, biological reason for believing that the procedure might work. And usually, there are already in the literature, documented case reports. I suggest that alternative medicine ought to try to meet the same standard. If you believe that curing disease by using a solution that contains no molecules other than the solvent, the water, is possible, then I suppose it's justified to put all sorts of homeopathic methods to the test. But it's so unlikely, it's so unreasonable, it's so difficult to understand how that could possibly happen. Weil: I would like to comment on the kinds of bias that exist in conventional science, and especially in medical journals, against the researching of many of these ideas that have been outside of the mainstream. Dr. Relman has dismissed whole fields of medicine, thousands of years of cultural tradition, such as Chinese medicine, as being superstitious and, on the face of it, ridiculous and absurd. I think that that attitude works very strongly to lead journal editors and heads of medical institutions to ignore or, at worst, to suppress evidence that comes in contrary to expectations. I don't think you can have it both ways; you can't demand evidence, and then when evidence comes in that contradicts your preconceptions, say you aren't going to look at it. Relman: As a former editor, I know that's simply not true. The fact is that there have been relatively few rigorous clinical studies of alternative methods submitted to the leading peer-reviewed journals. The data submitted to the best medical journals are judged on their own basis. There is no bias, no bias at all. Every editor wants to publish good data on new and original ideas. Weil: There is a difference between being an open-minded skeptic and a closed-minded skeptic. I consider myself an open-minded skeptic. The word "science" comes from the root of a verb "to know." I think there are various ways of knowing. Relman: In sharp contrast to mainstream medicine, alternative medicine makes no distinction between objective phenomena and subjective experience, between the external world and human consciousness. This allows the practitioners of alternative medicine to believe in the power of mind and thought to change physical matter and heal organic diseases, a concept that basically contradicts the laws of physics and the modern, scientific view of nature. We know that states of mind, that emotions, can have physical consequences. We know that there are many ways to calm down people so that their pulse and respiration slows, and they feel more relaxed. Can such things cure organic disease? The mind-body interaction that Dr. Weil is talking about is no big deal, no surprise. Everybody knows when you're nervous, you sweat, and you have tachycardia, and your mouth gets dry. And when you're relaxed, your pulse slows down. Will that cure disease? That's the question. Weil: I think we have wrong interpretations of placebo effects in much of conventional medicine. To me, a placebo effect is a pure healing response from within that's elicited by belief. I think whenever we give treatments that work, we also elicit placebo responses. That, to me, is the most significant finding that comes out of this era of randomized, controlled trials of drugs. The conclusion I draw is that any change we can produce in the human organism through a pharmacological intervention can be exactly reproduced, in at least some people, some of the time, by a mind-mediated mechanism. Relman: The placebo effect is the percentage of patients in a controlled study that show some result which is comparable to [that of] a much larger number of patients who were given the active agent. The trouble with concluding that mind cures ... is that there are no, or certainly not enough, studies that compare the placebo with nothing. The question is whether the placebo effect is simply the spontaneous variation in symptomatology that we know occurs. Weil: The first principle from which you should operate is that you do no harm. I would cite a lead article that was published in the Journal of the American Medical Association exactly a year ago,2 that estimated there are now 100,000 deaths a year in U.S. hospitals directly caused by pharmaceutical drugs. In contrast to the few disasters that happened with herbal medication, these are the correct drugs, correctly prescribed, for the correct condition. This is now estimated to rank between the fourth and sixth leading cause of death in hospitals in this country. Relman: There's no question that a lot of people die or are damaged from the side effects of prescription pharmaceuticals. Sometimes, unexpected reactions occur that can't be helped, but that's part of the balance that you have to weigh of the drug's benefit versus the risk. The reason that there are probably fewer deaths from herbals--although there are some and we don't know how many, because most of them are not reported--is that they have fewer effects. You don't get as much for your money. In one sense, herbal therapy should not be in fundamental conflict with the conventional medical curriculum, because many plant-derived materials have been proven to have important biological effects. We need to see many more controlled studies comparing standardized herbal preparations with conventional pharmaceuticals before concluding that herbs have any special advantage over conventional drugs and that herbal therapy should be taught in medical schools. Weil: In many drug plants, the active constituent is present in the amounts of 1 or 2 percent by dry weight of the plant, so when you give an herbal preparation, you're giving something very dilute, and the rise of concentration of the drug in the bloodstream and in the target organs is very slow. Therefore, the effects are much muted, and the toxicity is also much less. There is no difference between a drug and a poison; that's a fundamental point of pharmacology. The word "pharmacology" comes from the Greek root for "poison." Whenever you concentrate therapeutic effect, you inevitably concentrate toxicity. If what you get for your money is death from a pharmaceutical drug, that's not a very good bargain. Relman: Modern, science-based medicine is the way of the future. Alternative medicine belongs to the past. It is old wine, albeit sometimes now being served in new bottles, and is unlikely to produce new knowledge or improve future medical care. It has a strong appeal to those who want to believe in a human-friendly universe, and in the benevolent healing powers of nature. Alternative medicine can be a compelling hobby for the healthy, and a final hope for the dying. But however valuable these things may be for some of us, we ought not to forget that our best chance for a healthier future rests on continued advances in conventional medical practice, based on science and objective evidence. Weil: It's the patient that suffers in this. How much better it would be, if there were physicians trained to advise patients about the intelligent combination of the different kinds of therapies that are out there. We went back and looked at the records of cancer patients that we've seen over the past year and a half. Of the first 60 cancer patients that were seen in our integrative clinic, none was taken off any kind of conventional therapy, and 11 who said that they would not do conventional therapy were persuaded by our integrative fellows to do conventional therapy. The therapies that we aim for are those that are reasonable, that are supported by what evidence is now available, that above all are not harmful, and that work from the premise that the body can heal itself, if you give it a chance. A.S. Relman, "A trip to Stonesville," The New Republic, 219[24]:28-36, Dec. 14, 1998. J. Lazarou et al., "Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies," JAMA: The Journal of the American Medical Association, 279:1216-7, April 15, 1998.


Arnold S. Relman	Andrew Weil