On the home page of its website, the National Center for Complementary and Integrative Health (NCCIH) of the National Institutes of Health (NIH) states: “We conduct and support research and provide information about complementary health products and practices.” [1] One of NCCIH’s health information pages has more than fifty links to pages offering tips on various topics concerning “complementary health practices.” The links are preceded by this paragraph:
Decisions about whether to use complementary health practices are important. Learning the results of studies and understanding a therapy’s potential benefits, risks, and scientific evidence can help you make those decisions. Our tips can help! [2]
One of the tips pages, titled “6 Things to Know When Selecting a Complementary Health Practitioner,” [3] explains nothing about “the results of studies and understanding a therapy’s potential benefits, risks, and scientific evidence.” Nor does it attempt to provide a good reason for consumers to ever consider selecting a “complementary health practitioner.” Thus, it implies that seeking the services of a complementary health practitioner is advisable on at least some occasions regardless of relevant evidence. Yet it provides no guidance about when to seek or avoid such services. This is the entire introduction to the tips:
If you’re looking for a complementary health practitioner to help treat a medical problem, it is important to be as careful and thorough in your search as you are when looking for conventional care.
Here are some tips to help you in your search: [3]
Why “Complementary Health” Is an Ill-Conceived Category
To learn what NCCIH means by “complementary health,” NCCIH website visitors must find another page: “Complementary, Alternative, or Integrative Health: What’s In a Name?” The page suggests:
The terms “complementary,” “alternative,” and “integrative” are continually evolving, along with the field, but the descriptions of these terms below are how we at the National Institutes of Health currently define them.[4]
Nothing recognizable as a definition of either “complementary” or “alternative” is provided on the page. The page describes “complementary” and “alternative” health care in terms of what the supposed field is not rather than what it actually is:
According to a 2012 national survey, many Americans—more than 30% of adults and about 12% of children—use health care approaches that are not typically part of conventional medical care or that may have origins outside of usual Western practice. When describing these approaches, people often use “alternative” and “complementary” interchangeably, but the two terms refer to different concepts:
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- If a non-mainstream approach is used together with conventional medicine, it is considered “complementary.”
- If a non-mainstream approach is used in place of conventional medicine, it is considered “alternative.” [4]
The page goes on to explain that “Integrative health brings conventional and complementary approaches together in a coordinated way.” [4] Thus, it appears that, according to NCCIH, the same practices can be labeled “complementary,” “alternative,” or “integrative” according to their intended use. The only distinction among these categories is how approaches are used in relation to so-called conventional medicine.
“Conventional medicine” is a commonly used term for medicine consistent with standards of practice, but it misleadingly connotes a lack of innovation compared to supposed “alternatives.” [5] Science-based standards of practice change in response to new scientific developments. In contrast, many types of so-called complementary and alternative medicine (sCAM) approaches (including Ayurveda and traditional Chinese medicine) resist innovation as they are rooted in tradition and antiquity without regard to biomedical and clinical evidence.
NCCIH’s verbiage fails to address what should be the main concern of consumers: whether particular services offered provide greater potential for benefit than harm when addressing personal health concerns. Its jargon, such as “complementary,” “alternative,” and “integrative,” may make these services sound worthwhile even though they are ineffective [5], Examples include homeopathy, iridology, Reiki, Gerson therapy, aromatherapy, and chromotherapy.
Outside its usage in conjunction with medicine or health, complementary is used to mean “serving to fill out or complete” or “mutually supplying each other’s lack.” [6] But what NCCIH labels “complementary health” does not necessarily fill out or complete anything provided in standard health care. Nor should it be assumed to supply whatever standard health care lacks. Few offerings commonly represented as part of either “complementary medicine” or “alternative medicine” are well-supported by clinical evidence; many such offerings are of implausible value. [7]. Products or services of implausible value that are unsupported by clinical evidence should not be coordinated with any other health services as “integrative” medicine [8-10]. Nor should they be promoted to consumers [11].
Bad Advice for Selecting a “Complementary Health Practitioner”
“Complementary health practitioner” is generally a euphemism for unscientific practitioner. The specific tips offered by NCCIH for selecting a “complementary health practitioner” fail to help consumers determine whether or not a practitioner’s services are: (a) based on a plausible rationale or (b) supported by sound clinical evidence.
Consumers should be wary of types of practitioners such as naturopaths that offer so-called complementary health services based on pseudoscience or superstition [12]. Naturopathic doctors (NDs) present themselves as a solution to the lack of availability of primary care [13], but a clear-thinking former licensed ND has noted:
Naturopathic education is rich in pseudoscience and fake medicine, and it is devoid of legitimate medical training. Naturopaths are not trained in the rigors of medical science, and this leads to a severe lack of competency and a huge risk of patient harm. NDs seem nice and charismatic, but they do not possess medical competency, especially to prescribe drugs [14].
Tips are available elsewhere to help consumers identify non-scientific practitioners [15-16], but NCCIH fails to offer them.
Here are each of the tips (in added italics) from NCCIH followed by my comments (not italicized):
If you need names of practitioners in your area, first check with your doctor or other health care provider. A nearby hospital or medical school, professional organizations, state regulatory agencies or licensing boards, or even your health insurance provider may be helpful. Unfortunately, the National Center for Complementary and Integrative Health (NCCIH) cannot refer you to practitioners.
Most responsible health care providers do not prescribe “complementary” health services to their patients [17]. None of the types of organizations recommended by NCCIH for referrals are likely to distinguish practitioners who offer services based on pseudoscience or superstition from those who don’t. Various forms of health pseudoscience and superstition labeled as “complementary health” are now commonly taught uncritically in medical schools, offered to patients by prominent clinical services organizations, and promoted by professional organizations [18-26].
Find out as much as you can about any potential practitioner, including education, training, licensing, and certifications. The credentials required for complementary health practitioners vary tremendously from state to state and from discipline to discipline.
The problem with credentials goes beyond such variability. If a health approach is senseless, then licensing and certification of its practitioners will not protect prospective patients from its nonsense. Regulating the credentials of “complementary health practitioners” serves mainly to legitimize nonsense. As Dr. Edzard Ernst, the world’s first professor of complementary medicine wrote: “Those who believe that regulation is a substitute for evidence will find that even the most meticulous regulation of nonsense must still result in nonsense.” [27]
Jann J. Bellamy, J.D. has used the term legislative alchemy to refer to “how state legislatures transform scientifically implausible and unproven diagnostic methods and treatments into legal health care practices”:
The legalization of nonsense as health care has a deleterious effect on the public. Each year, millions in the U.S. visit state-licensed naturopaths, chiropractors, and acupuncturists, exposing themselves to diagnoses of conditions that do not exist and treatments for these non-existent conditions, as well as treatment of real diseases with implausible and ineffective therapies. They will spend millions of dollars on these visits, paying with either their money or yours [28].
Bellamy has provided many examples of how legislative alchemy has legitimized nonsense promoted by practitioners of (a) acupuncture, oriental medicine, and traditional Chinese medicine [29-36], (b) homeopathy [36], (c) “the profession of reflexology” [37], (d) naturopathy [38- 48], and (e) chiropractic as primary and specialized medical care [49-62].
Some practitioners of dubious “complementary health” services lack significant education and acquire degrees that may seem impressive but do not reflect clinical competence [63-67]. NCCIH provides no guidance to help consumers evaluate educational credentials or clinical competence.
Many “complementary” practitioners promote irrational health care even though they have respectable educational credentials, have appropriate clinical training, or have made significant scientific accomplishments [68-69]. NCCIH neglects to warn consumers that some well-educated, highly qualified practitioners offer quackery euphemistically described as “complementary,” “alternative,” or “integrative” health care.
Physicians often present board certifications as evidence of their expertise. But promoters of “complementary” or “alternative” approaches have created substandard specialty boards awarding certifications [70-71]. “Complementary health practitioners” often advertise various other types of certifications that are offered by organizations that promote dubious services [72-73]. NCCIH fails to warn consumers about substandard certifications.
Find out whether the practitioner is willing to work together with your conventional health care providers. For safe, coordinated care, it’s important for all of the professionals involved in your health to communicate and cooperate.
Health services based on pseudoscience or superstition cannot be “coordinated” with rational health care. Safe self-care methods for providing a sense of comfort or control such as meditation that are sometimes labeled “complementary” don’t need to be coordinated with rational health care.
Explain all of your health conditions to the practitioner, and find out about the practitioner’s training and experience in working with people who have your conditions. Choose a practitioner who understands how to work with people with your specific needs, even if general well-being is your goal. And, remember that health conditions can affect the safety of complementary approaches; for example, if you have glaucoma, some yoga poses may not be safe for you.
I have seen no evidence that consumers are able to make such judgments.A practitioner’s experience working people who have a particular condition may not matter when the practitioner is offering irrational services.
Don’t assume that your health insurance will cover the practitioner’s services. Contact your health insurance provider and ask. Insurance plans differ greatly in what complementary health approaches they cover, and even if they cover a particular approach, restrictions may apply.
This is one reason that so-called complementary services can add to out-of-pocket costs without necessarily adding to positive health outcomes. But even when insurance covers “complementary” care, it isn’t necessarily advisable. For example, Medicare covers chiropractic treatment of chiropractic “subluxations” even though subluxation-based chiropractic is baseless and harshly criticized even by many chiropractors.
Tell all your health care providers about the complementary approaches you use and about all practitioners who are treating you. Keeping your health care providers fully informed helps you to stay in control and effectively manage your health.
This tip is offered without a rationale. It doesn’t clarify how consumers are in control when they tell all health care providers about their use of complementary approaches.
On other pages of its website, NCCIH notes that health care providers need to know when their patients are receiving treatments elsewhere that might undermine treatments they are providing. For example, a “complementary health” practitioner might recommend herbal treatments that can interact harmfully with medication prescribed for a patient [74-75]. But it doesn’t make such risks clear in offering tips about choosing a “complementary” practitioner.
It’s not clear why health care providers would need to know about a patient’s use of a benign “complementary” treatment. Telling science-based practitioners about one’s use of benign “complementary” approaches could put added time pressure on health care providers who are already pressed for time.
The Bottom Line
NCCIH’s stated mission is to “to define, through rigorous scientific investigation, the usefulness and safety of complementary and integrative health interventions and their roles in improving health and health care.” It is misleading to refer to health interventions as “complementary” or “integrative” when they are unlikely to be useful in improving health.
“6 Things to Know When Selecting a Complementary Health Practitioner” is an advisory that misleads consumers about how they can improve their health. It fails to guide them to make intelligent, informed decisions about health care. It also fails to warn that “complementary health” is often a euphemism for quackery. The advisory is an indication of how misguided NCCIH’s mission is.
References
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Dr. London is a professor of public health at California State University, Los Angeles and the editor of Consumer Health Digest.
