A board certification in woo is born?

I’ve been harshly critical of the entire concept of “integrative medicine” (IM), which has over the last few years nearly supplanted the former term used for non-science-based medicine or medicine based on prescientific ideas represented as though it were scientific medicine, “complementary and alternative medicine” (CAM). Indeed, just last month I pointed out how IM is far more about marketing than it is about science or medicine, and over the last few years I’ve been particularly harsh on the concept of “integrative oncology,” which is actually being promoted as a legitimate “subspecialty” of IM. Despite the utter lack of a rationale based on science or the scientific basis of medicine, IM has, alas, been making inroads into academic medical centers, where I tend to refer to it with the unapologetically disparaging term “quackademic medicine.” Even worse, now, increasingly, such prescientific, vitalistic pseudoscience and mysticism have been insinuating their way into community medical centers as well under the rubric of CAM, IM, or whatever the nom du jour is.

Arguably, the physician who has done more than any individual to promote the quackification of science-based medicine is Dr. Andrew Weil. (At least, I can’t think of any single person who’s done more during his lifetime to promote the infiltration of quackery into medicine. Readers are free to chime in if they know of someone who could challenge Weil for the title of King of Quackademic Medicine.) As I pointed out the last time I discussed him, Dr. Weil doesn’t really like science-based medicine. Oh, no, he doesn’t like it at all. Unfortunately, he’s been very successful in promoting quackademic medicine. He’s also arguably been the single most successful person at legitimizing what used to be viewed as quackery. Master of the domain of “integrative medicine,” having formed a model of an “integrative medicine in residency” that’s attached itself like kudzu to medical quackademia, all from his desert redoubt at the University of Arizona, Dr. Weil has now announced his intention for the next phase of his “integrating” pseudoscience with SBM. I learn this from The Integrator Blog, which has as a recent headline Special Report: “Strategic Change in Direction” as Weil’s Arizona Center Commits to Creation of American Board of Integrative Medicine:

In a major strategic shift, the University of Arizona Center for Integrative Medicine (ACIM) has announced that it will lead the creation of a formal specialty for medical doctors in integrative medicine. ACIM, founded by Andrew Weil, MD and directed by Victoria Maizes, MD, is in dialogue with the American Board of Physician Specialties toward establishing an American Board of Integrative Medicine. They are collaborating with leaders of the American Board of Integrative and Holistic Medicine (ABIHM). Here is the ACIM announcement, a statement from two ABIHM leaders, a brief interview with Maizes and the list of 18 founding Board members. Is this the right strategic choice? What impact will this have on integrative medicine and the broader integrative healthcare movement?

At first, I wasn’t aware that this was, in fact, any sort of “strategic shift.” Being recognized as a distinct medical specialty, complete with standards for an educational curriculum during residency or fellowship and board exams for certification, is the ultimate validation of legitimacy as a medical specialty, at least as far as medical education, regulation, and the overall medical world goes. If Dr. Weil could achieve this, it would become virtually impossible to eliminate woo from medicine, at least in the United States. It would be codified as a medical specialty by one of the three major certifying boards that certify physicians as being qualified in specific specialties, in this case the American Board of Physician Specialties (ABPS). The other boards include American Osteopathic Association Bureau of Osteopathic Specialists (which only certifies doctors with the DO degree) and the American Board of Medical Specialties. Of these, the last one, the ABMS, is the only board that matters in most states. For instance, the board under which I’m Board-certified in Surgery is, appropriately enough, the American Board of Surgery. The ABS is the umbrella board that certifies surgeons in General Surgery, Vascular Surgery, Pediatric Surgery, Surgical Critical Care, Hand Surgery, and others. In addition, the ABMS certifies 23 other specialties, including Anesthesiology, Emergency Medicine, Internal Medicine, Pathology, Pediatrics, and many others. These boards set up minimum standards for knowledge and skills and devise tests and documentation necessary to be “certified.” Generally, board certification requires an MD or DO degree, completion of an accredited residency in the relevant specialty, and the passing of written and oral examinations. Some specialties require documentation of practice results (such as plastic surgery, which requires a case log, complete with “before and after” photos to demonstrate a surgeon’s proficiency at various categories of plastic and reproductive surgery).

One thing that our non-U.S. readers might find odd (and that a surprising number of U.S. residents don’t even know) is that there is no national licensure of physicians in the United States and never has been. Each state writes its own laws and has its own medical board. It is also necessary to understand that board certification is an entirely separate process from state licensure. In fact, you don’t have to be board-certified to have a medical license; in most states, all you have to have is a medical degree and a year of postgraduate training (internship). Indeed, I got my first medical license during my residency, long before I ever achieved Board certification in Surgery. In fact, in the old days, it was entirely possible to practice for an entire career without being board certified, and many physicians did just that. There are even a few older physicians left who still practice without board certification, having in effect been “grandfathered” into the system, but their numbers dwindle every year due to retirement and death. These days, however, if you want to be on the staff of a hospital or be an approved provider on an insurance plan, you pretty much have to be board certified in your specialty. If you’re not, you’ll be permanently consigned to a lower tier of practice, such as moonlighting jobs or jobs as “house physicians” who cover patients in hospitals without residents during nights and weekends. Exceptions are sometimes made in rural hospitals desperate for physicians, but even these exceptions are rapidly disappearing. Basically, in order to practice as a fully independent physician in the United States and be reimbursed by government and insurance payers for your efforts, you have to be board-certified or board eligible.

So why would Dr. Weil want to change course and seek a form of board certification for IM? Here’s how Dr. Weil himself describes the reason in the University of Arizona press release:

We are writing to let you know about an important decision that we recently made — a decision that represents a strategic change in direction for our Center. For many years we have resisted the idea of board certification in Integrative Medicine (IM). We have always believed that the principles and practices of IM should inform all specialties, rather than be developed into a new field. In other words, that dermatologists, surgeons, and family physicians alike all need to learn the principles of nutrition and mind-body medicine, and to value the innate healing capacity of the body. We still hold that belief.

But…

Earlier this year we approached the American Board of Physician Specialties (ABPS) to discuss creating a board in IM. We did so for many reasons; chief among them was to help patients discern who truly has training and expertise in IM. It is now popular in the marketplace to say you practice IM — yet anyone can say so, whether they studied for an hour, a weekend, or ten years.

This is actually pretty hilarious in its own way. This is almost the same reason that virtually every subspecialty that has ever applied to have a board certification process has cited as its reason for doing so. The reasons such a consideration almost inevitably come down to protecting the reputation of the specialty by defining who is and is not a member of the specialty. There’s also more than a little turf protection in forming such specialties, a measure of excluding the riff-raff. Apparently Weil’s desire to infuse all medical specialties with his woo just can’t stand up to the cold, hard reality of how medicine really works in the U.S. So now he wants his own boarded specialty, because he realizes that the only way IM will ever be taken seriously by patients (and, far more importantly, third party payers) is for it to be its own boarded specialty. Never mind where the board certification comes from, which currently is a highly dubious “board.”

The actual board that would be overseeing any board certification in IM would be, according to the press release the American Board of Integrative Holistic Medicine (ABIHM). This board was first formed in 1996 as the American Board of Holistic Medicine. A quick perusal of its FAQ regarding certification reveals a number of interesting things. First, the only qualifications necessary to sit for the ABIHM boards are (1) and MD or DO; (2) a current medical license in the U.S. or Canada; and (3) board certification or board eligibility in a specialty accredited by the Accreditation Council for Graduate Medical Education (ACGME). That’s it. No training program. No residency program in “holistic medicine,” “integrative medicine,” “complementary and alternative medicine,” or anything at all. You could be a radiologist, pathologist, or other specialties that don’t generally directly care for patients. In other words, if you’re a physician who’s board-certified or board-eligible in any currently recognized medical specialty, all you have to do to be board certified in IM is to take the test and pass it, which 85-90% of those who take it do on the first try and those who don’t can try again. Indeed, the ABIHM sends applicants its Course Curriculum Study Guide (CCSG) and recommends that applicants “be very familiar with the material in the CCSG before you sit for the exam.” The ABIHM also provides a review course but doesn’t require it.

You know, it’s half tempting for me to register for the exam and see if I can become a board-certified practitioner of IM. There’s nothing in the ABIHM’s rules that says I can’t do it, and I’d get access to the review materials, which, I suspect, would be most illuminating. For example, how much homeopathy would I be expected to know? Acupuncture? Would I have to memorize meridians and acupuncture points? Would I have to know how to do reiki? Inquiring minds want to know, although this inquiring mind doesn’t want to know badly enough to pay the $800 it would take to register. Perhaps there are other, richer physicians who might want to go that route. If so, the deadline to get the cheap rate to take the test on November 12 is today.

John Weeks of The Integrator Blog describes a “town versus gown” divide in IM, in which the “townies” (i.e., the private practice, non-academic IM practitioners) very much wanted some sort of board certification, while the “gowns” (i.e., the centers of quackademic medicine) did not. He doesn’t really elaborate on the reasons for this conflict (when in doubt, look for a financial motive, though). He does, however, point out that the name change to ABIHM was driven by a desire to “raise standards” (whatever that means). Of course, when one is discussing healing modalities not based in science but rather in prescientific mystical thinking, such as acupuncture, reiki, homeopathy, and the like, one can’t help but think that “raising standards” would involve eliminating such modalities from medicine altogether. Be that as it may, I find it rather telling as to why Dr. Weil chose to go the route he did, choosing a third rate certifying board over the certifying board that is generally recognized by every state, hospital, and insurance company:

Unlike the American Board of Medical Specialties (ABMS), which would require approval by every single specialty board, ABPS is interested in creating a single pathway, recognizes fellowship training, and is an innovator. We had hoped the ABMS would consider a Certificate of Added Qualification in IM — such as exists for geriatrics — which can be applied for by different residency specialties; but ABMS is eliminating that concept.

Our goal is to have all graduates of our 1000-hour fellowship become board certified. At the same time we have not relinquished our goal of bringing IM training to all physicians. The success of our Integrative Medicine in Residency makes us comfortable and confident that IM will become a part of all physicians’ basic training. This 200-hour program is being used in 22 family medicine and two internal medicine residencies. In 2012 we will begin a pilot in two pediatrics residencies.

This is an exciting step for the field of Integrative Medicine (IM). Board certification is widely recognized by physicians and the public alike as a critical step in establishing a field. The first meeting of the American Board of Integrative Medicine will take place in Tampa, Florida, October 10-11. Over a two-year period, we will set criteria for sitting for the board exam and develop a validated exam.

In other words, the ABMS had standards that were too high for Dr. Weil, whereas the ABPS is not. Let’s just put it this way. “Innovation” is not really what I want in a certifying board for a medical specialty. I prefer a boring dedication to science-based practice and a caution that leads new specialty acceptance to be evolutionary rather than revolutionary.

An end run around standards

Believe it or not, before I saw Dr. Weil’s press release and started doing a bit of research for this post, I had never heard of the AAPS or its companion board the ABPS. After all, the ABMS is the gold standard board through which the vast majority of physicians in this country are certified. Indeed, my very own specialty, surgical oncology, is not a boarded specialty at present. There are training programs approved by the Society of Surgical Oncology, but these fellowships do not lead to sitting for boards, and surgical oncology has traditionally been viewed mainly as an offshoot of general surgery. Indeed, ever since I decided that I wanted to go into surgical oncology in the mid-1990s (and long before my entry into the field), there has been a debate over what surgical oncology is as a specialty and whether it should be fully distinct from general surgery. Remember that most cancer operations for breast cancer, GI malignancies, melanoma, and some other cancers have long been the purview of general surgeonss and even today in the U.S. most such operations are still carried out by general surgeons in the community. Surgical oncology, as envisioned, was originally going to cover more complex cancer operations, those needed by patients referred to tertiary medical centers and cancer centers like Memorial Sloan-Kettering and M.D. Anderson Cancer Centers. There was also, let’s face it, the question of turf. For example, multiple surgical specialties claim colon cancer as part of their areas of special expertise, including (now) general surgery, colorectal surgery, surgical oncology, and, increasingly, minimally invasive surgery.

The lack of board certification for surgical oncology is a situation that will not last much longer. It was announced at the SSO Meeting in March 2011 that, after decades of trying, the SSO had finally managed to win board certification for surgical oncology from the ABMS. The new board certification will be called Complex General Surgical Oncology and will be a subspecialty board in general surgery under the ABS. As such, it will require board certification in general surgery, plus fellowship training of at least two years beyond that in an approved fellowship program, followed by passing a board examination in surgical oncology.

Another interesting aspect of board certification in Complex General Surgical Oncology is that current practitioners and graduates of even approved surgical oncology training programs will not be grandfathered in. Whenever a new subspecialty peels off from an established, more general specialty, such as when vascular surgery peeled off of general surgery to become a recognized specialty, inevitably there are cries from current practitioners of that specialty for a mechanism to “grandfather” them in and provide a means for them to become board certified too without having to undergo residency or fellowship training again. For example, I am rapidly finishing my fifth decade of life; going back to a fellowship is not practical, nor would it be for the vast majority of mid-career surgeons like me with a lot of experience but who still have a lot of time left to practice. That’s even if there were enough fellowship slots to accommodate them and surgeons finishing residency, which there are not. In marked contrast, every report I’ve seen about the new certificate in Complex General Surgical Oncology at SSO meetings over the last few years indicates that current surgical oncologists will not be able to take the examination and be grandfathered in. That includes even the eminent surgical oncologists who are the founding members of this new board. Unless I go back and do a surgical oncology fellowship again, I can never be board certified in surgical oncology. (No doubt some quack will attack me for that ten years from now, after the new system has started to crank out a significant number of board certified surgical oncologists.)

Readers might be thinking to themselves right now, “That’s all very interesting, Orac (well, not really), but why are you explaining this? What does any of this have to do with board certification in IM?” I answer: Compare and contrast, my friends. Compare and contrast. Dr. Weil could have tried to partner with the much more respected and authoritative ABMS. Why didn’t he? Because, at least for now, the ABMS wouldn’t touch this “integrative” woo with the proverbial ten foot pool (Weil et al. even admit that in their press release). Don’t get me wrong. Given the infiltration of quackademic medicine into so many medical schools and academic medical centers, I’m under no illusion at all that the ABMS is so science-based that this situation might not change in the future and it might not become more “open” to IM, but at least for now, the ABMS appears not to be interested in pseudoscience-based medical pseudo specialties. That is, of course, a good thing. In contrast, the AAPS is apparently–shall we say?–more “open minded.” Indeed, take a look at this video from the AAPS website describing board certification through the ABPS:

Notice the arguments? “Who’s got your back?” Fight against unfair “discrimination against deserving physicians.” The ABPS has a “big tent approach to medicine.” “You’re not a mere number” with ABPS. I don’t know about you, but I know that I want a “big tent” approach to medicine. A “big tent” approach is a major reason why quackademic medicine has gotten as far as it has. For example, apparently the AAPS has been having difficulty getting its emergency medicine boards recognized because it doesn’t require a specific emergency medicine residency and is mounting a major public relations and lobbying campaign to change that, with the goal of being recognized in every state (which of course means ABPS certifications in emergency medicine are not recognized in some states:

“We have a very aggressive and active governmental affairs program for 2010,” said Timothy Bell, the AAPS director of governmental affairs. “Our strategic plan for 2010 includes Alaska, Montana, Idaho, Utah, and North and South Dakota. It will put us on the path of achieving the goal of being recognized in every state.”

The plan puts ABPS on a collision course with the American Board of Medical Specialties as well as the Bureau of Osteopathic Specialists and Boards of Certification of the American Osteopathic Association, the most widely accepted agencies for medical specialty certification. Nowhere is the clash more evident than in the field of emergency medicine, perhaps because of the Daniel v. ABEM suit that spanned 15 years, casting a shadow over the field’s attempt to move from grandfathering for the field’s pioneers, who had no chance to enter an emergency medicine residency, to a residency-based approach. While ABEM bases board certification on completing an emergency medicine residency and testing, ABPS’s certifying body, the Board of Certification in Emergency Medicine (BCEM), allows applicants to have completed a primary care or anesthesiology residency along with 7,000 hours of experience in an emergency department.

Hmmm. Maybe I should see if the ABPS will set up a competing board in surgical oncology, so that I can be board-certified too! In any case, New York and Oklahoma, at least, have recently thwarted the ABPS initiative. Meanwhile, relatively few hospitals recognize ABPS certification as being “board certified,” and the American College of Emergency Physicians does not recognize the ABPS as a valid certifying body. Neither does the American College of Surgeons.

Seen in the light of the example of emergency medicine, it’s very clear why Dr. Weil and the ABIHM chose the ABPS. First, unlike leaders in surgical oncology, Dr. Weil didn’t want to go through what could be a decades-long (or more) process of convincing the ABMS that “integrative medicine” is a valid and distinct medical specialty. Second, the ABMS has made it clear that it’s not going to “grandfather” practitioners in, whereas the ABIHM almost advertises that you should take its test now while things are still easy, before the ABIHM institutes an IM residency requirement for its board certification:

Within the next few years, the ABIHM has plans to phase out the certification of physicians without formal training from an integrative medicine residency or fellowship program. We will also be raising the benchmark for passing the exam. Thus, physicians without formal training have a time limited opportunity to become Diplomates before the new standards are implemented. Our intent is to offer “grandparent” status to those who underwent certification prior to the installment of the upgraded requirements.

Get yer IM board certification while they last at this low, low price of $800 and no special residency needed!

The bottom line

There is little doubt that Dr. Weil has realized that his specialty of IM is, despite his massive success in infiltrating quackademic medicine into medical academia, still not taken seriously where it matters, namely by certifying boards, state medical boards, and, of course, insurance companies. If he can succeed in creating a medical specialty that appears legitimate based on board certification, then recognition by state medical boards and, more importantly, third party payers might well follow. If it takes partnering with an umbrella organization for various medical boards that aren’t as well-accepted and well-respected as those under the umbrella of the ABMS, so be it. Most of the public doesn’t know the difference, anyway. So Dr. Weil and a bunch of buddies, including people I’ve discussed before such as Dr. Mimi Guarneri (who was the pro-IM counterpoint to Steve Novella when he was on The Doctor Oz Show last spring), Dr. Brian Berman (who’s managed to slip bad acupuncture papers past reviewers into high impact journals), and Dr. Benjamin Kligler (who’s the research director in integrative family medicine for the Beth Israel-affiliated Continuum Center for Health and Healing), among others, got together and formed the American Board of Integrative Medicine.

One potential consequence of this effort might well be ticking off non-MD practitioners of woo such as naturopaths. John Weeks even mentions this as a possibility:

This strategic decision by ACIM has many dimensions. There are clear public health implications. The ACIM-ABIHM alliance represents a significant new alignment. Grassroots access to the “integrative medical doctor” title or at least board certification may disappear. There are guild dimensions here, ground claiming, and not just for IM doctors. Many naturopathic doctors and acupuncturists and chiropractors use the term. The brand “integrative medicine” may become even more closely associated with, and effectively owned by, medical doctors. New clarities will emerge, new boundaries will be drawn, new possibilities empowered.

Indeed. I rather suspect that this is a blatant effort of the “MD wing” of the alternative medicine world to claim the specialty for itself and push out all the “riff raff,” like naturopaths, homeopaths, chiropractors, acupuncturists, and the like by preventing them from using the term “integrative medicine” to describe what they do. One potential result, if Weil and his merry band of woo-meisters are successful, is to marginalize non-MD practitioners, which might not be a bad thing from the point of view of science-based medicine. What would be a bad thing is that it would simultaneously allow MDs like Weil to lay claim to the woo inherent in IM in order to give it the patina of legitimacy that, despite 20 years of the best efforts of doctors like Weil, IM or CAM or whatever the pseudorespectable nom du jour is still doesn’t have and doesn’t deserve because much of it consists either of Trojan horses or pseudoscience.

Whatever happens, one consequence that will not result from this effort is any improvement in patient care.