“Practice drift”: A feature, not a bug, in “integrative medicine”

I’ve said it many times, but it’s always worth repeating. “Integrative medicine” means, in essence, “integrating quackery and pseudoscience into medicine.” After all, as much as integrative medicine advocates and practitioners claim perfectly fine science-based modalities such as nutrition, exercise, and other lifestyle interventions as being somehow “alternative” or “integrative” as their own rather than just medicine’s, the entire raison d’être of integrative medicine is to integrate prescientific or pseudoscientific treatments or systems of medicine like acupuncture, naturopathy, homeopathy, energy medicine, and the like into medicine using a lesser standard of evidence. Basically, I like to say about integrative medicine what Harriet Hall likes to say about naturopathy: What is good about it is not unique to it, and what’s unique about it is not good. In other words, the exercise, diet, and lifestyle interventions claimed by integrative medicine are not unique to integrative medicine, but what is unique (e.g., the naturopathy, homeopathy, and the like) isn’t good because it’s quackery.

That’s why I was amused when I came across an article, by way of Jann Bellamy, published in the Journal of Alternative and Complementary Medicine, which is, as you know, edited by our old friend John Weeks, the one who earned my ire likening me to Donald Trump. It’s by two luminaries of integrative medicine, Dr. Melinda Ring of the Osher Center for Integrative Medicine, Northwestern University Feinberg School of Medicine, and Dr. Sandy Newmark of the Osher Center for Integrative Medicine, University of California, San Francisco. The article is entitled Practice Drift: Are There Risks When Integrative Medicine Physicians Exceed Their Scope? However, it should really be called Are there risks when doctors embrace quackery? The answer, of course, is yes, because there should be.

What would any article promoting integrative medicine be without a bit of revisionist history. First, Drs. Ring and Newmark:

Twenty-five years ago David Eisenberg’s seminal article on public use of “unconventional medicine” created momentum around the approach for treatment and prevention now known as integrative medicine.1 Physicians drawn to the field were able to participate in the first integrative medicine fellowship through the University of Arizona in 1997. The first convening of what is now the Academic Consortium for Integrative Medicine and Health took place in 1999 to conceptualize a vision for the emerging field and work toward achieving it.2 Now, there are thirteen academic fellowships approved by the ABOIM and over 600 board-certified diplomats, over 1200 fellowship graduates through the University of Arizona alone, and the Consortium has grown from 8 to over 70 member institutions.

Eisberg’s article, you might recall, was published in the New England Journal of Medicine in 1993, and it was hardly a call for integrating quackery into medicine. Basically, it found that more people than expected were using alternative medicine (or “unconventional therapies,” as the authors put it) and suggested that medical doctors “should ask about their patients’ use of unconventional therapy whenever they obtain a medical history.” That’s about it. Where most doctors would be alarmed by this finding and agree that perhaps they should make sure to ask their patients about any alternative medicine that they might be using, people like Drs. Ring and Newmark apparently view such a result as a good thing and a jumping-off point for adding quackery to medicine. In any case, it is true that the 1990s was the decade that saw the first serious movement to “integrate” quackery into medicine, with the formation of the Academic Consortium for Integrative Medicine and, above all, the formation of the National Center for Complementary and Alternative Medicine in 1998 as a massive leap to from its modest origins as the Office of Alternative Medicine in 1992.

Drs. Ring and Newmark note that physicians in integrative medicine are drifting “away from their original training.” They attribute this “practice drift” to the increasing complexity of integrative medicine, although my retort to that is: How complex can it be, given how much of it is based on magical thinking? OK, I realize that systems of pure quackery can be very complex. Functional medicine is complex, but it’s complexity without utility and meaning. Ditto naturopathy, homeopathy, and the vast majority of traditional Chinese medicine. In any event, they observe:

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. The arena is challenging; certainly much good for patient choice and professional development has come from increased integrative options. The purpose of this article is neither to censor any particular group of providers nor to advocate for unreasonable restrictions on integrative practices. It is rather to engender a thoughtful discussion about an issue regarding standards of care that should be of concern to all medical providers and especially to those in the field of integrative medicine.

Of course they don’t want to “censor” anyone. If there’s one thing about integrative medicine, it’s that its proverbial mind is so open that its brains fall out. Energy medicine, a system of medicine based on the manipulation of mystical magical energy fields that science can’t detect? It’s perfectly fine! Acupuncture, a treatment based on nonexistent anatomical structures like meridians? No problem! Functional medicine, a system based on massive overtesting and overtreatment plus quackery? Bring it on! It’s all good!

So is this, apparently:

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. Yet, in this new era of integrative medicine there is also risk, as physicians drift away from their original training. By the end of residency, a medical doctor has accrued a minimum of 16,000 h of clinical experience, the vast majority during residency, when physicians gain expertise in their chosen specialty under the supervision of an attending physician.7,8 Now, an increasingly common scenario is seen in which integrative healthcare professionals move outside this medical training and its implicit scope of practice to incorporate new approaches to healthcare diagnosis and treatment.

Here’s the thing. In real medical specialties, there are mechanisms for doctors to learn new skills when practice evolves. That’s how I learned to do various new procedures that rose to the standard of care after I finished my training. In surgery, it’s usually mentorship by a more senior surgeon or someone skilled at the procedure you’re trying to learn. In other specialties, there are courses that can be taken for continuing medical education. (Surgery has these as well.)

In integrative medicine, however, apparently this is what’s going on:

While the issue is alive across medicine, including in some other complementary and integrative professions, it seems particularly prevalent in the practices of medical doctors who have chosen to enter into complementary and integrative medicine. Here are some examples:

  • A psychiatrist completes functional medicine training and Lyme-literacy courses. He establishes a practice as an integrative psychiatrist and begins doing specialized testing, diagnosing patients with adrenal fatigue, parasites, and chronic Lyme and prescribes antibiotics, high-dose steroids, and extensive supplements for his patients. The physician’s postgraduate training, which establishes him as a board-certified medical doctor, consists of 3 years of a psychiatry residency. Other than medical school and intern year, which occurred 20 years earlier, his training did not include any infectious disease or endocrinology training.
  • An integrative gynecologist who prescribes bioidentical hormone therapy for women expands his practice to diagnose and treat not only women but also children and men- populations not included in his postgraduate residency- with hormones, pharmaceuticals, and dietary supplements.
  • A primary care physician curious about integrative medicine has done some self-education, then takes a weeklong class and rebrands herself as an integrative consultant.

At the heart of this quandary about health professional scope of practice lies the very basic question: does simply having graduated medical school entitle a physician to practice in any area of medicine, whether or not a few short trainings are added?

The answer in the rest of medicine is: Yes and no. Legally, having a medical license allows a physician to do virtually anything in medicine and to practice in any area of medicine. However, practically, that doesn’t happen nearly as much as it used to. Hospitals and insurers require board certification in a specialty, and physicians can only be practice and be reimbursed by third party payors for activities within the scope of practice of their specialty. Hospital privileges define scopes of practice based on the doctor’s board certification. For instance, I’m not certified in advanced laparoscopic surgery (although I can still do the basics, like laparoscopic cholecystectomies); so I’m not allowed to do them in my hospital. Similarly, I can’t do endoscopy because I haven’t had enough training in it. (I did some endoscopy as a resident, but not enough.) My scope of practice for purposes of my privileges is general surgery and breast surgery.

Contrast this to the examples above. Functional medicine claims to encompass endocrinology, metabolism, physiology, and so much more; yet most functional medicine doctors have little or no training in these areas. That’s yet another reason why functional medicine is to me “making it up as you go along.” Even if functional medicine were anything other than a made-up specialty that throws as many things against the wall as it can to see what sticks, it would be in appropriate for an “integrative medicine” doctor to be doing functional medicine without formal training. As for the second example, it’s just downright scary, but it’s a common story. The third example is also far too common. Basically, anyone can claim to be an “integrative medicine” doctor.

The criticism is very odd, as well, given that the American Board of Integrative Medicine (ABoIM), on whose board Dr. Ring sits, to be board-certified in integrative medicine. Also, as Jann notes, only recently did the ABOIM require a fellowship (none of which are ACGME-accredited) in integrative medicine, but even then the fellowship isn’t required if the physician has a degree from a naturopathic, chiropractic, or oriental medicine school. Prior to that, a medical license, board eligibility in anything, plus certain experience, plus CME credits like the ones Ring and Newmark complain of, were enough.

So what are these risks? They are:

  1. Risk to the patient—Of greatest importance is risk to the patient, who may be harmed by inappropriate diagnoses, missed diagnoses, or incorrect treatment, resulting from a provider’s lack of clinical experience and expertise in a particular area. Patients may also be subjected to significant financial risks from paying for excessive laboratory testing and other costs.
  2. Risk to the provider—In case of an adverse outcome, which can happen with even the best of treatment, a provider could have significant medicolegal difficulties from the perspective of a state medical board as well as increased civil liability should a patient choose to bring suit. At the state board level, clinicians may be at risk for penalties for practicing outside their scope of practice. At the federal level, practitioners may be liable for allegations of fraud and abuse.9
  3. Risk to the credibility of integrative medicine—There are comparable issues in other fields of medicine, as noted in a 2010 North Carolina Medical Board editorial on practice “drift,” but the risks of this “off-label” care may be a special threat to the credibility of the field of integrative medicine.10 Although integrative medicine is steadily gaining acceptance in the overall medical community, there is still much doubt and skepticism. When 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. A good example of this, from personal experience, is the reaction of infectious disease experts to the chronic intravenous antibiotic treatments recommended by the above noted psychiatrist.
  4. Risk of alienation of complementary providers—This is a sensitive area. Consider the question of Traditional Chinese Medicine and acupuncture. Training for a licensed acupuncturist requires 3–4 years of full time study, in contrast to the much briefer acupuncture courses for MDs/DOs. The American Board of Medical Acupuncture, for instance, requires only 300 h of training for an MD to be called an MD Acupuncturist. In most states, MDs can practice without any additional instruction, or perhaps just 100–200 h.11 This significant variance in training requirements could lead to concerns on the part of licensed acupuncturists, especially given existing differences in insurance reimbursement for LAcs versus MDs.

Imagine my relief that they listed potential harm to the patient first. Of course, if they were that concerned about harm to the patient, they wouldn’t be part of a movement that “integrates” prescientific and mystical treatments and medical systems like naturopathy and traditional Chinese medicine (TCM) into medicine. TCM, for instance, has a whole slew of diagnoses that have little or nothing to do with reality. As for the “financial toxicity” of integrative medicine, hell, functional medicine is based on excessive laboratory testing, with slates of dozens of tests of hormone levels, nutrient levels, cytokine profiles, hematology profiles, metabolic panels, genomic panels, and more, many of which are not covered by insurance. Of course, regarding the risk to the practitioner, integrative medicine practitioners don’t seem to be at too much risk for liability; they seem to be seldom sued, even though they should be sued way more often given the pseudoscience involved.

Let’s consider the last two, though. There remain much doubt and skepticism about integrative medicine for good reason. It integrates quackery with medicine! In particular, I laughed out loud when I read the example of the reaction of infectious disease experts to the chronic antibiotic treatments recommended by the aforementioned psychiatrist. Regular readers of this blog probably know that the only condition for which integrative medicine doctors recommend chronic antibiotics is chronic Lyme disease, which is a fake diagnosis. Yes, infectious disease experts have a problem with treating chronic Lyme disease, because it’s a “disease” that doesn’t exist and long term antibiotic treatment for a nonexistent disease can only do harm, not good. And it does: Catheter infections, antibiotic-related infections, and more.

I also laughed out loud at the example of acupuncture in #4. Given that acupuncture is magic based on nonexistent anatomy and physiology, who cares how much training MDs need to do acupuncture compared to acupuncturists? Does it matter? Of course it doesn’t. After all, it doesn’t matter where you stick the needles or even if you stick the needles in. As long as sufficiently sterile technique is used to avoid infection, it really doesn’t matter who’s doing the acupuncture. Of course, this all rather goes against the authors’ recommendations, such as this:

Individual level: it is the physician’s professional and ethical responsibility to make sure that he or she is competent to practice in a particular area. The MD should be transparent with patients about his or her training and expertise. Physicians moving into new clinical arenas should acknowledge their inexperience and seek reliable resources and mentors for guidance in application to patient care.

Of course, the problem with “integrative medicine” is that there really is no science-based standard to tell a physician whether he or she is competent to practice in that area. That’s because, for so many of the modalities that “integrative medicine” integrates into medicine, there is no science or even scientific plausibility to support them. So it shouldn’t be a surprise that the sort of physician attracted to such a specialty has little fealty to science and is therefore prone to “practice drift.” That’s not a bug. It’s a feature.