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AAFP Endorses CAM

I recently chastised the American Family Physician (the journal of the American Academy of Family Physicians) for assigning a high SORT (strength of evidence) rating to acupuncture treatments that did not merit that rating. While the AAFP claims to strongly support evidence-based medicine, I have observed a gradual infiltration of CAM into their journal, their website, and their CME offerings. They seem to be more concerned with the popularity of CAM and with not offending its believers than with maintaining scientific rigor. The problem is only getting worse.

Recently a “News Now” article was published on the AAFP website: “New Report Details Billions Americans Spend on Complementary, Alternative Medicine: Physicians Can Benefit from Adding CAM to Their Practices, Says FP” It is very disturbing.

It starts by talking about how many people use CAM and how much money is spent on it, and by recommending that family physicians try to get some of that moola for themselves. It says CAM “can help many diverse patients and earn FPs added compensation.” There is no doubt that it can earn FPs compensation, but the claim that it “can help many diverse patients” is questionable. An “integrative” family physician, Dr. Blackwelder, is quoted as saying 

Family doctors should recognize many patients use such approaches, and explore for them in an open and nonjudgmental way.

I can absolutely agree with that. He advocates good bedside manner and empathy. I can absolutely agree with that too. But then he goes on to say

In many ways, the physician-patient encounter creates a suggestible moment similar to what is done in a hypnosis session. Use that power!

I would hope that we are not hypnotizing our patients and gaining undue influence to promote things that don’t work!

That seems to be exactly what he is advocating.

Family physicians can build in discussions of CAM during face-to-face office visits for specific complaints, he said, by suggesting, for example, nasal irrigation for allergies and respiratory problems; yoga relaxation breathing for insomnia and anxiety; yin yoga for back, hip and flexibility problems; journaling for grief, depression, rheumatoid arthritis and asthma; and meditation and prayer for hypertension, stress and depression.

Sure, they could suggest those things. They could also suggest bloodletting to balance the humours, witch doctors, Perkins’ tractors, homeopathic remedies that are nothing but water, a Breatharian diet, and their own personal brand of snake oil. They could, but they shouldn’t.

Prayer for hypertension? Doesn’t work. In fact, one study showed that prayer actually increased the likelihood of hypertension. Journalling for rheumatoid arthritis? Says who?

He says

family physicians can take advantage of patients’ interest in osteopathic manipulation by making it part of their family medicine practices.

He doesn’t seem to care whether it is an effective treatment – patients are “interested” in it and that’s enough.

He recommends FPs go to a weekend course to learn acupuncture techniques, because “they’re helpful when working with patients who have addictions, such as smoking.” Oh, really? A recent Cochrane review was not confident that they were helpful. It concluded

There is no consistent evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation, but methodological problems mean that no firm conclusions can be drawn.

 Anyway, why go to a real acupuncture course? Why not just learn to do sham acupuncture? Sham acupuncture has been shown by good research to work just as well as “real” acupuncture and is a lot easier: you don’t have to bother learning the mythology of qi and the location of meridians and acupuncture points. You can just stick the needles anywhere.

He says

physicians are becoming more comfortable with botanicals and supplements now because such products can be standardized and specific dosages recommended.

Yes, they can be standardized, but unfortunately under the DSHEA most of the products on the market are neither standardized nor checked for purity. Unless you can recommend a specific product that you can be sure is safe and reliable, recommending supplements is a risky business.

Then he claims that a number of CAM remedies have solid study data demonstrating their efficacy and safety, and he lists several of these. Most of his examples are questionable. For some of them, there is solid study data showing they don’t work. For instance

  •  Saw palmetto for benign prostatic hypertrophy. The most recent Cochrane review (2009) found that it was “not more effective than placebo for treatment of urinary symptoms consistent with BPH.”
  •  Gingko for claudication. A Cochrane systematic review from 2009 found “no evidence that Ginkgo biloba has a clinically significant benefit for patients with peripheral arterial disease.”
  •  Turmeric to prevent Alzheimer’s. The only “evidence” I could find for this was the observation that people in India have a lower incidence of Alzheimer’s and they eat a lot of food with turmeric in it.

If he thinks these treatments are supported by solid study data, his idea of solid data is very different from mine. And yes, of course it is. Because he supports CAM and is willing to accept the results of any study that supports his beliefs, regardless of whether it is a well-designed study or junk science, or whether it is contradicted by more rigorous studies.

An AAFP policy statement on CAM says

The AAFP advocates the evaluation of these alternative treatments and complementary practice through various means including evidenced-based [sic] outcomes research as to their efficacy and effectiveness.

One wonders what other “various means” they would recommend. Stoned thinking a la Andrew Weil? Intuition? Dreams? The notoriously unreliable “in my experience” opinions of clinicians? Anecdotes? A popularity contest? Dowsing?

I was already embarrassed by my association with an Air Force that is now teaching battlefield acupuncture. Now I’m embarrassed to be a member of the AAFP.

Posted in: Science and Medicine

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21 thoughts on “AAFP Endorses CAM

  1. DevoutCatalyst says:

    When you get a chance maybe have a look at what the American College of Physicians are up to. They have a positive book out on CAM with the usual cast of endorsers, including the wonderful wizard of Oz.

    Battlefield acupuncture is absurd, you’re joking, right? I guess in the collective acupuncturist mind, a Swiss Army knife is nothing without its corkscrew. No stone left unturned to self-validate and self-promote. I also get the impression that acupuncturists are becoming ambulance chasers of a sort on civilian turf as well — wanting to “help integrate wellness services into existing First Responder and other programs” as one site claims. That’s the last place we need wannabe doctors poking their stupid needles into people — a momentarily captive and vulnerable subset of the population.

  2. Joe says:

    Thanks for this article. I will point-out that most herbs cannot be standardized in a realistic sense because the active ingredient (if any) is unknown. Therefore, “standardization” is arbitrarily based on some abundant, or characteristic, component. One might as well base the assay on cellulose content. A friend of this blog made the point, more politely than I usually do, http://scienceblogs.com/terrasig/2007/07/another_botanical_clinical_tri.php

    There is also a recent article that neatly summarizes the status of herbal products: Donald M. Marcus, MD, and Laurence McCullough, PhD “An Evaluation of the Evidence in “Evidence-
    Based” Integrative Medicine Programs” Academic Medicine, Vol. 84, No. 9 / September 2009, 1229–1234.

    Wallace Sampson also wrote on the topic of CAM education: “The Need for Educational Reform in Teaching about Alternative Therapies” Academic Medicine 2001 76: 248-250.

  3. David Gorski says:

    Battlefield acupuncture is absurd, you’re joking, right?

    You haven’t been reading SBM long, have you? :-)

    See:

    http://www.sciencebasedmedicine.org/?p=292
    http://www.sciencebasedmedicine.org/?p=314

  4. DevoutCatalyst says:

    I’ve read those, but it still blows my mind. We can’t invent this stuff as well as they can.

  5. MarkCC says:

    It’s not just CAM infiltrating – it’s the good old tactic of mixing in bits of *real* medicine with the CAM to give it credibility.

    Nasal irrigation is a well-researched, proven technique. It’s real medicine – backed by multiple peer-reviewed studies, and widely recommended by science-based ENTs and allergists. It is, in no way, shape, or form “alternative medicine”.

    Of course, it’s not a prescription drug. And since CAM folks always try to claim that so-called “allopathic” medicine only treats problems with drugs, they pull it under their umbrella, and take credit for it.

  6. Archangl508 says:

    Is yoga for increased flexibility really CAM? Seems more like just physical therapy to me. I wouldn’t see what is wrong with recommending that.

    Same with yoga relaxation techniques for anxiety. Seems reasonable to me as well, unless you are dealing with someone with obvious serious anxiety disorders or depression who would truly require medication.

    What is journaling? Is that writing in a journal? I could see that helping stress, grief, or anxiety, but how would it help asthma?

  7. Harriet Hall says:

    As MarkCC said, the author seems confused about what CAM is. His list combines a little “real” medicine and reasonable adjunctive measures with untested and improbable remedies.

    What is journalling? “Journal therapy transforms the traditional diary into a genuine, unique therapeutic method that offers cost-effective, holistic self-management.” http://www.journaltherapy.com/power_of_writing.htm

    If it has ever been put to a scientific test, I can’t find it.

  8. jmm says:

    Although many of your quotes are disturbing, I agree that nasal irrigation, yoga as a form of physical therapy, and yoga breathing for anxiety all make a lot of sense. As for whether they are CAM, it depends on how you define CAM. If you define CAM as unproved and/or ineffective techniques, then they are not CAM, but then if that is your definition, then arguing against CAM is tautological and silly, and hardly makes for authentic discourse. Better to stick to arguing for SBM and examine each instance of CAM on a case-by-case basis: this is the real conversation to be had.

    These are effective techniques with a non-Western history, raising cultural issues as to how best to integrate them into best practice, given that unlike much other CAM, they are effective. Or, if you don’t want to use the term CAM, find another, but clearly these techniques DO have a rather distinct history.

    Eg, although nasal irrigation is well-proven for allergies, many (although certainly not all) doctors will offer drugs only. How do we change this? I would love to see, for once, a SBM post arguing how a CAM technique like irrigation is well-proven by the data but underused in practice.

  9. kausikdatta says:

    I have long held that CAM practitioners try to (mis)appropriate genuine scientific terminology and concepts in furtherance of their pseudoscience, in order to gain legitimacy and acceptance.

    All the examples above (nasal irrigation, deep breathing, yoga exercises etc.) are techniques with adjunctive benefits at best. For example, yoga, like any good exercise regimen, will work in a particular way for most people. That is hardly in dispute, I think.

    What is atrocious, however, is the way in which these adjunctive regimens are touted by CAM practitioners to be practiced in absence of a regulated medicinal course – for many diseases that require that medical intervention; this, as one can understand, is essentially bad advice that can lead to disease aggravation, complications, and worse.

    A personal anecdote just to illustrate a point. My aged mother suffers from a condition called frozen shoulder (adhesive capsulitis) in which the shoulder capsule and the connective tissue surrounding the shoulder joint becomes inflamed and stiff, and grows abnormal tissue adhesions, greatly restricting motion and causing chronic pain. For first time sufferers, the therapy often begins with physical therapy and massage, and later, medication and even surgery. Physical therapists in India are more often than not practitioners of some form of CAM. We engaged one such, for my mother’s physical therapy – and it did work in lessening the pain and increasing the range of motion in the long term. However, the man was not content to do that job. During the sessions, he would often offer gratuitous advice as to how my mother did not really need insulin for her diabetes, or her pressure medications, but should take part in accupressure therapy or reiki, in order to alleviate these conditions! Thankfully, my mother knows better. I went through the roof when I heard this, but my mother merely humors him by lending an ear.

  10. Harriet Hall says:

    Mea culpa. I interpreted the author’s advice on coding as inconsistent with published guidelines, suggesting fraudulent billing, but I received the following clarification from the AAFP, and I will amend my post to delete any reference to possible billing fraud.

    Thank you for commenting on this article. The portion of the article on which you comment is copied below.

    “Moreover, he added, if a physician spends more than half of a face-to-face visit of 25 minutes’ duration counseling a patient about various health issues and treatment options, including CAM techniques, he or she can code that visit as a 99214 — even in the absence of history, physical exam or medical decision-making elements.”

    Note that this in no way advocates fraudulent billing. CPT has long stated that time spent counseling and/or coordinating care for patients may be the basis of selecting the level of evaluation and management service when 50% or more of the physician’s face-to-face time with the patient is spent in these activities (see the last page of the Evaluation and Management (E/M) Services Guidelines in the CPT manual). FPM magazine has published two articles explaining this concept, http://www.aafp.org/fpm/20030600/27time.html#box_a and more recently, http://www.aafp.org/fpm/20081100/17time.html?aafpvlogin=8124017&aafpvpw=&URL_success=http%3A%2F%2Fwww.aafp.org%2Ffpm%2F20081100%2F17time.html.

    I hope this clarifies the information and alleviates any concerns that the AAFP would ever advocate false billing. Indeed, it is AAFP policy to advocate for physicians and health plans to abide by CPT coding guidelines, http://www.aafp.org/online/en/home/policy/policies/c/coding.html.

  11. Doazic says:

    The key part is:
    “Physicians Can Benefit from Adding CAM to Their Practices, Says FP”

    The Physician benefits at the patients’ expense.

  12. David Gorski says:

    On the other hand, a professional coder elsewhere considered the advice in the AAFP article regarding 99214 to be dubious.

  13. Peter Lipson says:

    It is a widely held belief among docs that coding lots of counseling visits buys an audit, and the audit results rarely favor the physician.

  14. David Gorski says:

    Oh, I think it’s more than just a belief. At places I’ve worked, I’ve been warned about using such codes for counseling visits without making sure that every i is dotted and every t is crossed in the documentation.

    Regardless of whether the advice given in the AAFP article was strictly on the up and up from a legalistic and technical standpoint, it just doesn’t pass the smell test. It reeks of recommending shady (although possibly technically acceptable) billing practices to family practice docs in order to promote modalities that do not work and to make more money. Not good.

  15. wertys says:

    That comment about physicians using their authority to take advantage of pts suggestibility is enough to make me wanna quit medicine and join the woosters. That is EXACTLY the type of unscrupulous opportunism which allows sCAM to flourish and gain credence with the public.

    The other thing that really SH*&^ts me is when you have good scientific evidence for something in a particular contex, eg interdisciplinary rehabilitation programs which include mindfulness and body awareness training, physical reactivation etc for chronic pain sufferers and you are labelled by the woosters as supportive of mindbody or bodymind or integrative medicine. As has been pointed out elsewhere in this blog, ANY treatment which can be convincingly demonstrated to be of benefit will be adopted by real medicine. We just take more convincing than most other types of health professionals, and money is not usually as important as the knowledge that we can make a difference.

    My summary, people who want to upsell should go work at Burger King.

  16. Tsuken says:

    Soooo … the AAFP clearly have read your post, and took the time to insist they’re not advocating dodgy billing … but didn’t feel able to argue the points about abusing the doctor/patient relationship to promote ineffective interventions…. Interesting. Apparently that’s fine and dandy as long as your billing is accurate.

  17. David Gorski says:

    Indeed. It would seem that the AAFP was only angered by Harriet’s previous version of this post, which suggested that it advocated billing fraud. Instead of addressing the whole problem with advocating unscientific medicine and taking advantage of the physician-patient relationship in order for physicians to enrich themselves by selling CAM, instead they go all technical and legalistic, insisting that what Blackwelder said was technically acceptable.

    Disgusting.

  18. Harriet Hall says:

    A clarification: the AAFP was only responding to an e-mail I sent them about the issue of billing fraud. I don’t know if they saw my post or Orac’s. I answered their e-mail response with a note about my other concerns. No response to that yet, and I’m not really expecting one.

  19. A few years ago, my wife went to a physician who turned out to be much more “interested” in CAM than most patients. He did applied kinesiology and vega testing. He sold Chinese herbal remedies and prescribed homeopathy. All of CAM’s greatest hits.

    He was effectively an ND, but with MD behind his name. We have quite a few like this in Vancouver. Nothing like a majority, of course, but a disturbingly large minority.

    I wonder what their billing practices are like …

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