As I write this, I’m winging my way home from Seattle, where I just finished imbibing the latest clinical and translational science in surgical oncology (cancer surgery) at the Society of Surgical Oncology (SSO) meeting. (I find that four hour flights are a very convenient time to write posts and do other work, because otherwise the travel time would go to waste.) Given that my practice involves primarily breast cancer surgery, I attended mostly the sessions concentrating on breast cancer surgery and therapy, but, because I like to see what’s going on in other specialties, I also checked out other tracks, such as melanoma, GI surgery, and the like. Basically, physicians attend meetings like the SSO meeting for several reasons: to learn the latest research in their specialties, to meet up with colleagues and friends form across the country (all over the world, actually), and, of course, continuing medical education (CME) credits.
Although the requirements vary from state to state, all states require that physicians obtain a certain number of CME credits every licensure period in order to renew their medical licenses. Also, although again the specific requirements vary by specialty board, in order to retain board certification physicians and surgeons must meet certain specific CME credit requirements. Indeed, a particularly annoying new requirement is that a certain number of these credits be “MOC” credits, where MOC stands for “maintenance of certification,” a particularly contentious topic among physicians. Basically, in surgery at least, an MOC credit means that the CME activity has to have a post-test of some sort that the participant must pass in order to claim the credits. The American Board of Surgery, for example, requires, in addition to the usual CME requirements, 60 of these “higher level” credits every three years, to be documented—you guessed it—every three years. Personally, I find these sorts of credits to be a major pain and not particularly helpful when it comes to actually learning what the CME activity is supposed to be teaching, but that’s just me. However it’s done though, the processes by which CMEs courses are accredited is a big deal in the world of medicine.
The number one defender of quacks perceives a threat
The reason I started out with a little primer on CME credits is because there is a form of CME that I very much don’t like. I bet that you can probably guess what it is. Did you know that doctors can receive CME credits for studying pseudoscience and quackery? Regular readers won’t be surprised, as we’ve touched on this problem before (and, rest assured, I will discuss it again momentarily). After all, if we physicians have to imbibe a certain number of CME credits in order to maintain our medical licensure and specialty board certification, we’d like the information that we’re expected to be exposed to and learn to be high quality, science-based information, preferably recent updates in our specialties, so that chasing CMEs isn’t just a chore but a way that actually helps us to practice according to the latest science- and evidence-based standards. It’s the minimum that our patients deserve.
What got me started on this topic over the weekend was a post by someone we’ve met before, a post from the “other side.” The man writing the post is Richard Jaffe. You might remember him as the longtime attorney for a man who has been a frequent topic of this blog, Dr. Stanislaw Burzynski, the Polish expat physician based in Houston who has been administering peptides he calls “antineoplastons” (ANPs) to cancer patients for four decades now, with authorities seemingly unable to stop him. Jaffe might well have ceased to be Burzynski’s attorney last year, thanks to a falling out based (apparently) on Burzynski’s failure to pay his legal bills accrued during his defense against the Texas Medical Board. (Unfortunately, Burzynski got off lightly yet again, even without Jaffe shepherding his defense across the finish line.) Their falling out aside, over more than two decades, Jaffe defended Burzynski from all threats, be they from the FDA or the Texas Medical Board. Indeed, he was the architect of a scheme that allowed Burzynski to set up over 70 dubious clinical trials of ANPs, a strategy he’s been milking for 20 years to continue to administer ANPs without being prosecuted, despite ANPs lacking FDA approval. Even though he and Burzynski appear to have parted ways, though, Jaffe is still very much into defending quackery, as is easily verified by a perusal of his blog. Oh, and he’s pro-“vaccine freedom”—cough, cough, antivaccine—too.
Right now, Jaffe is not pleased, and if he’s not pleased that means I probably should be pleased. He expresses his displeasure in a post entitled “The next big CAM battle is here, and it’s ugly.” Guess what the battle is about?
CME:
CAM or integrative medicine doctors have had their problems with the state medical boards. And CAM organizations have had their run-ins with governmental agencies. However, the groups have always survived in large part because they have had a steady income from membership dues and from their annual conferences, where their members learn the latest and greatest from their thought leaders. But the CAM organizations’ income stream is now in jeopardy, and thus so is their existence, based on what looks to be well-planned, systematic effort to put CAM groups out of business, and stop the dissemination information about CAM therapies.
AND THAT MY FRIENDS IS A VERY BIG DEAL.
I can’t help but wonder if Jaffe really wanted to start his post that way. Think about it. He’s just basically admitted that CAM organizations exist on membership dues and by hawking their conferences as a source of CME. But wait, you say, isn’t that what all professional societies in medicine do? Yes, but that’s usually not all, and the big difference is that legitimate professional societies don’t peddle pseudoscience. CAM (complementary and alternative medicine) organizations do. Being able to offer CME provides a patina of legitimacy, too, because the organizations that offer CMEs have to meet standards laid down by the Accreditation Council for Continuing Medical Education (ACCME). The AMA, which certifies a large proportion of the CME credit programs in the US, requires that the activity meet all the requirements by either the ACCME or a recognized state medical society (SMS).
So what is this horrific threat to CAM or “integrative medicine” (IM) CME? Jaffe is more than happy to tell us:
For months, at least two CAM groups have been under review/ investigation by the primary private CME accrediting company, the ACCME (Accreditation Counsel for Continuing Medical Education). Recently, the ACCME has determined that a significant portion of the groups’ prior year’s CME courses does not meet various ACCME standards. ACCME is demanding that everyone involved in these courses be informed that:
“they were presented invalid information….”
and that the groups:
“instruct them [everyone] to avoid making any clinical decisions for testing and/or treatment based on what was presented, and direct the registrants to accurate and valid sources of information for the problems or systems presented.”
I should point out that this “incorrect” information came from some of the most accomplished, respected and published thought leaders/teachers in the CAM community. These folks have been giving CME courses without incident for decades.
My first thought upon reading this passage was that this is exactly the problem. Physician “thought leaders” in integrating quackery into medicine have been giving CME courses without incident for decades. My second thought was a retort to Mr. Jaffe, “Gee, you say this as though it were a bad thing.” My third thought was to wonder which two CAM organizations have run afoul of the ACCME, and how can we as skeptics get the ACCME to look into other CAM organizations running pseudoscientific conferences? After all, we’ve been complaining about the ACCME accrediting CAM conferences for CME for years, which makes the next passage in Jaffe’s little screed music to my ears, if it is indeed true (remember, this is Jaffe who is relating this story):
Further, in terms of future CME courses at their conferences, ACCME has informed these groups – and this is the key to understand what this is all about – that:
“recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients and all patient care recommendations must conform to evidence emanating from guidelines and data that meet generally accepted standards of experimental design, data collection, and analysis.”
In short, ACCME is trying to require these groups to only teach mainstream medicine! This is crazy and a huge deal!
I actually half agree here. Yes, this would be a very big deal indeed if the ACCME is actually starting to enforce some scientific rigor on CME conferences seeking its accreditation. No, it would not be “crazy.” It would be a long-overdue course correction, something the ACCME should have done at least a decade ago, if not much longer. You don’t believe me? Let’s take a look at what sorts of “courses” have received certification by the ACCME. Of course, it’s not just CAM organizations that get these courses certified. It’s some heavy hitters in the world of academic medicine too, an outgrowth of the problem of “quackademic medicine” (the integration of quackery into academic medicine) that has taken root in dozens of medical schools and academic medical centers across North America.
“Quack!” goes the CME course
There are a number of courses and conferences that offer CME credits for learning about “integrative medicine” or CAM. For example, Steve Novella once discussed how physicians can receive CME for acupuncture through Brigham and Women’s Hospital and Harvard Medical School’s course on “structural acupuncture,” as have others. I can’t help but note that the webpage is no longer there, but thankfully the almighty Wayback Machine still has it. Not that it matters that much, because, alas, Harvard is still offering the course. Only this time it’s called the The International Structural Acupuncture Course for Physicians: A Palpation Based Approach. Basically, at one of the most respected academic institutions in the world, you can take a course that spans nine months and requires you to come to Boston five times for live “hands-on” teaching about meridians and the latest quackademic studies trying to show that acupuncture “works.” Somehow, I bet that they’ll forget to mention how it doesn’t matter where you stick the needles or even if you stick the needles in because acupuncture is all an elaborate, theatrical placebo.
You can earn a lot of CME credits, too. The Harvard acupuncture course as currently constituted offers 300.25 (why the quarter?) CME credits, of which “182 hours will focus on the theory and science of acupuncture and 118.25 hours will involve live, clinical experience.” The course is run by Joseph F. Audette, MD, and an acupuncturist, David Euler, L.Ac., who in previous fliers was described as a “graduate of the Tristate Institute of Traditional Chinese Medicine in New York” and “a recognized authority in utilizing dry needling techniques for the treatment of pain.” Mr. Euler is described as a “recognized authority on modern Japanese styles of acupuncture and its integration with traditional Chinese styles and Western medical practice.” What amused me is that there is an actual professor of anatomy, Frank Willard, PhD, included in the course faculty, but he is not Harvard faculty. Rather, he is faculty at the College of Osteopathic Medicine, University of New England. Personally, as I did when I discovered that Georgetown University was “integrating” the teaching of acupuncture meridians into its first year anatomy courses, lo, these many years ago, I wonder just what the heck Prof. Willard will say about the anatomy of acupuncture, given that it’s based on a prescientific understanding of the human body. Now there’s a lecture I’d love to sit in on, if only for the yuks.
It’s not just Harvard, and it’s not just acupuncture, either, unfortunately. Harriet Hall has lamented how the American Academy of Family Physicians (AAFP) has succumbed to the quackery embedded “integrative medicine” in its CME program. Basically, the AAFP started including various “integrative medicine” modalities in its CME offerings without skepticism or critical thinking.
Then, in my own specialty, there’s the Society for Integrative Oncology (SIO)—which really, really, really does not like me—and its annual conference, which this year will be held in Chicago. The schedule and speakers haven’t been announced yet, given that the conference is in November, and its overarching goals are the usual CAM pabulum, but we can look at past conferences; e.g., when Dr. Francis Collins was the keynote speaker at the 2011 SIO conference. Let’s just say that, in addition to the usual science-based medicine modalities rebranded as somehow “alternative” or “integrative” (e.g., diet, exercise, and lifestyle), there was a whole lot of pseudoscience as well, plus a lot of “spirituality” thrown in, allowing the SIO to be far too generous in its assessment of reiki and other “energy medicine” modalities (or, as I like to call them, faith healing). You can get an idea of the sorts of activities that the SIO allows from “integrative oncology” guidelines for breast cancer that it published two years ago. Let’s just say that the science was…weak.
Of course, the SIO objected mightily when I published a perspective article on integrative oncology two and a half years ago. In particular, it objected to devoting so much verbiage to homeopathy in my article, where I used it as an example of how prior plausibility is so important in clinical trials. (Ironically, I expanded the section on homeopathy based on reviewer comments; the original version had a much shorter section on this, The One Quackery To Rule Them All.) “Oh, no,” Great Minds in SIO protested. “We know homeopathy is pseudoscience. We are evidence-based! We would never, ever recommend the use of homeopathy, and it was a horrible distortion on your part, Dr. Gorski, to imply otherwise.” I shut that down with one observation (well, three). First, SIO allows naturopaths in its organization. Second, homeopathy is an integral part of naturopathy. It’s required in the curriculum of naturopathy schools and is included on the NPLEX, the test used for licensure in states that license naturopaths. So most, although not all, naturopaths use homeopathy. Finally, one of the authors of the SIO’s breast cancer guidelines at the time had a clinical trial of homeopathy registered at ClinicalTrials.gov.
This is the sort of organization that offers CME for CAM conferences.
Mr. Jaffe has a plan
Based on learning that the ACCME might be cracking down on accrediting CME courses and meetings that promote pseudoscience, Mr. Jaffee is afraid:
Beyond these two professional groups, a disease based group has recently been informed that its CME status for future conferences has been rescinded by its CME intermediary. The intermediary denies that it received any pressure or orders from ACCME.
Three CAM groups which have previously received ACCME course certification without any undue problems who in the last few months have had their prior CME course approval rescinded and/or their future CME approval withdrawn or placed in serious doubt.
Is this all a coincidence? Not a chance in hell.My guess is that more of the same has or is going to happen to other CAM groups.
I certainly hope so. After all, I’ve seen examples as egregious as the offering of CME credits for a course offered at that quackiest of quacky “autism biomed” quackfests, Autism One. Oddly enough, I would not favor retroactively rescinding CME credit, which would harm physicians who attended courses in good faith, believing they were offering CME credits. However, I would very much favor the ACCME shutting down CME credits for future CAM and integrative medicine conferences teaching pseudoscience like reiki, acupuncture, homeopathy, and the like.
Jaffe is also curious how this horrible (in his mind) state of affairs came about:
Someone out there has to know something or know someone who knows something about how this came about, and who or what group is behind it. (My guess is that ACCME is the vehicle not the originator.)
I think there is a smoking gun out there, and if we find it, we can probably reverse ACCME’s decision quickly, so my suggestion is that all the CAM groups and interested parties get the word out to search for the smoking gun.
How much does anyone want to bet against my prediction that in a future post he announces that he’s discovered that big pharma or the FDA was behind this move on the ACCME? Yeah, you’re probably wise not to take that bet.
Not surprisingly, Jaffe’s plan is to go straight to state legislators, because state laws generally require ACCME accreditation of CME credits used for state medical licensure:
In all the big CAM states like Texas and California, I know there are legislators who are pro CAM. My suggestion would be to identify who they are (not hard in Texas). I think the boards in a few of these states need to hear from some legislators about how ACCME is undercutting board rules (in Texas) or the CAM statutes (like in California).
These legislators should copy ACCME on their concerns expressed to the boards. If one of them is on a legislative health committee, even better. Better still would be for a couple states to start an investigation on ACCME’s motives. Maybe even an invitation to appear at a specially called hearing. Legislators can hold hearings for all kinds of reasons. So can federal legislators. I think with all the politically connected CAM docs out there, mulitipled [sic] by their politically connected patients, well I think there’s a heap of trouble that could be stirred up for ACCME.
It doesn’t have to happen in every state, or even many states, just a couple of the big ones. The story is going to get out, and questions are going to be raised. The widespread dissemination of ACCME’s action might even turn-up that smoking gun I mentioned earlier. And once the nefarious motive and scope of the conspiracy publicly surfaces, I think ACCME will be forced to rescind its actions. So, we need to shine some light on these jokers.
Actually, it’s the CAM groups who are promoting the teaching of this sort of nonsense who should have some light shined on them.
Still, this is classic Jaffe. It’s the very technique he used to strike back in favor of his client Stanislaw Burzynski against the FDA. He’d use his connections, such as to Rep. Joe Barton, who in the 1990s would regularly haul the FDA Commissioner in front of his committee to demand why the FDA was “persecuting” Burzynski. It worked, too. There are a lot of quackery-friendly (or at least sympathetic) legislators out there, particularly in Texas, where appeals to “health freedom” are powerful enough to fuel a resurgent antivaccine movement. Then, of course, California is home to all manner of quacks.
Jaffe’s plan might just work.
The real problem
I have no idea what two CAM organizations are the ones running into trouble with the ACCME over their CME offerings, and, to be honest, it doesn’t really matter that much. The reason is simple. Jaffe is throwing red meat to his base over a perceived threat that is really not a huge threat at all. Yes, there are CAM groups that hold dubious conferences, and, yes, they are a problem. However, they’re not the biggest problem. They are not existential threats to medicine as a science-based discipline.
The most serious threats to medicine as a science-based discipline do not come from most CAM groups. Rather, they come from within medical academia itself. Do you think that Harvard had any trouble getting the ACCME to accredit its CME offering for its acupuncture course? I highly doubt it did. Similarly, I really doubt that quackademic medicine conferences offered by high profile, respected medical schools and academic medical centers have trouble getting the ACCME to accredit the CMEs for their courses, either. The same thought applies to the AAFP; I’d be surprised if there were any pushback by the ACCME against its inclusion of dubious CAM in its “integrative” offerings. The list of academic medical centers offering dubious CAM courses for CME appears to be growing, as well, with examples like the aforementioned Harvard, the University of Arizona, the University of Florida, The Ohio State University, the University of Michigan, and many more. Add to that the infiltration of CAM into medical school curricula, the infiltration of integrative medicine residencies, and even board certifications, and Jaffe’s getting the quacks riled up over a minor issue.
The real problem is not that the ACCME is targeting two CAM organizations, if it’s really doing anything of the sort. The problem is that it’s not targeting all the universities that offer courses integrating quackery with medicine and that medical academia is embracing CAM in its medical school curricula and residencies, two areas where the ACCME has no authority. The ACME really needs to go much, much farther in enforcing scientific rigor in its CME accreditation process, but, even if it does that, it won’t mean much if the LCME (which accredits medical schools) and the ACGME (which accredits residency programs) don’t do the same.