Freedman’s Atlantic Essay on Alternative Medicine and the Holy Trinity of Patient-Centered Outcomes

Summary: Some associated with integrative practice who read David H. Freedman’s recent Atlantic Monthly feature, “The Triumph of New Age Medicine,” are repelled. Some don’t get past the wave of antagonism from the anti-CAM vigilantes. Some don’t like Freedman’s apparently retro decision to call his subject matter “alternative medicine.” The article, from the influential author of a recent piece on John Ioannidis’ dismissal of most claims by conventional medical researchers, is undoubtedly influential. Those who persevere will find that Freedman may well be re-framing the entire argument over science, evidence and CAM. He does this, in this era of aspiration toward patient-centered care, through quietly referencing, one after the other the Holy Trinity of patient-centered outcomes: satisfaction, functionality and cost.



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Atlantic David A. Freedman

David H. Freedman’s recent
Atlantic Monthly feature, “The
Triumph of New Age Medicine,”
begins a radical re-framing of the research debate
over “alternative medicine,” as he prefers to call it. Freedman doesn’t quite name
where he is heading. But he sanctifies the field via what may be called the Holy
Trinity of patient-centered outcomes: satisfaction, functionality and cost.

The feature is all the more important as Freedman’s most
recent Atlantic piece was an
examination of John Ioannidis’ life-work. 

In Lies,
Damned Lies, and Medical Science
, Freedman weighed Ioannidis’ considered view that much of what medical researchers claim is “misleading,
exaggerated, or flat-out wrong.”

   
Freedman’s elevation of alternative medicine
does not
happen without 40 days and nights
in the desert of reductive trials. 

   

Freedman’s elevation of alternative medicine does not
happen without 40 days and nights in the desert of reductive trials. His article
has caused more than one integrative practitioner’s blood to curdle.  The lead-in dismisses the possibility that alternatives
have scientific support. Therapies are no better than placebos. Antagonists gain
center stage, wagging their favorite fingers. 
Acupuncture is a 3,000 year-old relative of blood-letting. Alternative
practitioners lie to patients. University of Maryland biological researcher Steven
Salzberg, PhD passes off the whole mess as “cleverly-marketed, dangerous
quackery.” Anti-CAM blogger David Gorski, MD gleefully dubs academic
integrative medicine “quackademic.” Multimodal care with natural therapies is a
“sham-treatment ritual.”

This vigilante duo wears their favorite colors: black and
white. Conventional medicine is scientific. Alternative medicine is not. Freedman
lets the antagonists bark. Reductive research has not been kind to alternative
medicine. Who among those who experience their own health as bettered via use
of natural agents has not shuddered at recent findings? Couldn’t at least one
of the major NIH National Center for Complementary and Alternative Medicine (NCCAM)
herb-as-drug trials have shown unequivocally positive outcomes? Who among the
advocates would rather not feel a need to wrap their continued beliefs in the protective shrouds of methodological questions and paradigmatic
dismissal? Some bricks hit their marks.

Yet in Freedman’s drama, alternative medicine’s
Gorski-Salzberg lynch-mob faces venerable foes. One is Salzberg’s colleague at
the University of Maryland, Brian Berman, MD. Berman, an integrative clinician
with depth training in homeopathy, acupuncture and mind-body skills, is also the
NIH NCCAM’s best-funded researcher. Another is Amit Sood, MD, an integrative
medicine doctor and researcher representing an institution famous for its
attention to evidence, the Mayo Clinic.

   
      In Freedman’s drama, alternative
medicine’s
Gorski-Salzberg lynch-mob
faces venerable foes.

Freedman clothes these two advocates in humanistic colors.
We meet Berman’s work through a patient at his Maryland Center, Frank Corasaniti,
a retired fire-fighter with nasty neck pain from a work-related injury. Note
that the patient is not an easy-to-dismiss, upper-class, believer with time on
her hands. Corasaniti comes for modern blood-letting (acupuncture). He receives
the whole sham ritual: counseling on his diet and physical activity, discussion
of the weight of his responsibilities and his stress. His practitioner’s ritual
includes suggestion that Corasaniti envision his blocked “energy pathways”
opening to lessen his pain.

After six months of treatment, Corasaniti’s “fairly typical”
response, as Freedman frames it, includes: 
major diminution of the pain, loss of 10 pounds, cleared up constipation
and urinary difficulties, and increased general fitness. Says this patient of
alternative medicine: “I just feel so much better.”

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Imagine accompanying Atlantic article

At Mayo, a burly patient named Ryan with horrible pain
following thoracic surgery – also not an idle dabbler in self-help – shows up
for integrative care. Within minutes on the massage table this N-of-1 is,
according to Freedman-as-witness, “as compelling a picture of suffering
relieved as I have ever seen.” 

By the time we read of Berman’s transition from regular
medicine to the integrative approach he dubs “cluster care,” his decision to
join the insurgency is a no-brainer. Freedman quotes Berman: “I saw how much
more I could do to help people. For the first time since medical school, I felt
a healer again.”

The antagonists are named. Their battleground is how we
value research, the placebo effect and outcomes.

Freedman uses a Mayo hematologist to comment on the
science/anti-science polarization the vigilantes favor. The hematologist allows
that no randomized trial data back 80% of the conventional treatments he
delivers daily. One might call this a classic TKO (technical knock-out).

But it is when Freedman engages the question of
alternatives being no better than placebo that this public re-framing of the scientific
debate over alternative medicine begins in earnest. The placebo emerges as a
beneficial agent used by virtually all practitioners. Alternative practitioners
distinguish themselves by unleashing a stronger healing response. “One might
argue,” writes Freedman, “that a system of care that merely delivers a powerful
, relatively safe placebo for many conditions – without side effects – has at
least something to commend it, when compared with the system of care we
actually have today.”

   
   Freedman takes readers directly into the
paradigm
shift alternative practitioners promise, an
“adherence to a ‘healing’ model of patient care.”

 

Then Freedman takes his readers directly into the
paradigm shift alternative practitioners often promise: “Yet to focus on
alternative medicine’s placebo effect ignores what may be its largest benefit –
it’s adherence to a ‘healing’ model of patient care.”

Freedman cites a modern prophet – a Mayo endocrinologist –
to drive his point home. The endocrinologist thinks mainstream doctors “ought
to be praising, or at least tolerating alternative medicine for the way it
plugs gaping holes in modern medicine. Who cares about what the mechanism is.
The patient will be healthier.”

Freedman closes his case with a note on cost. Integrative
medicine pioneer Dean Ornish, MD puts a price tag on potential savings from widespread
application of these sham rituals. He reminds us that 75% of the $2.6-trillion
of US healthcare costs are linked to the kinds of behaviors that the
firefighter, Corasaniti, seems to have successfully changed.

Freedman’s argument for the reconsideration of
alternative medicine rests on the Holy Trinity of patient-centered outcomes: satisfaction,
functionality and cost. What else do patients care about?  Who
cares about mechanism,
indeed? “Alternative medicine,” concludes Freedman,
“often seems to do a better job of making patients well, and at a much lower
costs, than mainstream care.”

   
Will we ever have patient-centered care

if we don’t
engage a frontal campaign to
understand what promotes this Holy Trinity
of
patient-centered outcomes?

   

I like that Freedman calls what he witnesses
“alternative” rather than the more diplomatic “integrative.” It is an alternative approach, and a bold one at that. What would happen in the troubled system U.S.
medical delivery if this alternative, an “adherence to a healing model of
care,” were elevated to standard of practice? Not surprisingly, the
anti-alternatives bloggers are taking him to task. (See David
Freedman responds to critics of his CAM apologia
.) 

I take Freedman to task on just one count. He doesn’t go
far enough. Alternative medicine, in Freedman’s reframe, is an exemplar of patient-centered care. Mainstream stakeholders
of all sorts are, if not aspiring toward greater patient-centeredness, at least
advertising that they are. To move these
interests, we need to break the still god-like grip of
reductive research on the still shut gates to a better collective future. 

Will we ever have patient-centered care if we don’t
engage a frontal campaign to understand what promotes this Holy Trinity of
patient-centered outcomes?  Maybe
Freedman will take on this dialogue next.  

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