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 Freedman's Atlantic Essay on Alternative Medicine and the Holy Trinity of Patient-Centered Outcomes  
The following is one in an ongoing series of columns entitled Integrator Blog by . View all columns in series
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.

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."

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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Resumes are useful in employment decisions. I provide this background so that you may understand what informs the work which you may employ in your own. I have been involved as an organizer-writer in the emerging fields......moreJohn Weeks
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