Counterpoint: InspireHealth: What’s under the hood?

Two years ago, I bought a used car. I don’t count myself as an unintelligent man, but my ex­perience gave me, I hope, further wisdom and insight into the ways that we can all be inclined to believe what we want to. 

Looking back on that purchase, I feel differently about my interaction with the vendor than I did at the time. I never did get real answers to my questions about expected repair costs. When I asked about fuel consumption, I heard about saving the planet by continuing to use an already-manufactured car. My queries about the safety of rear-wheel drive in the snow were answered with a homily about how those who wound up in ditches didn’t understand performance-car steering. All of the things I was told were true, but they weren’t replies to the questions that needed answers. I’ll always love the false image I had of that car.

In many types of consumer encoun­ters, things can be advertised in ways that emphasize the most positive as­pects of what the buyer wishes were there. Sometimes a closer examination shows the reality to be quite different from what the advertising would portray.

The same can be true of programs that purport to enhance health. It is hard to criticize programs that are packaged in the language of compassion. Terms like “engagement,” “wellness,” “holistic,” “patient-centred,” and “integrated care” can all mean different things to different people. 

All of the foregoing labels can be used to describe programs that are obviously beneficial. Medical students have long been taught patient-centred “holistic” medicine in the sense of addressing the social and psychological needs of patients. Scientific medicine is at the forefront of prevention and wellness initiatives and programs that include vaccines, mental health programs, smoking cessation, clean water, physical activity, and an innumerable array of other measures that go far beyond the treatment of acute disease. 

Doctors “engage” and educate their patients every day as active participants in their care. Health au­thorities create “integrated” clinics to bring together services and professionals that do things that improve health. But in all of the foregoing, it is understood that these terms refer to programs that offer truly effective treatments and to initiatives that en­gage patients in activities that deliver real benefits.

While casual observers can be forgiven for assuming that programs bearing the foregoing labels refer to bona fide health measures, not all uses of the terms above refer to programs that enjoy convincing scientific support. There is growing concern that programs promoting unproven therapies are being sold to the public, health authorities,[1] and to academia[2] under the guise of wellness and prevention initiatives. The current parlance in des­cribing programs where alternative medicine is offered along with varying amounts of conventional prac­tices is “integrative medicine.” 

Often avow­ing a commitment to evidence-based care, these programs speak the language of choice, prevention, and empowerment, and deliver treatments that can fall well beyond the bounds of scientific medicine.[3] For example, the Arizona Center for Integrative Medicine declares, “Good medicine is based in good science,”[4] yet students are in­struct­ed in traditional Chinese medicine, ayurveda, chiropractic, and hom­eopathy.[5]

In his article “Integrated medicine: Smuggling alternative practices into rational medicine?” Edzard Ernst, the world’s foremost authority on (and critic of) alternative medicine refers to the tendency of integrated medicine proponents to use the language of love as a euphemism for the delivery of questionable treatments: “They merely seem to hijack fundamental principles (e.g., holism, therapeutic relationship, patient-centred medicine, EBM) of any type of good health care … ”[6]

Physicians have long recognized that the needs of patients go beyond the boundaries of what randomized trials can offer. And while doctors are expected to deliver evidence-based care in a compassionate way, there are opportunities to accommodate pa­tients’ spiritual, philosophical, and cultural needs in a manner that does not in­volve making medical claims that can’t be proved. For example, many hospitals have a chaplain service. Often a patient’s sense of hope, control, and quality of life is enriched when such services are available. A key part of the bargain, however, is that we do not place those figures in charge of medical decisions. The ethical boundary is important if patients are to receive the best psychological support possible without compromising medical quality. 

Arguably this line is crossed in the realm of integrative medicine. In this realm, therapies such as homeopathy (long debunked by the scientific community) are offered to patients in a context defended as patient-centred or holistic. But here, the purveyors are either making medical claims or generating invoices (or both). The hope gained can come at many prices: finan­cial cost, misinformation, and delay in seeking proper treatment. Compassionate care should also be ethical care.

Wellness has become big business. For physicians who struggle every day to provide quality care with limited resources, it can be disheartening to be the one providing real patient-centred care and prevention only to see the public’s trust diverted into fads that promise “optimum health” at a price. 

The trend is particularly concerning to primary care physicians who are frequently the targets of claims by other groups that most, if not all, of their job could be done by others—including naturopaths.[7] Introducing alternative therapies onto the primary care landscape under the guise of patient-centred engagement will not enhance the effectiveness of care provided by medical doctors, nor will it strengthen their long-term position in the medical system. 

Admittedly, we live in a libertarian society where, within limits, people have the freedom to make choices other than the most reasonable ones. This includes health care. But that does not mean that governments do not have a duty to protect other rights, such as truth in advertising, and to ensure that health care funds are spent wisely.

It is in the spirit of consumer protection and holding the government to account for spending tax dollars that we ask questions. We need to ask about decisions to direct scarce public re­sources to programs that offer unprov­en therapies and that imply that pa­tients with serious diseases will live longer as a result. We hope to get forthright answers that address the scientific and ethical questions asked—not legal threats. Science should never be put under the gun. 

The InspireHealth website is replete with messaging about empowerment, “healing journeys,” engagement, and lifestyle changes. Such packaging is intuitively attractive, but it is what lies within the package[8] that generates scientific concerns. Why, for example, are patients being directed to “naturopathic oncology,” intravenous hydrogen peroxide, homeopathic remedies, therapeutic touch, and a long list of highly dubious treatments? More troubling is the fact that patients incur charges for the provision of many of these modalities. Further questions are raised by the fact that this occurs in the context of messaging that im­plies that InspireHealth programs ex­tend life. 

For example, one press release reads: “Cancer patients from Vancouver Island and the Gulf Islands will now have immediate access to cancer care that will enable them to do better, live longer, and have an improved quality-of-life.”[9] It is difficult to be­lieve that this breathtaking claim would make cancer patients less willing to pay both the $44 510 membership and for the programs at InspireHealth. To be sure, miraculous breakthroughs do occur, but it seems a trifle bold to presume such an outcome and begin ad­vertising prior to actually having proof in hand. 

Dr Gunn has acknowledged that there is no compelling evidence that InspireHealth’s programs really extend their patients’ lives although his co-workers claim that they do.[11] In fact, the information revealed to date seems more akin to what one would expect to obtain by running a private-pay patient-centred COPD program on the seventh floor of a building with no elevator. Only the hardier and better-off patients would attend, and comparisons with the overall COPD population would seem very favorable. The “healthy/wealthy volunteer” effect is a well-known phenomenon that makes comparison with “all patients” (as Dr Gunn’s data do) essentially invalid. 

It is somewhat puzzling that Dr Gunn invokes the endorsement of the privately-funded Samueli Institute as a demonstration of how InspireHealth is a model of patient-centred care. This may not satisfy the scientific or semantic curiosity of skeptical readers who will note that the Samueli Institute is headed by people trained in “mind/body methods, spiritual healing, electro-acupuncture diagnostics, homeopathy, and bioenergy therapy.”[12] 

Dr Gunn’s lengthy exploration of the link between lifestyle and disease is engagingly written, but it does not address the concerns expressed about the effectiveness of the alternative medicine modalities employed at InspireHealth. Similarly, the fact that InspireHealth may be a nonprofit organization with salaried physicians does not answer the questions about the appropriateness of government funding for a clinic that is charging for unproven cancer therapies.[13] 

It is also problematic that the government presumably believes the programs truly have the life-saving effects advertised. If so, how can one defend charging for medically necessary services? One would hope that publicly funded cancer-treatment facilities would operate in a manner free from any perception of two-tiered access or financial conflict of interest. Perhaps there are good answers to these questions, but they have not been provided.

Patients with serious illnesses un­derstandably need hope. Doctors have long worked to accommodate this need in compassionate ways that don’t compromise clinical care. A large part of this is the asking of hard questions and demanding scientific proof before promotion. We need to encourage government to ensure that public resources go to areas of proven benefit. Government needs to look beyond the packaging and actually check the contents of programs that appeal for funding.

I’m again in the market for a car. As I pore over the auto websites, I’m dazzled by just about anything that doesn’t really matter, but I’ve come to recognize the importance of getting real answers, and I’m better at saying no to highly skilled salesmen. This time around, I’ll look under the hood.

This article has been peer reviewed.

Point: InspireHealth: Engaging cancer patients in health

References

1.    Ernst E. College of Medicine is a lobby group promoting unproven treatments. The Guardian. 10 January 2012. Acces­sed 3 May 2012. www.guardian.co.uk/science/blog/2012/jan/10/college-medicine-lobby-group...
2.    Marcus DM. How should alternative medicine be taught to medical students and physicians? Acad Med 2001;76:224-229.
3.    InspireHealth Integrated Cancer Care Guide, page 10. Accessed 5 May 2012. www.inspirehealth.ca/files/icc_guide.pdf. 
4.    University of Arizona, Arizona Center for Integrative Medicine. What is Integrative Medicine? Accessed 3 May 2012. http://integrativemedicine.arizona.edu/about/definition.html.
5.    University of Arizona, Arizona Center for Integrative Medicine. Fellowship. Acces­sed 3 May 2012. http://integrativemedicine.arizona.edu/education/fellowship/index.html. 
6.    Ernst E. Integrated medicine: smuggling alternative practices into rational medicine? Focus on Alternative and Complementary Therapies 2011;16:1-2.
7.    InspireHealth. Healing Modalities. Acces­sed 3 May 2012. www.inspirehealth.ca/programs/healing.
8.    InspireHealth. Integrated Cancer Care Guide. Accessed 5 May 2012. www.inspirehealth.ca/files/icc_guide.pdf.
9.    InspireHealth. Press release. Integrative Cancer Care Comes to Victoria. 13 October 2011. Accessed 3 May 2012. www.inspirehealth.ca/news/2011/10/19/integrative-cancer-care-comes-victoria.
10.    InspireHealth. InspireLife Membership. Accessed 3 May 2012. http://inspirehealth.ca/programs/LIFEprogram.
11.    Godkin D. Cancer clinic on a roll in empowering patients. The Medical Post. 20 September 2011.
12.    Samueli Institute. News and Information. Biography, Wayne B. Jonas, MD. Ac­cessed 3 May 2012. www.samueliinstitute.org/news/news-home/aboutus/team/86-SIIB.html.
13.    InspireHealth. Integrated Cancer Care Guide, page 66. Accessed 5 May 2012. www.inspirehealth.ca/files/icc_guide.pdf.

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Dr Oppel is chair of the BCMA’s Council on Health Promotion and an emergency physician at UBC Hospital’s Urgent Care Centre.