Just yesterday, Steve Novella decried the alternative medicine propaganda that “has been slowly leaching into the medical culture” because it “weaken[s] our collective dedication to a rigorous science-based standard of care.” In addition to delay or avoidance of effective treatment, opportunity costs, financial and psychological harm, and overall promotion of unscientific medicine,
[p]erhaps the most insidious form of harm, however, comes from the erosion of standards within the medical profession. Medicine is only science-based and ethical if its practitioners are science-based and ethical. There is a standard of care within medicine to maintain a minimum of both quality and ethics.
This integration of alternative medicine, that is, unproven, disproven and/or frankly fantastical diagnoses and treatments, into conventional medical practice is otherwise known as “integrative medicine.” Surprisingly, in a recent article, two practitioners of, and advocates for, integrative medicine agree that quality and ethics are problematic in their chosen “specialty.” The article is full of the uncritical boosterism that characterizes integrative medicine and only tangentially acknowledges that a lack of evidence of safety and efficacy might be an issue. To their credit, however, it does seem to be slowly dawning on them that, in Mark Crislip’s immortal words:
when you integrate cow pie with apple pie, the cow pie is not made better, the apple pie is made worse.
We’ll return to the authors’ particular take on the infestation of poor quality of care and unethical behavior in integrative medicine in a moment, but first, let’s briefly introduce the authors and the journal in which their article appears.
The article, described as a “commentary from the JCAM [Journal of Alternative and Complementary Medicine] partnership with the Osher Collaborative for Integrative Medicine,” was written by Melinda Ring, MD, and Sandy Newmark, MD. Ring is with the Osher Center for Integrative Medicine at Northwestern University’s Feinberg School of Medicine and a member of the Board of Directors of the American Board of Integrative Medicine (ABOIM), the organization offering a dubious board certification in integrative medicine. Newmark is with the Osher Center for Integrative Medicine at the University of California San Francisco.
Both are full-throated proponents of integrating unproven or disproven treatments into medical practice. Ring has written, for example, that
Acupuncture can balance glucose and insulin sensitivity, assist in weight loss, reduce inflammation, balance hormones, and induce ovulation in patients with PCOS.
Newmark admits using “nonstandard” testing sent to “specialty labs” in his treatment of autism spectrum disorder, as well as “biomed” treatments (including gluten-free, casein-free diets, a “non-supported as a treatment for autism“), herbs, dietary supplements, and Traditional Chinese Medicine, his rationale apparently being that if evidence-based treatments aren’t available, the physician should feel free to abandon evidence-based medicine.
The editor of the Journal of Alternative and Complementary Medicine is John Weeks, who has no background in science or medicine of the type that would be expected of a medical journal editor. He is a relentless cheerleader for integrative medicine. (And no fan of this blog.) His loyalty is such that, in his Editor’s Note, he can’t even bring himself to accurately describe Ring and Newmark’s article, saying their “focus is on the mosaic of integrative practices of medical doctors,” completely ignoring, as we shall see, their actual focus on what they see as the primary risk to patients from integrative medicine practitioners. The JCAM‘s editorial board is chock full of those who promote integrating unproven/disproven/fantasy treatments, such as homeopathy, acupuncture, and functional medicine, including Dana Ullman, Iris Bell, Wayne Jonas, Heather Boon, Richard Niemtzow, Patrick Hanaway, Suzanna Zick, and Gloria Yeh.
In the title of their article, Ring and Newmark ask:
“Practice Drift: Are There Risks When Integrative Medicine Physicians Exceed Their Scope?”
Despite their enthusiasm for unproven/disproven treatments in their own practices, the authors admit to misgivings about integrative medicine:
In response to the growing number of providers seeking a new practice model, individual clinicians, educational organizations, and businesses are increasingly providing trainings and certifications in areas such as functional medicine, antiaging medicine, regenerative medicine, and integrative medicine. These trainings are typically offered as brief in-person courses or online modules. Some are promoted as profitable, turn-key sources of revenue [citing “Functional Medicine University” as an example of the latter].
While these proliferating continuing education and certification opportunities can provide expanded options for providers and patients, they often lack third-party verification of their standards through organizations that accredit credentialing bodies. They may enroll medical doctors from any medical specialty, and typically lack clinical oversight in the practical application of diagnostic testing and treatments to real patients.
In this context of practice expansion for clinical, business, or mixed reasons, providers from disciplines across the board risk going beyond their primary training in unethical or dangerous ways.
Which made me wonder: What sort of practitioner did they expect would be attracted to integrative medicine and its rejection of science (and even scientific plausibility) and evidence as the appropriate measure of a treatment’s efficacy and safety? Did they not anticipate that the embrace of quackery would invite those prone to ethical lapses?
In fact, they need look no further than two luminaries of the integrative medicine movement as excellent examples of their concern. Andrew Weil, MD, the main instigator behind the creation of a board certification in integrative medicine, did a one-year internship but did not complete a residency in anything. Mark Hyman, MD, functional medicine guru, did a family practice residency and has no university-level education in nutrition.
However, the authors quickly disavow any criticism of these practices per se:
The purpose of this article is neither to censor any particular group of providers nor to advocate for unreasonable restrictions on integrative practices.
The growing complexity can be viewed as a positive in many ways, with greater access for patients and increasing diagnosis and treatment options for medical doctors who are interested in expanding their care options and approaches.
Thus, their issue with functional medicine, antiaging medicine, regenerative medicine (a legitimate specialty hijacked by stem cell quackery), and integrative medicine is not that these practices lack evidence of safety and efficacy to the point of rank quackery. It is that their practitioners may not have sufficient education and training to use the unproven or disproven diagnostic methods and treatments they typically employ.
The impression that they are unconcerned with evidence-based medicine, as opposed to the practitioner’s level of training in alternative medicine, is reinforced by three examples they give of a physician’s moving outside his training and scope of practice, a phenomenon they admit “seems particularly prevalent in the practices of medical doctors who have chosen to enter into complementary and integrative medicine.”
- A psychiatrist, who has no training in infectious diseases and endocrinology, completes functional medicine training and Lyme-literacy courses. His practice includes specialized testing, diagnosing patients with “adrenal fatigue,” parasites, and “chronic Lyme” and prescribing, among other treatments, antibiotics and “extensive supplements.”
- An “integrative gynecologist” prescribes bioidentical hormones not only for women, but also children and men, “populations not included in his postgraduate residency.”
- A primary care physician does some self-study and takes a weeklong class and “rebrands” herself as an integrative consultant.
Ring and Newmark fail to note that “chronic Lyme,” parasites, and “adrenal fatigue” are popular fake diagnoses. They also fail to explain that “bioidentical hormones” is a marketing, not a medical, term, and are of both unproven effectiveness and questionable safety. To them, the problem is whether
simply having graduated medical school [should] entitle a physician to practice in any area of medicine, whether or not a few short trainings are added.
This is an odd criticism coming from Ring, who sits on the ABOIM. The ABOIM does not require board certification in any particular specialty to become board-certified in integrative medicine. It is only recently that the ABOIM required a “fellowship” (none of which are ACGME-accredited, as best I can tell) in integrative medicine. Even then, a fellowship is not required if the physician has a degree from a naturopathic, chiropractic, or oriental medicine school. Prior to these requirements, all an applicant needed was to be board certified or board eligible in anything, have a license to practice medicine, and rack up 500 points of “documented training and experience,” including at least one year of clinical experience, worth up to 250 points and could be documented with a couple of short letters. The rest could be gotten by taking the very type continuing education courses the authors complain about.
The authors identify four risks of inadequate training, two of which are real and two of which are of concern only to those who buy into integrative medicine ideology. They correctly point out that patients may be harmed by inappropriate or missed diagnoses and incorrect treatment and “subjected to significant financial risks from paying for excessive laboratory testing and other costs”. They also correctly point out the risk of malpractice liability and board discipline for practicing outside one’s scope.
In fact, it was not too long ago that a ABOIM board-certified integrative medicine physician had his license revoked by the Florida Board of Medicine when a young patient died under his care for lack of treatment of her cancer. He rejected the cancer diagnosis of several experts in favor of those favorite integrative bugaboos, allergies and hormonal issues. Several physicians have been disciplined for their substandard care based on their quack diagnosis and treatment of “chronic Lyme.” And just this week, Kaiser Health News reported on the discipline of a California physician, Prudence Hall, for her inappropriate prescription of “bioidentical hormones,” a standard but unproven “integrative” treatment. She also failed to diagnose a cancerous uterine tumor in one patient despite performing numerous ultrasounds, which she was not qualified to read. The news report noted that another California physician had previously lost his license for inappropriate “bioidentical hormone” prescribing.
The authors also say that practice “drift” is “a risk to the credibility of integrative medicine”, which, again, they identify solely as a function of lack of training, ignoring the lack of evidence of safety and efficacy of the practices that define the field:
Although integrative medicine steadily gaining acceptance, there is still much doubt and skepticism. Then providers treat outside of their scope of practice, negative judgment about the particular provider involved could generalize to negative impressions of the entire field of integrative medicine.
As an example, one of the authors cites personal experience in the reaction of infectious disease experts to the IV antibiotic treatments employed by the psychiatrist treating “chronic Lyme”. Somehow, I doubt that lack of training was the ID experts’ only objection.
The authors cite no evidence supporting the notion that integrative medicine is “steadily gaining acceptance”, although, anecdotally, it appears to be true, as Steve Novella discussed yesterday. It is also true that there is “much doubt and skepticism”, well-deserved in SBM’s view, although the main critics seem to be limited to bloggers, either in the blogs themselves or in the medical literature (also here and here). Otherwise, academic medicine appears to be fully on board and it’s crickets from the rest of the medical community.
Finally, practice “drift” risks “alienation of complementary providers”, something the ABOIM has already managed to accomplish by its very existence. In any event, the authors cite, as an example, licensed acupuncturists, who have far more training than medical doctors in acupuncture. Once again, it’s the lack of training in theatrical placebo that is the problem, not the use of theatrical placebo itself.
As a remedy for integrative physicians exceeding their scope of practice, the authors prescribe various remedies, like acknowledging inexperience to patients, patient resources on identifying “red flags” on provider practice websites and materials (actually, these already exist – also here and here – but their warnings would eliminate too many integrative practices), ethics and scope of practice modules in fellowship and certification programs (apparently, this not standard practice or they wouldn’t have mentioned it), and medical board discipline.
In the end, what the authors really want to have their gluten-free cake and eat it too.
As the [integrative] medical field grows up, it must be considered how best to guide it toward its best self – one who recognizes the risks of “off-label” practice and ensures that safeguards are in place to prevent harm, while balancing the need for practice autonomy and individualized clinical exploration and care.
In other words, they want to ensure “safeguards” to “prevent harm” while, at the same time, rejecting the one method that actually ensures that an adequate risk-benefit analysis is performed for any diagnostic method or treatment: the rational application of science to the practice of medicine. “Practice autonomy” and “individualized clinical exploration and care” are, of course, dog whistles for rejecting science-based medicine, as evidenced by the authors’ studied refusal to criticize their “specialty” for its signature feature: the embrace of, at best, unproven diagnostic methods and treatments, and, at worst, outright quackery. Recognizing “the risks of ‘off-label’ practice” is welcome, but it ignores the most important risk to patients and the practice of medicine from integrative practitioners: the abandonment of science as benchmark for the standard of care in medicine.