Wednesday, April 13, 2016

Academic Consortium plan: force medical residents to practice integrative medicine

The Integrative Medicine Wheel

The Integrative Medicine Wheel

“Integrative medicine” is an ideological movement within medicine driven in large part by those whose livelihoods depend on its continued existence. This includes both those with positions in academic medicine and individual practitioners who use the integrative medicine (IM) brand to attract patients.

Despite integrative medicine and its antecedents (alternative, complementary, alternative and complementary, complementary and integrative) having been around for about a quarter century, we still do not have a working definition of integrative medicine or have any idea whether it positively affects patient outcomes. And, despite the lip service given to IM’s being evidence-based, or “evidence-informed” or incorporating “appropriate” services into conventional medicine, there does not seem to be any standard for determining which modalities are appropriate for inclusion. We can infer, however, that evidence of effectiveness is not a criterion, as reiki, cranial sacral “therapy” and homeopathy are standard fare.

In fact, the prospect for actually improving patient outcomes by importing CAM treatments (such as acupuncture) into medical practice would seem to be decreasing over time, as more and more fail to hold up under the scrutiny of well-designed and conducted clinical trials. Perhaps the dearth of evidence for “alternative” treatments is the impetus behind the importation of conventional modalities, such as nutrition and exercise, into the IM fold, treatments that were never viewed as CAM when the whole enterprise started. It has also led to special pleading demanding that research standards be loosened, most recently by the NCCIH, its director’s promise to ensure “rigorous science” notwithstanding.

There is no standard delivery model for integrative medicine or, importantly, an agreed-upon role for the various practitioners who bring the “integrative” to integrative medicine, such as chiropractors, naturopaths and acupuncturists. For example, should they be allowed to practice independently or should the medical doctor have final say on patient care? And, if they differ in their proposed diagnoses and treatments, how are those issues to be resolved?

None of these deficiencies have stopped the establishment of IM programs at more than half of the medical schools in the US and Canada. And, as we shall see in a moment, the federal government (meaning you, the taxpayer) continues to fund an effort to force integrative medicine on medical students even though a previous government-funded IM experiment in residency training  failed to produce positive results.

We don’t know what IM is, but let’s do it anyway

But first, let’s take a look at a recent article in Academic Medicine, the journal of the Association of American Medical Colleges, which details just how dysfunctional the whole academic IM program enterprise is.  The lead and second authors of the article, “Establishing an Integrative Medicine Program Within an Academic Health Center: Essential Considerations,” are David Eisenberg, MD, and Ted Kaptchuk, two of IM’s biggest cheerleaders. Kaptchuk, as regular readers of SBM will recall, made a recent appearance in another of my SBM posts, as the co-author of two execrable journal articles advocating the “public health benefits” of homeopathy, including homeopathic vaccines.

Eisenberg, et al., offer some tips on how to construct your own academic IM center based on their experience in creating and running the Osher Clinical Center for Integrative Medicine at Brigham and Women’s Hospital and Harvard Medical School, or “OCC” for short.  They begin with the observation:

Surprisingly little attention has been devoted to developing optimal delivery models whereby individuals can responsibly access IM care safely, effectively, and reproducibly across medical setting in a coordinated and cost-effective way.

Frankly, I’m surprised that they’re surprised. What were they thinking would happen when the whole IM enterprise started? That a vague idea about incorporating pseudoscience into medicine for some as-yet-to-be-determined patient benefit would somehow blossom into a structured system offering cost-effective care?

Not surprisingly, allowing CAM providers into the medical fold raises some sticky questions, such as: should CAM practitioners participate in the Electronic Health Records (EHR) system?  If so, the authors note,

A considerable amount of effort may be necessary to establish a lexicon which can be readily  understood by both “conventional” care practitioners and CAM professionals. Without such attention, office “notes” of some CAM professionals (e.g., acupuncturists) may be unintelligible to the average conventional medical colleague who is caring for the same patient.

I think the issue is bigger than they let on. It’s not just the office notes that are the problem. I’d venture that all of acupuncture is “unintelligible” to the “average,” or even above-average, conventional medical doctor because it doesn’t make any sense whatsoever.

Yet no amount of effort or expense seems to have been spared in trying to solve this one:

An extensive lexicon of terms, definitions, and standardized EMR templates and forms was developed, and all IM team members were required to document all clinical encounters on the hospital’s shared EMR system.

Unfortunately, we aren’t given a single example of this “extensive lexicon,” which would have been highly informative, just not in the way these lexicographers intended.

Of course, in the IM setting, one must address the delicate issue of the CAM providers’ scope of practice. The authors tiptoe around this one:

While licensed CAM professional groups often have suggested scope-of-practice guidelines, individual institutions may choose to limit certain practices or procedures.

I’ll be they do. No academic medical institution is going to let a chiropractor or naturopath loose to do as they wish. Even if they wanted to, the folks in risk management wouldn’t stand for it.

Apparently, their liberal attitude toward evidence does not extend to practices that might actually cause patient harm, as opposed to their being merely ineffective and “unintelligible.”

By way of example, some medical institutions’ clinical leaders oppose the chiropractic manipulation of the cervical spine owing to concerns about elevated risks of cerebrovascular accident.

Good call. Unfortunately, the OCC didn’t see it that way. They allow it, but limit it. (Presumably, for example, cervical manipulation for “wellness” wouldn’t be allowed.) And they require “hospital-approved informed consent” even though chiropractors argue there isn’t a risk and informed consent is unnecessary.

The article ends with a recognition that we don’t know if these IM centers produce an enhancement in clinical outcomes and a reduction in overall costs, or, at least, at comparable costs. But first things first. Eisenberg, Kaptchuk, et al. say all the IM centers need to get together and decide “how IM models are to be organized, replicated and evaluated,” admitting that “we are still in the early days of organizational development and consensus building.” And, for that, you need data, which the IM centers are just beginning to share.  So, they say, we need

a commitment from advocates and skeptics of this controversial area to jointly describe and evaluate integrative care model more precisely in an effort to prove or disapprove their comparability, replicability, clinical effectivity, and costs-effectiveness (or lack thereof) for a range of patient populations.

For this they need “resources” from the public and private sectors to sponsor “best practices” research so they can be standardized. It is only then, they say, that we can apply “rigorous cost-effective evaluations.”

So, basically, these people want to decide on an optimal product delivery model and then decide whether the product works. And they admit they are going to continue treat patients with this nebulous concept even though they admit they don’t know if it works.  Do they not see any ethical issues with doing this?  Are they going to close the doors if this research they want to carry out shows the whole thing doesn’t improve patient outcomes? As you will see as you read further, the answer is “no.”

And let’s force it on medical residents

Undaunted by these barriers, the good people at the Academic Consortium for Integrative Medicine and Health (ACIMH) (formerly, The Consortium for Academic Health Centers for Integrative Medicine)  have teamed up with the Academic Collaborative for Integrative Health (ACIH) (formerly, The Academic Consortium for Complementary and Alternative Health) and the Arizona Center for Integrative Medicine to bring you the National Center for Integrative Primary Health Care. (The ACIH is the CAM equivalent of the ACIMH, including chiropractic, naturopathic, acupuncture, ayurvedic, massage therapy, homeopathic and direct-entry midwifery organizations.)

(Please bear with me while we wade through the rest of this alphabet soup.)

Also on board are several integrative medicine organizations. One is Integrative Medicine in Preventive Medicine Education (IMPriME), funded by the government as part of the American College of Preventive Medicine (ACPM) to provide technical support for medical residency and other health care profession training programs interested in incorporating “evidence-based integrative medicine content into their programs.” (We’ll return to that effort shortly.)  There’s also Integrative Medicine Access (IMA), an organization that connects people who can’t afford CAM with CAM practitioners. For example, if you have cancer, the IMA can hook you up with practitioners of homeopathy, healing touch, reiki, chiropractic or naturopathy, which are, according to the website, “modalities that have been shown to treat cancer.” Finally, IM4US, another organization promoting CAM for the “underserved,” is participating.

One thing becomes immediately clear as you explore the website of the National Center for Integrative Primary Health Care (NCIPH): medical education, at least in the eyes of ACIMH, has gone beyond merely teaching medical students about various CAM practices so they know what is out there. In ACIMH’s view, primary care (including pediatrics) now includes a “collaboration” between physicians and naturopaths, chiropractors and acupuncturists. These are seen as “primary care disciplines” with which medical residents will share “10 ‘meta-competencies’” developed “through a collaborative process” with CAM providers, who are “team members.”  (As is typical of pro-IM discussions, all manner of conventional practitioners are lumped in with the CAM providers as “team members:” pharmacy, public health, nutrition and behavioral medicine.)

And, if all goes according to plan, this collaborative system of primary care and its recently-developed “core competencies” will ultimately become required part of primary care physician education and training. Medical residents will have to master all 10 competencies, including

“developing a personalized plan of care to promote health and wellbeing that incorporates integrative approaches including lifestyle counseling and the use of mind-body strategies.”

They must be able to “work effectively as a member of an interprofessional team” and must incorporate IH into community settings and into the healthcare system at large.”

In other words, family practice and pediatric residents will be forced to learn “core competencies” of an IM ideology that views naturopaths, chiropractors and acupuncturists as fellow primary care practitioners, whether they embrace IM or not, or even view the whole enterprise as nonsense.

The development of these “core competencies” in IM and the plan to require IM training with this “interprofessional team” are set out in an article, “Interprofessional Competencies in Integrative Primary Healthcare,”  published in a journal called Global Advances in Health and Medicine.  Just to give you a flavor of the kind of thing the editors of this journal go for, a recent special supplement was devoted to the “biofield,” and included an article co-authored by Deepak Chopra, “Biofield Science and Healing: An Emerging Frontier in Medicine.”

According to the authors of “Interprofessional Competencies,”

Published evidence is accumulating regarding both the clinical effectiveness and cost effectiveness of IH [integrative healthcare, yet another new name for CAM/IM?].

Had I been a reviewer of this manuscript, I would have required citation of more than one article each for the proposition that clinical and cost effectiveness evidence is “accumulating,” but that’s just me. One article, “Acupuncture for chronic pain: individual patient data meta-analysis,” was decimated by both David Gorski and Steve Novella. The other, “Are complementary therapies and integrative care cost effective?” was deconstructed in a post by Scott Gavura, appropriately titled “Don’t call CAM cost-effective unless its actually effective.”

As is typical of IM/IH ideology, the rationale for including CAM providers in this effort has nothing to do with CAM:

  • Providing “quality care.”
  • Strong emphasis on prevention and patient engagement to control cost and deliver quality care
  • Whole-person, patient-centered care.

These, according to the authors, have been absent or underemphasized in conventional care but are the “core skills” of IH practitioners. I have yet to see any actual evidence that naturopaths, chiropractors or acupuncturists have some unique ability to provide these skills, but you see this sort of statement over and over in the medical literature.

The authors are aware that “finding time in the curriculum” of medical education and training will be a barrier, yet they are committed to this mandatory IH training, including “onsite experiential and clinical activities in order to assess the knowledge in IH skills” and “faculty development” to support it. One wonders what subjects will be bumped in favor of the IH program. They also acknowledge “the lingering criticisms of IH as non-evidence-based that persist in some sectors of the primary care system.” Just wait until these “sectors” find out about this plan of forced indoctrination into IH. I image the criticisms will “linger” even longer and spread to even more “sectors,” especially those sectors whose subjects will be bumped from the curriculum in favor of IH.

For starters, the NCIPH has developed a 45-hour on-line pilot program “Foundations in Integrative Health.” According to the Oregon College of Oriental Medicine, one of the sites selected by NCIPH for the pilot course, you can complete just 80% of the course and attain a score of 70 on the test to get a Certificate of Completion from the University of Arizona Center for Integrative Medicine. I don’t know if this is a special deal just for OCOM students and faculty or applies to all participants.

There’s no such thing as failure

This project was funded by the Health Services Research Administration (HSRA), a part of the Department of Health and Human Services, to the tune of about $1.7 million. HSRA, whose mission “is to improve health and achieve health equity through access to quality services, a skilled health workforce, and innovative programs,” has taken an unfortunate turn toward handing out funds to promote IM. Perhaps they will be relieved of this burden now that Sen. Tom Harkin, who is behind this effort, is gone. HRSA also funded the establishment of an “Integrative Medicine in Preventive Medicine Education program” in 12 preventive medicine residency programs, an undertaking headed by Dr. David Katz and covered in my previous SBM post, “The elusive ‘potential’ of integrative medicine.” This program was carried out under the auspices of IMPriME, which, as noted above, is a partner in NCIPH.

Apparently, nothing was learned from the preventive medicine residency experiment, or maybe they just chose to ignore what they learned.  As I said in the previous post,

At the end of the two-year grant, it was far from clear that the PM residency programs would continue with IM training. According to the post-program analysis, the most prevalent expectations were for IM rotations to continue, but only as elective rotations, and for IM lectures and grand rounds to become less frequent. . . .

In the post-program analysis, the inclusion of CAM emerged as the main stumbling block in implementation of IM training in residency. . . .

[T]he authors of the post-program analysis think the “foremost” question to be answered in further discussion among the preventive medicine community in integrating IM into training and practice may be “the extent to which inclusion of CAM procedures is essential to the practice of IM.” They note that the IOM [report on Integrative Medicine] offers “little guidance” in answering this question and that the reference in the definition to “therapeutic factors known to be effective and necessary . . .” could exclude CAM just as well as include it.

In other words, our last experiment involving IM in residency programs showed us that no one really liked the idea, so let’s spend more money on a plan to force IM on medical residents.  But, of course, lack evidence is never a barrier to implementation in integrative medicine.

Academic Consortium plan: force medical residents to practice integrative medicine Jann Bellamy

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