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Our Center’s Niche at NIH

October 30, 2012
John (Jack) Killen, Jr., M.D.
John Killen, Jr., M.D.

Deputy Director
National Center for Complementary and Alternative Medicine

View Dr. Killen's biographical sketch

This post addresses a couple of themes that are coming up with some regularity in comments posted to this blog. They include: 1) questions about what makes something “specifically complementary and alternative medicine (CAM),” or why other NIH Institutes or Centers (ICs) can’t do what NCCAM does, since the scientific methods and approaches are the same; and 2) a perspective that CAM borrows from other science-based fields “to lend false legitimacy to pre-scientific magical thinking.”

As it is generally defined, the term CAM encompasses an extremely large and eclectic assortment of substances, interventions, practitioners, approaches, theories, and dogmas that share only one common denominator: they once were or still are—by virtue of origin or use in the real world—somehow “out of the box” of modern, scientific biomedicine. While generally useful in describing attributes of health care, such definitions by exclusion pose challenges for NCCAM and the field of research we support. Among them are the plethora of potential research topics, vagaries about when or whether something is in or out of “the box,” and issues highlighted in my previous post on “Plausibility”.

Frankly, we do not spend much time wrestling with questions about whether something is “specifically CAM.” Instead we look at the wide range of things that fall more or less under the CAM umbrella from a much more pragmatic perspective on real-world health practices, and see four things. First, the public is using many of these interventions on a large scale, very often “off the shelf” or otherwise without professional guidance. Second, health care providers of all sorts are integrating some of these interventions into their health care practices on a substantial scale. There are many reasons, some good and others less so, but the fact that this is happening more and more is clear. Third, consumers and providers are, in some instances, perceiving benefits; in other instances, consumers are experiencing harms. Finally, everyone is confronted, routinely, with a paucity of reliable scientific evidence concerning safety and usefulness. NCCAM’s congressional mandate and our strategic approach rest squarely in the highly pragmatic need to bring more, objective, reliable scientific evidence to the most important of these evidence gaps.

The “Plausibility” post addressed how we use the first two of our four criteria for priorities in our decisions about investing public resources most prudently. The third and fourth criteria relate much more specifically to the practical matters of what is actually going on in the real world of peoples’ health practices and health care, and how to shape research so it will be most useful to consumers, providers, and policymakers.

The Four Factors for Priority Setting

Scientific Promise:
How strong is the body of evidence supporting the concept?
Amenability to Rigorous Scientific Inquiry:
Are there reliable and reproducible methods—e.g., diagnostics, outcome measures, biological effects, quality control, etc.?
Potential To Change Health Practices:
Is it reasonably likely that the results will make a difference to consumers, providers, or policymakers?
Relationship to Use and Practice:
Do the methods and approaches actually address the most important questions about use or practice in the real world?

Hence the priorities of our strategic plan, which include study of selected nonpharmacological approaches in managing chronic pain and other symptoms; basic and safety-related research on herbal medicines, dietary supplements, and probiotics; and exploring the potential of some mind and body practices as adjuncts in promoting or sustaining healthy behavior change. These priorities, very well reflected in the research we are actually funding, are all grounded in realistic assessment of potential benefit and risk, and the scope or urgency of public health need for better evidence.

There are two points to make about NCCAM’s ecological niche within NIH at large. First, we consult and collaborate all the time with our colleagues in other ICs. For example, we routinely seek advice on proposed intervention trials to ensure that the study is clinically relevant and employs state-of-the-art methods and measures. Second, NCCAM’s primary scientific identity, now honed by more than a decade of actual experience, lies in understanding how best to address the specific scientific challenges of studying interventions that fall under the CAM umbrella. For example, NCCAM has evolved a set of policies and practices for applying the tools and methods of pharmacology and pharmacognosy to investigation of herbal medicines, dietary supplements, and probiotics (nccam.nih.gov/research/policies/naturalproduct.htm). These set the pace at NIH for research on these products because they specifically address a variety of issues related to the often unusual regulatory status of these products. Similarly, we have learned through extensive experience about the challenges confronting study of procedure-based mind and body practices (nccam.nih.gov/about/plans/2011/objective1.htm), including how to ensure scientific rigor when double-blind experiments are not possible, and the need to understand and specifically explicate the role of placebo or other such context effects and confounders.

It may be unavoidable that some choose to see the existence of Government investment by NIH in this research as lending false legitimacy to interventions before it is due. We see things differently, believing very strongly that the net benefits of more, reliable, objective scientific evidence—whether or not it favors use—far exceed any risks of “false legitimacy.” NCCAM is simply not about legitimizing anything unless that is where the evidence points. As the track record of NCCAM-funded research demonstrates clearly, it sometimes does and often does not.

Comments

Comments are now closed for this post.

This is just another incredibly weak defense of NCCAM, demonstrating its inability to even define CAM.

Your research has disproven many types of CAM, yet your education grants support uniformly positive teaching of CAM quackery in medical schools. How can you live with that dishonesty?

Could you comment on this funding Dr. Killen? It appears that NCCAM is providing funding for tuition and training of CAM practitioners./Administrative Supplements for CAM Practitioner Research Experiences/

Notice Number: NOT-AT-07-005/

Update: The following update relating to this announcement has been issued:/

July 18, 2012 - See Notice NOT-AT-12-005. Notice to Update Submission and Review Dates of NCCAM’s Administrative Supplements./

Normally the duration of the award will be for one year, but it can be extended for a second year if evidence is provided to show that the CAM practitioner is actively pursuing the next step in his/her research career. The principal investigator (PI) of the grant being supplemented can request up to $100,000 per year in direct cost for support of one CAM practitioner candidate. These funds may be used for salary and fringe benefits for the CAM practitioner, research supplies, travel, and/or tuition for courses if they enhance the research experience. Salary and fringe benefits for the candidate should be consistent with the institution’s salary structure. No funds may be requested to supplement the salaries of the PI or other personnel, or to purchase equipment. This initiative is focused on providing a research experience for CAM practitioners and is not intended to support clinical residency training or other clinical practitioner training. Upon completion of the supplemental support, those CAM practitioners who chose to pursue a research career will be expected to compete for research training, career development, or research grant funds appropriate for their stage of career./

Could you comment on this as well, Dr. Killen?/Notice of Intent to Publish a Funding Opportunity Announcement for Interdisciplinary Complementary and Integrative Health Clinical Research Training Award (T90/R90)/

Research Initiative Details/

This Notice encourages partnerships between institutions with demonstrated expertise in training complementary medicine practitioners and institutions with demonstrated expertise and capacity in conducting clinical and translational research./

With this new FOA, NCCAM is developing a clinical research training program aimed at improving the capacity of the integrative health field to carry out rigorous research. The program will fund coherent and unified partnerships between institutions with research intensive environments (e.g., T32 and CTSA institutions) and institutions with curriculums focused on clinical training of practitioners in complementary modalities and disciplines that also have faculty with a substantial interest in rigorous clinical research. The partnership must be committed to create a comprehensive interdisciplinary complementary and integrative health clinical research training program that builds on the existing strengths, expertise and infrastructure of both institutions. The program will support mentored research-training and hands on experiences in clinical research as well as trainee-focused developmental efforts including didactic activities in clinical research methodology, integrative health, and trainee-initiated pilot clinical research projects within NCCAM’s research priority areas (http://nccam.nih.gov/grants/priorities). The funded institutional programs are expected to generate a cadre of research clinicians who are able to participate fully in multi-disciplinary teams engaged in complementary and integrative health research./

I don’t see how these two proposals fit into any of the “Four Factors For Priority Setting” that you outlined above. In fact, it appears that NCCAM is paying tuitions for CAM practitioners and paying expenses to expand “intergrative medicine” and CAM programs.

The question that remains unanswered here is how the problem of a perceived government imprimatur on CAM therapies creatd by the work of NCCAM, and the costs of the research conducted, are balanced by the claimed benefits of rigorous scientific study when 1) after about $1.4 billion spent since 1992 virtually no practices have been validated and 2) there has been no apparent decrease in the popularity of practices not found to have a benefit?* The value of rigorous scientific study ought to be changes in actually clinical practices consistent witht he results. In the case of CAM, however, the fact that the category is defined more by a set of belief-systems than by a collection of techniques, the results of any research are inevitably accepted only when they support existing beliefs, and negative results do not result in unsupported practices being discarded. How will NCCAM ensure that the results of research it funds actually affect clinical behaviors appropriately?

*Offit PA. Studying complementary and alternative therapies. JAMA 2012;307:1803–1804.

My fear with this article is that it demonstrates a total lack of scientific understanding of the study of medicine. THE NCCAM is looking for a cheap acceptable alternative to real medicine that can be foisted upon the unsuspecting to ease a healthcare fiscal problem. Mao used accupuncture, not for its effectiveness but for its inexpense and general acceptance. NCCAM is using the same criteria to evaluate and push its nostrums. Fortunately the US has a higher education level than post WWII China.

Thank you for taking the time to respond to the criticisms that myself and a few others have made in the comments of previous posts. I’d like to take the time to respond to some of your clarifications and comments.//First you attempt to define CAM, which is of course the logical way to begin such a discussion. Note, however, the only definition you can come up with which ties together what “CAM” may actually be: “they once were or still are—by virtue of origin or use in the real world—somehow “out of the box” of modern, scientific biomedicine.” However, I contend that this is a wholly unsatisfying definition which provides no extra utility to the framework of understanding the role of NCCAM and the proper study of CAM as a category. By the definition you have provided, literally ANYTHING not only CAN be “CAM” but actually IS “CAM.” At one point, every single medical practice came from “out of the box” of modern, scientific biomedicine. Even techniques such as using a Fogarty catheter for VTE removal was, at its inception, “out of the box” in that Fogarty himself, as an intern, proposed it and the prevailing “biomedical” practice stated that it was a ridiculous idea (this is what his mentor at the time told me over a vascular surgery journal club, commenting on the prevailing sentiment of what was “mainstream” and “reasonable” to do). Yet now we can’t imagine doing the procedures in a different way. Does that make it CAM? How much time needs to elapse between it having been “out of the box” and subsequently losing its “CAM” status? Or is it the current usage? Can something be both CAM and not CAM? Take yoga for example. Is that “CAM?” We recognize that exercise is a quite science based and mainstream recommendation and there are mountains of data supporting the healthful effects of regular exercise. Heck, I can’t pass my board exams if I don’t know that the first line for treatment of glucose intolerance and borderline hypertension is lifestyle changes, diet improvement, and exercise. Yoga is fabulous exercise - I do it myself. But what if you make the claim that yoga has some intrinsic “spiritual” benefit because it “realigns” your “chakras” and can thus cure cancer? (http://articles.timesofindia.indiatimes.com/2012-05-29/fitness/31270197_1_yoga-bhastrika-pranayam) Does that then make it “CAM?” Why would such a claim make it “CAM” and not “medical negligence?” Can you imagine if I, as a medical doctor, recommended to my patient whom I just diagnosed with cancer that yoga is a viable option for cure? Would I not be (rightfully!) open to medical malpractice litigation? Of course, I can go on endlessly about how every case creates an exception to the sole shared “common denominator” that defines “CAM.” The only shared common denominator I can see is that CAM is simply medicine which has not been demonstrated to be effective or which has been demonstrated to not be effective. It is also common, though not universal, for “CAM” to have an extremely low or zero scientific plausibility (like intercessory prayer to lower HIV titers, a study funded by the NCCAM). You do touch on the difficulty this poses, but then do not address what the resolution is. You simply move on and hand-wave the issue by saying “we do not spend much time wrestling with questions about whether something is “specifically CAM.”” Instead the focus essentially seems to boil down to an admission that the NCCAM’s raison d’etre is to test ANY therapeutic modality (no matter how loosely defined) as long as it seems to be popular. Once again, I do not see how there need be a unique IC of the NIH to do this, especially considering your previous post about how studies will need to meet prior plausibility requirements. On the one hand you are espousing a mission statement of rigorous scientific inquiry. Yet in this post you demur by saying that investigation is justified by popularity of use coupled with some vague and undefined “pragmatic” understanding of what seems to “fit under the CAM umbrella.” So which is it? Investigation based on rigorous scientific criteria or perceived popularity? The issue raised about lending undue legitimacy to CAM modalities is integral to this question. By stating publicly that the NCCAM only pursues rigorous scientific studies of modalities that have sufficient prior plausibility, any study done will automatically receive a minimum of legitimacy. However, by studying what seems to be popular regardless of plausibility, the undue legitimacy is conferred. The only remedy to this is to decide what the actual goal of the NCCAM is. If it is about the pragmatism of popular modalities, regardless of plausibility, then not only should this be stated clearly, but when evidence demonstrates no utility it should be clearly and unequivocally stated and a lack of support by the NCCAM made clear. After all, scientific knowledge is not just gained by learning new useful things, it is also gained by eschewing what we learn is of no use (intercessory prayer, reiki, homeopathy are easy examples; acupuncture is another example). Just like any rigorous scientific study, goals and purpose should be explicitly stated up front. // Yet, as you continue to describe the “ecological niche” of the NCCAM you describe specifics which do not support your case. For example you illustrate how the principles of pharmacognosy inform the NCCAM’s policies and methodologies for the study of herbal “CAM.” Why wouldn’t the original IC’s from whence this information came from be unable to conduct the studies themselves? What is unique about the NCCAM that allows it to take the methodology of a different IC and apply it to a study that the IC wouldn’t have done itself?// You also discuss “selected nonpharmacological approaches in managing chronic pain and other symptoms; basic and safety-related research on herbal medicines, dietary supplements, and probiotics; and exploring the potential of some mind and body practices as adjuncts in promoting or sustaining healthy behavior change.” Once again, this type of research is already done by many other research groups and IC’s within the NIH itself and the scientific community at large. I’m sorry but I am continuing to fail seeing a unique benefit or rationale for the NCCAM taking lead and funding these studies when there are other research avenues already doing this. If the issue is that they don’t have the resources to do it, why would a unique center be needed rather than just adding resources to the other research centers?// Lastly, you close by saying: ” As the track record of NCCAM-funded research demonstrates clearly, it sometimes does and often does not.” Yet, the track record I have seen is one of uniformly negative or equivocal and poorly designed studies. Perhaps a simple post outlining a list of positive studies coming from the NCCAM would be useful. Augmenting that list by annotating which studies (positive or negative) actually lead to a change in health practice would also be useful. However, I think it is telling that the founding patron of NCCAM, Sen. Tom Harkin, was noted to say “One of the purposes of this center was to investigate and validate alternative approaches. Quite frankly, I must say publicly that it has fallen short. It think quite frankly that in this center and in the office previously before it, most of its focus has been on disproving things rather than seeking out and approving.”// Once again, thank you for taking the time to post on this topic. However, it leaves more questions unanswered than answered and raises an internal conflict in how the NCCAM conducts business and decides what to study and what initiatives to fund. David’s comment above is a valid criticism, with the NCCAM funding educational grants for modalities which have evidence demonstrating their lack of utility and thus making it difficult for me to accept your statement “We see things differently, believing very strongly that the net benefits of more, reliable, objective scientific evidence—whether or not it favors use—far exceed any risks of “false legitimacy.””

@David in response to “…your education grants support uniformly positive teaching of CAM quackery in medical schools”.

You appear to have a fundamental misunderstanding about NCCAM’s education grant initiatives, two of which have involved awards to medical schools. The first (2000-2003) was aimed at one side of the well-documented lack of communication between clinicians and patients about CAM – i.e. most doctors and nurses had neither evidence- nor experience-based perspectives from which to talk with their patients about potential risks or benefits of CAM use. To help address this important problem, NCCAM encouraged the development of curriculum materials which could, if they were competitive with other demands for curriculum time, be introduced into the education of medical and nursing students. The basic premise was that these should be developed by hands-on academic educators working within mainstream medical and nursing institutions because they would be closest to the demands of their peers for academic rigor in their products. The last of these grants was awarded in 2003. The major outcomes and lessons learned were presented five years ago in a series of peer-reviewed articles published in Academic Medicine in October 2007 (http://nccam.nih.gov/grants/types/r25/amarticle.htm). A subsequent critique in the September 2009 issue (http://www.ncbi.nlm.nih.gov/pubmed/19707062) was addressed in a series of letters to the editor published in February 2010 (http://www.ncbi.nlm.nih.gov/pubmed/20107332).

At present, NCCAM supports only two R25 education grants to medical schools. These awards were made as part of a multi-Institute NIH initiative entitled “Strengthening Behavioral and Social Science in Medical School Education (R25).” They are not about CAM curriculum development.

@ lilady: 1) These initiatives do not support clinical practitioner training or clinical care programs. They support interdisciplinary training in clinical RESEARCH. For example, we would allow support of tuition for courses in various aspects of clinical research methodology, but not for schooling to practice a CAM discipline – or for that matter medicine or nursing. This approach is modeled directly on other NIH-funded RESEARCH training programs. 2) The four factors for priority setting relate to our priorities for research studies or initiatives. Our research training programs are about improving capacity in the field to design and implement rigorous, interdisciplinary, collaborative, research addressing those priorities. Our strategic plan (objective 4) addresses this and the broader context of capacity building. See http://nccam.nih.gov/about/plans/2011/objective4.htm.

Thank you for taking the time to respond Dr. Killen. I was hoping you would address my concerns as well, though I recognize my post was long. I believe the concerns and problems I have raised deserve and indeed warrant an equally thorough response, but in the interim since I am certain you are always pressed for time, a short response to the central questions would be greatly appreciated.

You specifically say: “we do not spend much time wrestling with questions about whether something is “specifically CAM.””

How can you square this statement with the fact that this IS, after all, the National Center for Complementary and Alternative Medicine? I would think that the first, most important, and central question would be to both rigorously define and then determine if something “is specifically CAM” for a center devoted entirely to CAM.

To do otherwise would be akin to the NIAID saying that this IC’s “ecological niche” is defined by sharing only one common denominator of “being anything that was once thought or still is thought to do with allergy and infectious disease” then saying there is not much time spent ” wrestling with questions about whether something is “specifically allergy or infectious disease”” and then studying whether miasms do affect disease states and whether spontaneous generation of animicules contributes to the disease burden of society.

I cannot understand how a center whose sole purpose is supposed to be the rigorous study of CAM yet simply “[does] not spend much time wrestling with questions about whether something is “specifically CAM.””

I eagerly await an explanation.

Thank you for responding to my comment Dr. Killen./

I’d like to refer you to the NCCAM-funded T32 Clinical Research Training Program In Complementary and Alternative Medicine at the University of Arizona…and Project # 5T32AT001287-10. I clicked on the “History” Section of that project and find that the University of Arizona has been funded 10 consecutive years (FY 2002-FY 2011) inclusive with a cumulative amount of $ 3,015,042. It appears to me that NCCAM is a constant funding stream for the grant administrator Dr. Iris Bell, M.D. to “train” researchers in homeopathy. Doing a “Google” search, I find that Dr. Bell is a consultant for a homeopathy medicine manufacturer, as well.

I now refer you to Dr. Bell’s own biography on the University of Arizona CAM website. Dr. Bell is a licensed M.D. and a licensed Homeopathy Doctor, whose recent research has been devoted to homeopathy. This is what that biography states, “She is a clinical researcher with an emphasis on systems theory as a conceptual framework and the use of psychophysiological methodologies (EEG, cardiovascular) to study the linear and nonlinear effects of homeopathic remedies and low level environmental chemicals. In specific, she has studied neural sensitization as a mechanism for amplified reactivity to environmental factors in civilians with multiple chemical sensitivity and fibromyalgia and in Gulf War veterans. She is a Board-certified psychiatrist with added qualification in geriatric psychiatry who is also licensed to practice homeopathy/alternative medicine in the State of Arizona (MD[H]).”/

Dr. David Gorski, M.D., a blogger on the Science Based Medicine website has analyzed Dr. Bell’s recent homeopathy studies and has found them to poorly designed, poorly executed, without a placebo arm and reported in some very questionable journals. I agree with his analyses./

http://www.sciencebasedmedicine.org/index.php/getting-nccams-moneys-worth-some-results-of-nccam-funded-studies-of-homeopathy/

Why has NCCAM generously funded ($ 3,000,000 plus), the University of Arizona CAM program to “train” and provide tuition to health care professionals in the practice of CAM for the past 10 years? Why didn’t the NCCAM grant reviewers question why a Homeopathy Doctor is administering this grant…if in fact two of NCCAM’s “Priorities” (Scientific Promise: How strong is the body of evidence supporting the concept? and Amenability to Rigorous Scientific Inquiry: Are there reliable and reproducible methods—e.g., diagnostics, outcome measures, biological effects, quality control, etc.?), are not met by the grant administrator?/

NCCAM supposedly wants to train doctors and nurses to recognize what CAM is…based on your reply to “David” above, “You appear to have a fundamental misunderstanding about NCCAM’s education grant initiatives, two of which have involved awards to medical schools. The first (2000-2003) was aimed at one side of the well-documented lack of communication between clinicians and patients about CAM – i.e. most doctors and nurses had neither evidence- nor experience-based perspectives from which to talk with their patients about potential risks or benefits of CAM use. To help address this important problem, NCCAM encouraged the development of curriculum materials which could, if they were competitive with other demands for curriculum time, be introduced into the education of medical and nursing students.”/

Dr. Killen, the awarding of “educational grants” to the University of Arizona and its M.D./Homeopathy Doctor grant administrator, IMO as a registered nurse who practices science based nursing, will provide these physicians and nurses with a totally biased, not-based-in-science “education” in homeopathy./

I have two suggestions for the NCCAM:/ Firstly, why not award grants to the CDC and State Health Departments’ Reference Laboratories, to conduct sophisticated laboratory tests on homeopathy “medicine”…to finally determine that water has no memory, water that has undergone multiple succussions beyond Avogadro’s number has not one molecule of the original substance diluted in the water./Secondly, I would suggest that NCCAM assign their computer technology staff to this blog’s comment section, to make it more user friendly. It is very disconcerting to have to use slash marks to delineate paragraphs and to read those same paragraphs.

@ Lilady:  Please refer to my response on 11/19 (above). The T32 mechanism supports interdisciplinary RESEARCH training and capacity building. It does NOT support clinical practitioner training or clinical care programs

@nybgrus: I appreciate the interest and questions, and want to take the opportunity to attempt to clarify a few points.

 

1) Actually, I was not attempting to define CAM. I was merely noting that the term is inclusive of many very different things and that the boundaries between CAM and conventional medicine are often gray and shifting. Given that, the four criteria help us invest our finite research resources in scientifically sound ways that address important public health needs.

 

2) Re: “So which is it? Investigation based on rigorous scientific criteria or perceived popularity?” These are not either/or criteria. We use all four but there must be a substantive scientific case, and there must be methods available to do the required research. Furthermore, the criteria about use and practice are not about “popularity.”  They are about making sure the research we support actually addresses questions of patients, consumers, health care providers, and health policymakers who most often find that use in the real world is ahead of the data.

 

For example, our priority focus on integrative strategies for managing chronic pain reflects a combination of potential scientific opportunities (identified through a combination of observations in real-world practice and emerging basic and clinical research data), available methods, and substantial public health need. Our priority on herb-drug and herb-herb interactions reflects, in part, legitimate concerns about potential problems in the real world of widely marketed consumer products, and few incentives for private sector investment in research.

@Dr. Killen, First off thank you for taking the time to respond. I know how busy I tend to be as student of medicine let alone being deputy director of an NIH IC. Also apologies for my own delay in replying - family time over the holidays took precedence. I am still left at a bit of a loss at your clarifications.  1) I appreciate that in this particular post you did not directly attempt to rigorously define CAM. In fact, from the NCCAM page on the topic “What is CAM?” the number one point below the introduction is “Defining CAM” which starts out by saying “Defining CAM is difficult…” This is understandably so as it is my contention, and the contention of others, that the entire category itself is a politicoideological one rather than anything based on any sort of scientific premise. From my perspective, which is indirectly supported by the NCCAM statements on the matter, CAM is merely all the things that haven’t yet been tested or have been and failed testing that could conceivably be applied as a medical therapy. As such I fully agree that CAM is a shifting and often gray category that overlaps with modern medicine and sometimes becomes medicine (and vice versa). I did, after all, say as much when I commented that by definition all “medicine” is “alternative” until sufficient evidence accumulates to justify incorporation into nation and world wide practice guidelines.  Where we seem to disagree is the implication of this realization. From my perspective this creates a non-starter for the NCCAM. If the 4 principles you outline are the only thing that governs NCCAM decisions for funding studies, then I see no possible justification for a unique center to tested untested claims since that is precisely what the NIH in general does. Regardless of the origin of a claim, idea, or therapy uniform criteria mean that any IC at the NIH can account for and study anything in the shifting gray of CAM. It additionally a non-starter to then include the concept of “integrative medicine.” If anything - whether CAM or not - is sufficiently investigated and deemed to be suitable for a medical practitioner to practice how can it still be called CAM? In other words, if I as a practicing physician, can look at the evidence and prescribe something to my patient I can only be practicing medicine not integrative medicine. What is being “integrated” if the standard of evidence is the same? If ACE inhibitors for hypertensive diabetics is the evidence based practice of medicine and some so-called CAM modality has the same level of evidence then what is being “integrated?” Am I no longer just practicing medicine? At what point does the therapy lose the “CAM” moniker? Does that mean if I practice the same “integrative” medicine for long enough I will one day suddenly be practicing just plain medicine without having actually changed what I do?  The methodical and rigorous definition and study of medicine and the science underpinning it has been the single greatest success of mankind’s endeavor to improve health and well being. Muddying the waters with studies of nebulous and ill defined categories of medicine, with no ratioanle for what defines something as CAM, when it loses that status, how it can be “integrative,” etc seems to me antithetical to that great success. Once again, I will stress that I am not saying so-called CAM should never be studied - but I am merely failing to see what rationale can be used to separate it from any other medical study and what utility that separation brings. 2) I also recognize that the two topics are not mutually exclusive. Of course popular use modalities can and do overlap with rigorous research criteria. But the times these don’t overlap are simply not defined nor explicitly stated.  You bring up the example of “integrative strategies for managing chronic pain.” This presumably means that it is a combination of standard modern medical therapy coupled with CAM modalities for pain treatment. Yet we have already determined that CAM is difficult to define, nebulous and changing, and that indeed the NCCAM seems to have little concern in actually defining it. But lets assume that is not an issue for the moment. How does the chronic pain management become integrative? If the other modality of treatment has evidence to support its use why would it simply not just be called medicine and used by physicians? If the other modality does not have evidence to support its use, why are we using it on patients? By analogy, if we are studying minoxidil for pulmonary hypertension and people start using it because they think it regrows hair does that suddenly make minoxidil CAM? What if we then study it for hair regrowth and determine that it actually does work that way - is it still CAM? Would I be a regular physician if I only prescribed minoxidil for pulmonary hypertension and then suddenly become an “integrative” physician when I prescribe it for hair loss? The fundamental issue I have been raising still seems unanswered to me. CAM as an entity simply does not make sense from a scientific standpoint - that is why it is so hard to define. However we know of the politicoideological origins of it and the constructs surrounding it. On the one hand a center devoted to studying and giving definitive results and recommendations for popularly used modalities is useful. But having an IC like the NCCAM that hasn’t been able to define its own subject of study, all while having funded studies like intercessory prayer to lower HIV titers and homeopathy, whilst simultaneously touting rigorous scientific principles and prior plausibility as central to the studies NCCAM does simply doesn’t jibe.  For example, in perusing the list of grants given out by the NCCAM in 2012, I am hard pressed to find anything I would call “CAM” as being funded. Investigations of botanicals in the consumption of food and weight loss seems to be purely pharmacognosy: http://projectreporter.nih.gov/project_info_description.cfm?aid=8323351&icde=14700652&ddparam=&ddvalue=&ddsub=&cr=5&csb=default&cs=ASC Immune mechanisms of CAM in autoimmune diseases is a study of specific compounds in herbs that demonstrate specific anti-inflammatory markers and pathways. This is also purely pharmacognosy: http://projectreporter.nih.gov/project_info_description.cfm?aid=8456687&icde=14700652&ddparam=&ddvalue=&ddsub=&cr=7&csb=default&cs=ASC The study of echinacea to determine immunostimulatory effects is also pharmacognosy. The further purported goals of trying to do so for flu and cold treatment also lacks prior plausibility since the corpus of evidence demonstrates that there is no clinically useful changes when using echinacea to treat a cold: http://projectreporter.nih.gov/project_info_description.cfm?aid=8298384&icde=14700652&ddparam=&ddvalue=&ddsub=&cr=42&csb=default&cs=ASC Metal chelation in athersclerosis has not only been demonstrated to be negative in the TACT trial, but has very low prior plausibility and is a priori destined to be never used in clinical medicine since any postive effect would have to be dramatic in order to outweigh the risks and onerous nature of IV chelation therapy: http://projectreporter.nih.gov/project_info_description.cfm?aid=8377896&icde=14700652&ddparam=&ddvalue=&ddsub=&cr=96&csb=default&cs=ASC And lastly, how can the use of intravenous thiamine in the context of septic shock possibly be considered CAM? Every single sentence of the grant proposal is in the terms of modern medicine and scientific inquiry and there is absolutely no reference to or implication of CAM coming into play:http://projectreporter.nih.gov/project_info_description.cfm?aid=8256604&icde=14700652&ddparam=&ddvalue=&ddsub=&cr=80&csb=default&cs=ASC In conclusion, it is my contention that CAM is hard to define, nebulous, and often changing because it is not a valid scientific or therapeutic construct but a politicoideological one rooted in pre-scientific medicine. I also posit that in the past, research by the NCCAM reflected this by studying things without sufficient prior plausibility and further that new studies are just as easily studied by any other relevant IC, mostly those that already deal with pharmacognosy. Lastly, I believe that in many cases doing clinical research on modalities with putative effects and outcomes that have not been established to be real in the first place is nothing more than tooth fairy or cargo cult science and brings nothing useful to the academic table.  The current push by the NCCAM to be more rigorous, apply prior plausibility, and have uniform criteria for analysis is admirable but seems to also make the functionality of it redundant to the rest of the NIH and simultaneously lend creedence to the notion of CAM as a valid scientific entity in health care which can be “integrated” into medicine as if by some other means than generally accepted medical practice thus giving a false imprimatur of legitimacy to CAM modalities. This is further compounded by the NCCAM studying topics which do not reasonably fall under the moniker of CAM, never mind the fact that we can’t even seem to define what that means, which is of genuine concern in terms of licensing and the practice of highly dubious treatments on the general population.

@nybgrus, Thanks for your perspectives. At NCCAM, we focus on providing more objective scientific evidence about whether specific interventions which are being integrated into Americans' health care and personal health practices are helpful and are safe. In fact, NIH values having a Center focused squarely on addressing these real world questions of consumers, health care providers, and health policy makers; and we take as a given the need to use state-of-the-art scientific methodology or technology to carry out this research.

Thank you Dr. Killen for your succinct and logical answers, you relay so much in such a short reply.I am an advocate for the Complementary side of Complementary and Alternative Medicine (CAM) and pepost a definition of what is meant by Complementary as used in Medicine.Complementary medicine: complement conventional medicine and do not purport to embrace diagnostic skills. They are used together with conventional medicine. An example of a complementary therapy is using Reiki in addition to usual care to help lessen a patient’s discomfort following surgery. Complementary medicine is different from alternative medicine.Whereas complementary medicine is used together with conventional medicine, alternative medicine is used in place of conventional medicine. An example of an alternative therapy is using a special diet to treat Cancer instead of undergoing surgery, radiation, or Chemotherapy that has been recommended by a physician.

I found your blog while doing research on alternative medicine. The concept of CAM, is refreshing and I hope the valued work does not get lost in the bickering over funding and the politics of  the medical community. I personaly believe, Prevention is the Cure. Thank you for your continued work. 

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This is just another incredibly weak defense of NCCAM, demonstrating its inability to even define CAM. 

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