Exactly one year ago tomorrow, The Bravewell Collaborative shut down, an event so momentous that few seem to have noticed. It’s been awhile since we at SBM devoted much attention to Bravewell, although, at one time, its doings were a regular feature of SBM posts.
For those of you not familiar with Bravewell, a brief history. The main mover and shaker behind The Bravewell Collaborative is Christy Mack, wife of former Morgan Stanley head John Mack and a financier of sorts in her own right. She and the widow of another Morgan Stanley bigwig, Susan Karches, neither of whom had any particular expertise in finance, managed to get about $220 million in bailout funds from the Federal Reserve, a boondoggle recounted in Matt Taibbi’s 2011 hilarious Rolling Stone article, “The Real Housewives of Wall St.” Ms. Mack had established the Bravewell Collaborative a few years earlier, with her own money and that of other philanthropists, as a private operating foundation, a further opportunity to benefit from government largesse in the form of tax deductions.
Here’s Bravewell’s definition of “integrative medicine”:
Integrative medicine is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person’s health. Employing a personalized strategy that considers the patient’s unique conditions, needs and circumstances, integrative medicine uses the most appropriate interventions from an array of scientific disciplines to heal illness and disease and help people regain and maintain optimal health.
This vague, and typical, cut and pasting of appealing terms: “personalized strategy,” “appropriate interventions,” “optimal health,” and so forth, is a hallmark of integrative medicine. It masks the one characteristic of integrative medicine that differentiates it from “conventional” medicine — the incorporation of quackery into medical practice — a feature that becomes clear once you dig into the details, which we’ll get to in a moment.
In the words of Ms. Mack, the organization was “sunset” on June 17, 2015, because
We formed back in 2002, and have since worked together to change how Americans think about their health and the kind of healthcare they receive, and to bring about the cultural change necessary to create a healthier nation. Then, when our principal strategies had achieved our goals, and when integrative medicine had become part of the national conversation on healthcare, our members collectively decided that it was time to sunset the organization.
Note that she does not claim Bravewell actually improved healthcare or the nation’s health one whit, and she’s right. There is no evidence that it had any such effect. I suppose you could truthfully say that “integrative medicine had become part of the national conversation on healthcare” – it was certainly part of our conversation here at SBM.
So, what did Bravewell accomplish? Here’s the highlight reel, according to its website, which is still up and running.
Bravewell Clinical Network
The Bravewell Clinical Network is a group of nine “leading” integrative medicine sites. (I guess this means the 60 or so integrative medicine centers in the Academic Consortium for Integrative Medicine & Health don’t all rate as “leading.”) The Network develops “successful models of care” and improves their financial viability. (Someone call David Eisenberg and Ted Kaptchuk with this revelation; they seem totally unaware that all of their problems have already been solved by Bravewell.)
This effort resulted in “Best Practices in Integrative Medicine,” published in 2007, and, as far as I can tell, not updated in the 9 years since it came out. “Best practices” in these “leading” IM sites include offerings of acupuncture, acupressure, aromatherapy, herbs, Chinese and “Eastern” medicine, craniosacral therapy, reiki, healing touch, functional medicine, homeopathy, Qi Gong, reflexology, rolfing and zero balancing. See what I mean? You don’t have to dig far to find the quackery.
Network patients can participate in “Patients Receiving Integrative Medicine Interventions Effectiveness Registry” (“PREMIER”), patient-reported outcomes modeled on the NIH’s Patient Reported Outcomes Measurement Information System (“PROMIS”), the major difference being that PROMIS measures patient-reported outcomes from evidence-based interventions, while PREMIER is currently evaluating pseudoscientific interventions such as acupuncture and energy medicine. Preliminary findings, based on a small sample of patients, indicate that a combination of manipulation, acupuncture and energy medicine (such as reiki) yielded an “impressive decrease” in pain. Of course, if the underlying treatment isn’t evidence-based, and there are no controls, this “research” can’t really tell us anything useful. Or, GIGO.
To ensure that the nation is not deprived of a supply of fresh IM practitioners, Bravewell sponsored 88 fellowships in IM at Andrew Weil’s University of Arizona IM program, where they learned about botanical medicine, homeopathy, naturopathy and energy medicine, among other pseudoscientific practices. Wouldn’t Abraham Flexner be pleased to learn that, having worked so hard to bring medical education out of the darkness of quackery and into the light of science, Andrew Weil and Bravewell have played their part in marching them right back in to the 19th century?
Academic Consortium for Integrative Medicine & Health
Bravewell’s funding of the Academic Consortium for Integrative Medicine & Health for 10 years may be its most significant achievement, just not in the way Bravewell thinks. The Consortium has probably contributed more than any other factor to the devolution of academic medicine into quackademic medicine through its relentless devotion to the ideology of integrative medicine. It is interesting to note that, even as the possibilities for finding any evidence of safety and efficacy to support the use of alternative treatments have shrunk, both Bravewell and the Academic Consortium have stubbornly insisted that CAM must absolutely be a part of this always promised, but never realized, potential for transformation of American medicine. The Consortium has established clinical centers offering sheer quackery like craniosacral therapy, various forms of energy healing, acupuncture, naturopathy, herbal medicine and the like, having apparently dropped the pretention that evidence has anything whatsoever to do with the services they sell to patients. (Because, you know, you need a “more fluid” concept of evidence.)
It has been less successful in instituting a standard IM curriculum in medical school or IM as part of residency programs, try as they might. “Core Competencies in Integrative Medicine,” from 2004, another Bravewell project, is still on both the Consortium and Bravewell’s websites, apparently without updating in the past dozen years. While they have been no doubt enjoyed some victories, especially at certain institutions such as Georgetown, in making quackery at least an elective at some schools and a part of some residency programs, their main achievement has been the establishment of what are essentially spas offering both “conventional” (diet, exercise) and “CAM” services.
The Summit on Integrative Medicine and Health
A signature “achievement” of the Bravewell Collaborative received its share of attention here on SBM. The Summit on Integrative Medicine and Health of the Public, a partnership between Bravewell and the Institute of Medicine, is the perfect exemplar of integrative medicine’s ongoing attempt to rebrand preventive medicine and its emphasis on exercise and diet as “integrative,” while, at the same time, slipping quackery into medical practice. Kimball Atwood called them out on this, but good, with a long list of preventive health measures supported by science advanced by “conventional” medicine” compared to those from integrative medicine, the latter being exactly zero. This was back in the day when you could actually write to institutions being unduly influenced by integrative types, like the IOM here, and hope that you might make a difference, which is exactly what the late, great Wally Sampson did in response to this effort, to no avail.
Team SBM v. Bravewell
“Integrative Medicine in America”
Perhaps no one document has been so thoroughly investigated by Team SBM than Bravewell’s “Integrative Medicine in America: How Integrative Medicine is Being Practiced Across America,” which garnered what must be a record 4 posts for any one event: from Steve Novella, David Gorski, Kimball Atwood and Mark Crislip. Taken together, their posts are as good a lesson as you’ll get in wading through the doublespeak and false premises of integrative medicine in general and Bravewell in particular.
Misleading language (Kimball Atwood):
Misleading language is the sine qua non of ‘integrative medicine’ (IM) and its various synonyms. The term itself is a euphemism, intended to distract the reader from first noticing the quackery that is its distinguishing characteristic. As previously explained, Bravewell darlings Andrew Weil and Ralph Snyderman, quack pitchmen extraordinaires, recognized nearly 10 years ago that if you really want to sell the product, you should dress it up in ways that appeal to a broad market.
Co-opting concepts from conventional medicine (Steve Novella):
The integrative movement . . . co-opted this term [“patient-centered care”] and made it their own, as if they invented it, and then ironically accused mainstream medicine (who invented the idea and the term) of not being patient-centered. You will see this pattern repeated.
Importation of quackery into medicine (Novella):
Next we get to the core fiction of integrative medicine, that it “uses the most appropriate interventions from an array of scientific disciplines.” That, of course, is a description of mainstream medicine. We use any intervention that is science-based – that has an appropriate combination of plausibility and direct evidence for safety and efficacy. Integrative medicine, rather, is the mixing of appropriate science-based interventions with treatments that are not science-based, that are highly implausible, or have been shown to not work. Otherwise they would already be part of medicine.
Rebranding of conventional modalities as CAM (David Gorski):
I conclude that “integrative medicine” integrates pseudoscience with science, quackery with medicine. Where it fails to do that, it rebrands science-based modalities like nutrition as somehow being “alternative” so that it can be listed as being CAM.
Quackery is not necessary to good patient care (Gorski):
The problem, once again, is that it is not necessary to “integrate” pseudoscience with science-based medicine in order to practice collaborative patient-centered care. It’s really not, just as it’s not necessary to “integrate” pseudoscience into SBM in order to be “holistic” or to “take care of the whole patient.” Bravewell keeps selling that false dichotomy. I’m not buying, and neither is any member of the SBM team.
Or, more succinctly (Guess Who):
If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.
Leadership Program in Integrative Healthcare at Duke University
Bravewell’s last, and ongoing, project is
The Leadership Program in Integrative Healthcare at Duke University. This leadership program is designed to create a new type of leader for the future of medicine — one grounded in the philosophy of integrative healthcare.
A practical strategy, integrative medicine puts the patient at the center of the care and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person’s health. Treating the whole person addresses both the patient’s immediate needs as well as the effects of the long-term and complex interplay between a range of biological, behavioral, psychosocial and environmental influences are addressed. This process enhances the ability of individuals to not only get well, but most importantly, to stay well.
Sounds like the “new type of leader” is a whole lot like the old type of “integrative medicine:” a lot of high-minded talk about patient-centeredness, wellbeing, and so on, but (when you check out the curriculum) a chance to sneak quackery into healthcare. (Actually, when I read through the program’s materials, what came to mind was not so much integrative medicine as Silicon Valley’s “Conjoined Triangles of Success.”)
Bravewell’s demise was brought to my attention by none other than John Weeks, in a recent post on Integrative Practitioner, who highlighted the intractable problem with integrative medicine that neither Bravewell nor any other integrative medicine proponent has been able to solve: Just how integrative does integrative medicine want to be?
The care, while multi-disciplinary, is physician-directed. . . . Conventionally degreed physicians oversee the care and personally deliver conventional medical services, mind-body interventions, nutritional counseling, and in some cases acupuncture. Other appropriately trained health care providers deliver services such as Healing Touch, acupuncture and massage.
This annoys Weeks, who, while congratulating Bravewell, criticized what he calls its “cam-ectomy.”
The leaders credit their success in part to “vetting [their] partners well” as Mack . . . put it: ‘Identifying and engaging the right people has always been key to Bravewell’s success.’ To Bravewell this meant, with minor exceptions, choosing to work with and through medical doctors in academic medical settings. Chiropractors, naturopathic physicians, licensed acupuncturists and the other licensed “CAM” professions and the work of their organizations to foster an integrative health and medicine future did not make the grade.
My single significant concern with Bravewell has continuously been that, while they promoted a new model of care, they did so while upholding a vertical, top-down, MD-dominant hierarchy. Strategically, the “other” consortium with the “CAM” fields, the Academic Collaborative for Integrative Health, did not merit consideration. The policy-related interprofessional Integrative Health Policy Consortium also failed to make the grade. Bravewell’s exclusiveness, given its power as a donor, sometimes fostered a chill between the two academic consortia.
So, there is dissension in the ranks, with chiropractors, naturopaths and acupuncturists not wanting to sit around twiddling their thumbs until the MD calls them in to do a few carefully supervised procedures. Get the popcorn ready.
Bravewell wasted a cool $30 million promoting quackery tarted up as patient-centered care. It’s biggest accomplishment was the establishment of an entrenched integrative bureaucracy, housed mostly in academic medical centers, where too many salaries depend on the survival of integrative medicine for it to easily go away. As Kimball Atwood said,
Bravewell is what can happen when ditzy rich people who know little about medicine or science get it into their heads that they know something—some crucial secret or secrets, little known to most in medicine except for a few cranks who themselves have found the secret to easy money.