A board certification in "integrating" quackery and pseudoscience with real medicine

It’s hard to believe that it’s been nearly two years since I first noticed that a board certification in quackery was in the works and appeared to be nearly ready to go. I’m referring, of course, to Andrew Weil’s effort to create a board certification in so-called “integrative medicine,” better known to those of us on the science-based side of medicine as integrating quackery and pseudoscience with real medicine. Since it’s been so long since I last addressed this issue, it’s probably worth a brief recap. Basically, back in 2011, Andrew Weil and his Arizona Center for Integrative Medicine (ACIM) at the University of Arizona announced that they were going to 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, was in dialogue with the American Board of Physician Specialties (ABPS) toward establishing an American Board of Integrative Medicine in collaboration with the American Board of Integrative and Holistic Medicine (ABIHM). In that time, the plan has gone forward and over the last few months has come to fruition. Now there is indeed a board certification process for “integrative medicine,” and I can’t help but take a look at it.

As I noted at the time, the choice of the ABPS instead of the more established and respected American Board of Medical Specialties (ABMS) as the board responsible for certification in “integrative medicine” virtually guaranteed second-class status for this budding specialty because in most states the ABMS is the only board that matters for MDs. There is a board that certifies DOs, the American Osteopathic Association Bureau of Osteopathic Specialists, that also counts, but for purposes of this discussion, it’s the ABMS that rules. For instance, the board that certified me as a surgeon, the American Board of Surgery, is part of the ABMS. It’s the board that certifies surgeons in General Surgery, Vascular Surgery, Pediatric Surgery, Surgical Critical Care, Hand Surgery, and other surgical specialties. 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.

Before I look at the examination process for integrative medicine, I can’t help but recap a brief video from the ABPS that describes its board certification:

As I pointed out at the time, take a look at 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 don’t 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. Fortunately, relatively few hospitals recognize ABPS board certifications. And no wonder! take a look at the “integrative medicine” certification process. Take a look at the eligibility requirements to sit for the board examination in this “specialty.” Basically, all that’s required of applicants is that they be physicians in the US or Canada with an unrestricted license to practice, be board-certified in some specialty (and those specialties can be ABPS-boarded specialties); and then either:

a. Have completed an ABOIM approved Fellowship in Integrative Medicine OR

b. Have graduated from an accredited 4-year naturopathic college OR

c. Have graduated from an accredited National Certification Commission on Acupuncture and Oriental Medicine (NCCAOM) college OR

d. Have graduated from an accredited Council on Chiropractic Education (CCE) college OR

Oh, yes, there is more after the “OR” at the end of item “d.” I’ll get to that in a minute. First, let’s look at the fellowships in quackery “integrative medicine” quackery. It’s a depressing list to behold, and academic medical centers that really should know better have such pseudo-fellowships, including the Albert Einstein College of Medicine, Harvard, George Washington University, and The Ohio State University. Having gotten my M.D. from the University of Michigan, I can’t help but gloat a bit over that, at least until I remember that my alma mater is currently steeped in woo itself and offers its own quackery fellowship as well). Sadly, OSU and U. of M. are by no means alone.

However, apparently the outcry of “integrative medicine” practitioners who were unhappy with the thought of being locked out of a potentially lucrative certification that would elevate them over the run-of-the-mill naturopaths, acupuncturists, and homeopaths had an effect. At the time, I found it rather amusing, because the “integrative medicine” practitioners reacted pretty much the same way that many medical practitioners react to a proposed new specialty. They complained about being excluded. They wanted a mechanism whereby they could be somehow either grandfathered in or be eligible to take the test without having to take a whole new fellowship training program. (I still simultaneously chuckle and cry when I think about training programs incorporating homeopath and other quackery.) And apparently they got it, as this section of the ABPS eligibility requirements for integrative medicine shows:

Applicants submitting completed applications no later than December 1, 2016 may qualify under the following eligibility requirement (7e). This option is being offered for a limited time to allow current practitioners and leadership in integrative medicine to obtain Board Certification. As more fellowships and instruction in integrative medicine become available, this option will be phased out.

e. The board acknowledges that many MDs and DOs have become proficient in integrative medicine through extensive training from CME, self-study and clinical experience. The board will consider physicians with a minimum of 500 points of documented training and experience in integrative medicine subject areas, as demonstrated by alignment with domains listed in the exam description. See “Notes on the Limited Time Option” at the bottom of this page for more details on the documentation required.

  • For each year of clinical practice in Integrative Medicine, up to five years, 50 points will be awarded.
  • For active Diplomates of the American Board of Integrative Holistic Medicine (www.abihm.org) 200 points will be awarded. Active status is defined as having a current, unexpired certificate and will be confirmed using ABIHM’s online search.
  • For successful completion of category 1 AMA CME in Integrative Medicine, 1 point will be awarded for each documented hour of CME.
  • For successful completion of category 2 AMA CME in Integrative Medicine, 1 point will be awarded for each documented hour of CME (max 150 hours).

Hurry! This offer is only good until December 1, 2016! I expect that this scheme will be a boon to organizations offering CME in integrative medicine!

But what about the examination itself? Take a gander at this description. The examination is made up of nine sections:

  • Nutrition
  • Dietary supplements, botanicals and other natural products
  • Mind-body medicine and spirituality
  • Complementary and alternative therapies
  • Whole medical systems
  • Lifestyle, prevention, and health promotion
  • Integrative approaches (including conventional medicine)
  • Foundations of integrative medicine
  • Professional practice of integrative medicine

As I’ve said before, I’d love to get a copy of the exam, but that’s highly unlikely. Boards guard their examinations with a zealousness so great that even Edward Snowden probably wouldn’t have been able to get a copy if he had worked for the ABPS. In any case, it’s hard not to note that there’s a lot of quackery on this examination. We’re talking homeopathy, traditional Chinese medicine, Ayurveda, shamanism, “energy medicine” (reiki, therapeutic touch, and the like), and manipulative therapies (osteopathic, cranial-sacral, chiropractic, and the like). At this point, I have a hard time not making my usual observation about examinations like this, and that’s basically this: How on earth do you construct questions about such quackery that have answers that all the quacks can all more or less agree on? I’ve been involved in making examinations on science-based surgery. There are nuances, and the wording of a question can make an enormous difference in interpretation, and even in science-based questions it’s easy to be ambiguous. Now imagine questions about when to use homeopathy versus when to use acupuncture versus when to use Ayurveda. How do you choose one over the other? What is the evidence base? The answer, of course, is obvious: There is no evidence base. It’s basically whatever the practitioner wants to use. But how do you put that in an examination, and how on earth do you justify the answer? It’s hard enough to justify some answers when there’s science to do it, but in the case of an examination like this it’s a horrible conundrum. I almost feel sorry for the writers trying to put together multiple choice questions on this nonsense. I’m half tempted to try to write a few sample questions myself.

In the end, to me it’s quite obvious what the purpose of this certification is. It’s to provide legitimacy to pseudoscience and quackery. After all, if there’s a “board certification” in something, it must be legitimate, right?

Wrong.