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CAM practitioners as primary care providers under the Affordable Care Act: Part 2

In the last post, we took another look at Section 2607 of the Affordable Care Act, which prohibits “discrimination” against licensed CAM practitioners by insurers, and how chiropractors are continuing their PR campaign to rebrand themselves as primary care physicians. This time, we review a recent white paper by the Academic Consortium of Complementary and Alternative Healthcare, an organization that might be seen as CAM’s answer to the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM). The Academic Consortium for Complementary and Alternative Health Care (ACCAHC) is a group of “complementary and alternative medicine” educational organizations representing chiropractors, naturopaths, acupuncturists, homeopaths, ayurvedic practitioners, direct entry midwives and massage therapists. The executive director is John Weeks, a relentless promoter of “integrative medicine,” both on the Integrator Blog website and in the Huffington Post. The ACCAHC is dedicated to ensuring that its members and the practitioners they represent are included in all aspects of health care, such insurance reimbursement, financial resources for education and delivery models. ACCAHC’s stock-in-trade is its practitioners’ supposed expertise is being patient-centered, holistic, taking into account the whole person and such, as well as an alleged emphasis on healthy lifestyles, nutrition, well-being, and the like.

In fact, the stated vision of the ACCAHC is remarkably similar to that of the CAHCIM:

ACCAHC envisions a healthcare system that is multidisciplinary and enhances competence, mutual respect and collaboration across all healthcare disciplines. This system will deliver effective care that is patient centered, focused on health creation and healing, and readily accessible to all populations.

The CAHCIC’s vision is:

A comprehensive and compassionate health care system offering seamless integration of effective complementary and conventional approaches to promote healing and health in every individual and community.

Indeed, there is an overlap in governance of the two organizations. Benjamin Kligner, MD, Adam Perlman, MD, Mary Jo Kreitzer, PhD, RN, and Aviad Haramati, PhD, are all on the ACCAHC’s Board of Advisers, as well as being either current or former members of the CAHCIM’s Executive Committee. The Board of Advisers also includes other integrative medicine luminaries such as Brian Berman, MD, Wayne Jonas, MD, and David Katz, MD. The two organizations have worked together in several endeavors. One wonders why the they don’t just go ahead and merge. (Actually, one knows perfectly well why they don’t.)

As might be imagined, actual evidence that CAM practitioners can deliver on the lofty generalities of its vision and mission is in short supply. That has not stopped the ACCAHC from several initiatives aimed at cheerleading its way into modern healthcare. In this it has attained some success, according to its website.

The ACCAHC has issued “Meeting the Nations Primary Care Needs: Current and Prospective Roles of Doctors of Chiropractic and Naturopathic Medicine, Practitioners of Acupuncture and Oriental Medicine, and Direct-Entry Midwives,” a white paper “developed through the Primary Care Project of the ACCAHC,” under the editorship of Michael S. Goldstein, PhD, of the UCLA Center for Health Policy Research and John Weeks, published in March, 2013.

The paper laments that, despite the shortage of MD/DO primary care physicians and the consideration of other health care providers as means of addressing this gap, such as nurse practitioners and physicians assistants,

workforce analyses and healthcare delivery practices have not to date engaged the potential contributions of chiropractors, naturopaths, acupuncturists and direct-entry midwives as providers of primary care.

Thus,

the goal of this paper is to assist policy makers, regulators, third-party payers, delivery system administrators, practitioners, and other concerned parties as well as the disciplines themselves in considering the optimal use of these professions as part of the nation’s primary care matrix.

Toward this end, teams were chosen by the Association of Accredited Naturopathic Medical Colleges, Association of Chiropractic Colleges, Council of Colleges of Acupuncture and Oriental Medicine, and the Midwifery Education Accreditation Council to set forth how each field meets, or does not meet, “conventionally used definitions of primary care.” (The Midwifery Education Accreditation Council has jurisdiction over direct-entry midwives. These midwives do not have the equivalent education and training of nurse midwives. I will not cover their portion of the paper in this post.)

We should note here that, according to one of the “conventional” definitions of primary care referenced in the paper, primary care includes the ability to meet the health care needs of the “undifferentiated patient”, that is

persons with any undiagnosed sign, symptom, or health concern . . . not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis.

(From the American Academy of Family Physicians [AAFP], 2010)

According to the same definition, primary care physicians must also be able to “treat acute and chronic illness in a variety of health care settings.” This is not all that they do, of course. The AAFP’s definition of primary care also includes health promotion, disease prevention, health maintenance, counseling, patient education, promotion and maintenance of wellness.

In supposedly answering the question posed, the paper provides a lot of platitudinous statements about wellness, health promotion, patient-centered care, the whole person, natural remedies, the body’s self-healing abilities, and so on. There is also a great deal of talk about being a “first contact” provider for patients, insurance coverage, what the scope of practice acts say, the fact that this or that provider is called a “physician” or “doctor,” what government programs include or do not include, accreditation by the U.S. Department of Education, what their patients think about them and other information not directly relevant to two key components of primary care practice if one is to practice independently, without supervision of an MD or DO. If these components are not part of the practitioner’s skill set, then he or she shouldn’t be claiming rights to the PCP title.

To determine whether these key components are present two questions must be answered: (1) does the chiropractor, naturopath, or acupuncturist have the education, training and ability to see the undifferentiated patient in his office and know what to do with her, that is, can he diagnose the undifferentiated patient, either deciding to treat her or refer her to another provider? And, (2) does he have the education and training to treat acute and chronic illness in a variety of health care settings?

Let’s see how this paper addresses these critical aspects of primary care because, if CAM practitioners can’t convincingly argue that they can do these things safely and effectively, they shouldn’t be considered for the job, credulous legislators aside.

“Acupuncture and Oriental Medicine Practitioners in Primary Care”

(Statement approved by Council of Colleges of Acupuncture and Oriental Medicine)

The acupuncturists admit that they do not have sufficient “biomedical training” (their term) to serve as primary care providers if one’s definition of primary care means that the practitioner meets all of the biomedical and health needs of the patient. Depending on which accreditation agency oversees a particular acupuncture school, students have between 450 and 588 hours of biomedical training, although the subject matter and quality of these courses is not addressed. They add that there have been no published studies examining AOM providers as primary care providers.

However, like chiropractors, there is a faction within acupuncture which supports the development of acupuncturists as primary care practitioners. This group formed the National Certification Commission for Acupuncture and Oriental Medicine, but the organization has not been recognized as an accrediting body by the U.S. Department of Education. The authors believe acupuncturists must reach a consensus that they want to be PCPs before this idea moves forward, but “the acupuncture terrain is rapidly changing and this situation could change within 3-5 years.”

Oddly, they say that

there has been an opinion within the CAM community that a one year primary care training program would prepare AOM practitioners to work within mainstream medicine, with training similar to that of a physician assistant (PA).

One year?

The authors note that there are three states (California, Florida and New Mexico) which define acupuncturists as “primary care physicians” in their practice acts. These statutes

imply that providers in these states provide comprehensive biomedical care commensurate with the training of a primary care biomedical provider. This issue has led to some providers within the profession to assume that they have the same primary care mandate as a medical doctor or nurse practitioner without the commensurate level of biomedical training and to push for an expanded role within primary care, even with the current level of training in the US.

On the other hand, the authors vigorously defend their ability to be a first contact health care provider seeing patients who have not been seen by a medical doctor, provide care for those who do not need “more intensive biomedical care” either initially or during the course of being under an acupuncturist’s care, and are trained to make both emergency and non-emergency referrals when necessary.  No matter what their actual education and training, the authors point to studies that patients actually used acupuncturists for musculoskeletal complaints, anxiety, depression and other mood disorders, and other conditions including digestive disorders, respiratory disorders, urinary and reproductive disorders, infections conditions, autoimmune disorders, headaches, fatigue, stress, and allergies, among others.

“The Chiropractic Profession and Primary Care”

(Endorsed by the Association of Chiropractic Colleges)

The chiropractors claim, right off the bat, that they are primary care physicians. This is based on the Council on Chiropractic Education, the American Chiropractic Association, International Chiropractors’ Association and other chiropractic organizations saying that they are. The authors say that chiropractors can practice as a first-contact provider for patients of all ages and genders, assess a patient’s health status, formulate a clinical diagnosis, develop a case management plan that includes treatment, prognosis, and any necessary referrals. They can (according to the ACA) address “a large majority of personal health care needs.” The ICA says that the chiropractor can “provide all three levels of primary care interventions and therefore is a primary care provider, as are MDs and DOs.” The authors further claim that chiropractors “are trained to appropriately diagnose and manage the majority of healthcare issues that may present to their offices.”

If that is the case, it is certainly not proven in this document. Although studies and various surveys were cited, none supports the claim that DCs are capable of acting as primary care physicians nor do they support the assertions made by the CCE, the ACA or the ICA.

The chiropractor portion of the white paper ends by seeking to bifurcate primary care into two different types: primary medical care and primary health care. This allows the authors to hold forth on two of the CAM practitioners favorite subjects: how “holistic” they are and how bad medicine is.

The distinction aligns with the holistic biopsychosocial model of health as opposed to the biomedical focus on disease alone. . . Primary health care pays attention to both objective and subjective findings; it is truly patient-centered. Instead of medical specialists, the emphasis is on generalist health professionals who are trained and willing to work together. In this view, while primary medical care is dominated by medical physicians and internally focused on its own institutions and behaviors, primary health care explicitly seeks community participation and a wide range of professionals, always working the with patients as partners in the relationship.

However, in discussing barriers to chiropractors playing a greater role in primary care, the authors have (most certainly unintentionally) provide an unflattering picture of what chiropractic primary health care would look like. They note that some payers won’t “reimburse DCs for primary care services. An egregious example is that Medicare that pays for manipulative treatment but not for the diagnostic work that must precede it.” What they are referring to is the fact that Medicare pays for manual manipulation of the spine to correct a “subluxation” but does not reimburse for an x-ray to “detect” the subluxation. Of course, the chiropractic subluxation doesn’t exist and it can’t be detected at all, on an x-ray or otherwise. The “holistic biopsychosocial model” indeed.

“Naturopathic Physicians in Primary Care”

(Endorsed by the Association of Accredited Naturopathic Medical Colleges)

Naturopaths, as did the chiropractors in their report, like the Institute of Medicine’s definition of primary care because of its appealing vagueness when plucked from the context in which it was created.

Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

The actual 1996 IOM report from which this definition is taken is 400-plus pages long. Nowhere in the report does it indicate that the IOM thinks medical education and residency should be chucked for PCPs or that chiropractors or naturopaths should be primary care physicians. (Quite the contrary – see chapter 7.) Yet naturopaths seem to think that declaring they can meet the IOM definition, without knowing what the IOM was talking about, is sufficient to claim the role:

By philosophy, training and practice, modern naturopathic primary care satisfies these criteria by providing individualized, comprehensive, patient-centered care for all conditions and demographics.

Does it? Let’s look at the evidence presented.

There is virtually nothing about naturopathic education and training in the report, much less any hard evidence that it is sufficient to support a PCP scope of practice. (Mark Crislip came to a similar conclusion in his review of an earlier attempt by naturopaths to convince us.) In attempting to address their lack of clinical education, they make the curious argument that, since most primary care occurs in community settings and in-patient care is provided by hospitalists, their lack of hospital-based training is not problematic.  The authors apparently hold the misguided impression that training in a hospital is simply for learning about “hospital-managed pathology” (their term) and therefore unnecessary. (Of course, this also ignores the 3 additional years of clinical training an MD or DO primary care physician must undergo.)

As for research, the authors claim that naturopathic “principles are continually being reexamined in light of scientific advances.” But in the very next paragraph, they say that some naturopaths specialize, giving as an example the specialty of homeopathic medicine, a naturopathic principle that is most certainly not examined in the light of science at all, much less scientific advances. They then go on to claim:

Although the literature based on naturopathic outcomes in disease and health is limited, there is increasing evidence demonstrating effectiveness and cost-effectiveness.

Eleven studies (one of which was addressed by David Gorski here) are cited, but they don’t tell us what these studies actually concluded. There is also a reference to the Naturopathic Physician’s Research Institute but that is equally unimpressive. Some of this research is downright disturbing, such as “Safety and efficacy of oral DMSA therapy for children with autism spectrum disorders: part B – behavioral results.” This study, done at the Southwest College of Naturopathic Medicine,

investigated [DMSA’s] use for an off-label application, namely treating children with ASD who have evidence of significant heavy metal exposure (based on urinary excretion after DMSA challenge). DMSA preferentially binds to lead, but can also increase the excretion of several other toxic metals (including tin, bismuth, thallium, mercury, antimony, and tungsten) to a lesser extent. Another paper resulting from this study discusses the strong correlation of the initial severity of autism with the body burden of toxic metals.

The urine toxic metals test is a scam and the “theory” that the severity of autism is correlated with any “burden of toxic metals” is quackery.

Conclusion

What the Academic Consortium for Complementary and Alternative Health Care white paper demonstrates more than anything is that the state practice acts for chiropractors, naturopaths and acupuncturists give all of these practitioners a scope of practice that far exceeds their abilities. Acupuncture practice is more limited in most states but, as the acupuncturists themselves noted, they have a scope of practice in three states they are not properly educated or trained to assume. Even where they are not specifically defined by law as PCPs, they believe they can see the undifferentiated patient as an acupuncture and oriental medicine provider, while referring patients when they need “biomedical” care. Yet they fail to realize that without “biomedical” education, they cannot reliably determine when such care is required.

Chiropractors in all states can see any patient with any disease or condition, although there are a handful of diseases they are, by law, prevented from treating. The same is true for naturopaths in most states where they are licensed. But given the opportunity to present evidence that they can safely and effectively act as primary care physicians, that is, first contact providers who can diagnose and treat (or safely refer) all patients, they have fallen far short.

The ACCAHC has unwittingly provided an excellent resource for anyone lobbying for reform of the CAM provider practice acts. This is especially true in light of Section 2607 of the Affordable Care Act, which mandates reimbursement based on scope of practice allowed by the state, not the provider’s actual abilities.

Posted in: Acupuncture, Chiropractic, Legal, Naturopathy, Politics and Regulation, Traditional Chinese Medicine

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44 thoughts on “CAM practitioners as primary care providers under the Affordable Care Act: Part 2

  1. Andrey Pavlov says:

    The distinction aligns with the holistic biopsychosocial model of health as opposed to the biomedical focus on disease alone…

    Funny. It was the so-called “mainstream” medical folk that invented the biopsychosocial model of care and it us we that continue to learn, refine, and practice it. How nice of them to hijack our own progress within our field and then use that to somehow differentitate them from us. The tortuous logic and complete lack of intellectual honesty boggles the mind.

    Also, it is ridiculous to think that just any field can be primary care and deal with the undifferentiated patient. Even most actual medical professional fields wouldn’t be able to do so (and don’t even attempt to do so). Can an optholmologist or surgeon or even cardiologist deal with the undifferentiated patient? Of course not. The one thing they could do much better than any DC, ND, or whatever is know when to refer and probably whom to refer to. Which would lead to referall in most cases. And what is the point of creating a primary care portal of entry that spends the vast majority of the time referring to others? It really isn’t sufficient to just know when to refer. By that token a plumber could be just as effective a PCP as a DC – he would just refer 99% of cases and pull out a splinter, trim a hangnail, and throw a bandaid on paper cuts for the rest.

    The real danger is that, unlike the plumber, the DC or ND would think he can actually treat some disease states and indeed mischaracterize many of them in the process.

  2. I could not even bring myself to read this post thoroughly lest I succumb to utter despair, but rather skimmed through. It seems that we are simply going to have to see this Tooth Fairy Medicine through to its ugly end, which is that significant numbers of people will have to be shown to have died from lack of actual medical care before science will trump belief–and I’m not sure that will be enough as the following anecdote demonstrates.

    I had a beer with a neighbor last night–she sees a chiro once a month for “maintenance” of her two herniated discs (she’s “NOT having any damn surgery!”). She doesn’t care if the chiro is s quack (she actually listened to my summation of chiropractic and its dangers!), he “makes her feel better” and “doesn’t push any pills” on her. She accepts my facts, but it doesn’t matter.

    I’m pretty sure she’d like insurance to pay her Chiropractor.

  3. windriven says:

    Today’s blog leaves me with a sense of resignation and dread. The lunatics are indeed taking over the asylum. The very idea of a chiro or naturopath or – and you’ve just got to be kidding me here – an acupuncturist as a primary care provider is so ludicrous and yet so unbelievably dangerous that I cannot fathom that any educated person could admit to the possibility.

  4. erikttr says:

    There is a veterinary office in my neighborhood that advertises acupuncture and massage on its windows. I’d heard from word of mouth that this particular practice was terrible & didn’t know to do a fecal test for giardia for a dog that had frothy diarrhea and there was a documented community outbreak at our city’s biggest dog park. He recommended rest, massage, “natural” diet, etc. So frustrating when the treatment is simple and effective & within a day, most dogs improve. It’s strange because I only see these acupuncturists & chiropractors in well-to-do neighborhoods where you’d think the clientele would know better. I wish these centers for integrative medicine werent in so many of the nation’s top medical schools. they tend to be squeeky wheels and be very self promotional within the institution, as well as suck up significant administrative resources. I’m going to browse this white paper during my commute to work today.

  5. Chris Hickie says:

    I’ve been amazed that chiropractors actually claim to treat ear infections in children with their usual adjustment thingy. As it already stands, I have a few families that come to me a few days after that fails…after their child has been running fevers and miserable a few days longer than they needed to. Given their was no tort reform in the ACA, I do hope these new “primary care providers” have to pay the same amount I do for my malpractice insurance–but I’m holding my breath to see if that actually happens.

    1. windriven says:

      @Chris Hickie

      “but I’m holding my breath to see if that actually happens”

      I’d exhale if I were you. The best information that I can find is that medical malpractice insurance costs ~10 to 40 times more than chiropractic insurance. Insurers cite the higher risk patients seen by physicians and higher risk procedures performed. We’ll see if that holds when quacks work as PCPs and start missing slam dunk diagnoses.

  6. cowboybill says:

    I have several comments. Thanks for the post.

    ACKACK and CAKIM (how these orgs are pronounced): ACCAHC was created so that a cadre of CAM folks might find a way to be drafted into the mainstream (by CAHCIM) without giving up their “autonomy/authority” as real world practitioners of “their medicine” which they differentiate from “western” or “biomedicine.” The recent report ACKACK has produced is their attempt to establish credibility in the world of academic medicine. The effort has flopped. The info is dated. Their conclusions are CAMs are not ready, especially in the case of licensed acupuncturists (LAcs) to work in the mainstream. The fulcrum is the insistence of ACCAHC leaders that “their medicine” should be recognized for its legitimacy alongside and on par with plain old vanilla culturally dominant medicine.

    Primary care is one entry point for any CAM provider willing to be trained in medicine. The primary care provider gap is real. The ACA is already overwhelming the US healthcare system. It is not possible to train enough mainstream providers to meet the current and forthcoming demand for care; not in a decade. Looking towards CAM providers and deploying them strategically seems obvious. However, first they must be trained alongside mainstream providers. This is a sticking point for the ACKACK crew since they are unwilling to relinquish what in their minds is their established autonomy. They are deluded. The roots of that belief are for a political psychologist.

    Several of the prominent NOMAA folks were trained as LAcs in a lone Calif program that included medical traditions including working with cadavers and in mainstream clinical sites. This lone program disappeared with legislation that liberated LAcs from Medical Board oversight in the early 1980s. The earliest acupuncture legislation in Calif “grandfathered” 900 non-credentialed acupuncturists into licensure. This kind of fraud is emblematic of a continuing problem in the profession. When will ACKACK address these issues? Not their problem.

    NOMAA is not the primary care source cited in the ACCAHC report. The principal goal of NOMAA was to accredit acu training programs that would raise the standard to 4,000 hours. The additional 1500 hours (ca. 2003) would have focused on medicine, placing acupuncture and so-called Oriental medicine in the context of modern medicine. The reference made is to a paper published in 2008 that suggested LAcs could work in a primary care provider ROLE doing triage if the LAcs trained in a clinical setting alongside for a year and completed coursework in the basics of primary care as one finds in a PA program.

    This is the tip of an tiny iceberg floating somewhere in a vast healthcare ocean.

  7. park.au says:

    While I’m personally skeptical of a lot of alternative medicines, I’m accepting of them when they are proven to work. I think as long as these practices hold up to scrutiny, then it is fair for them to market themselves as panaceas. A lot of our current medications came from herbal remedies (aspirin was willow bark, lovastatin from red yeast rice and oyster mushrooms, opioids and poppy plants, etc). That being said, it is the holding up to scrutiny that is the rub. Databases such as Natural Standard show a huge amount of variance in the quality of studies and the results that CAM has. Without strong evidence, there’s little compelling reason to adopt them into practice yet.

    1. Jann Bellamy says:

      @cowboybill:

      Thanks for the correction. I have changed the reference in the text.

      You make some very interesting comments and appear to have inside information. I wonder why you say that the info is dated because it came from the accrediting agencies for their schools and I would think they would have up-to-date information. As for CAM providers being a part of primary care, I cannot agree. I don’t think any provider whose practice is not based on the rational application of science to medicine and healthcare should participate in the system. If these practitioners were guided by that standard, they wouldn’t be chiropractors, naturopaths, and acupuncturists.

      @park.au

      When therapies previously labeled “alternative” are proven to work, they become
      “medicine,” not “alternative medicine.” No one argues that plants have not been a source of modern drugs. The difference is that pharmaceuticals must be proven safe and effective before they go on the market. This system has its faults, of course, as CAM promoters are fond of pointing out. But it is a lot better than selling plant-based medicines that haven’t been subjected to the same standard as pharmaceuticals while at the same time promoting their use for medical purposes.
      That said, you are at least an informed and skeptical consumer — the vast majority of CAM customers/patients are not.

      1. cowboybill says:

        “inside information” I have spoken with several acupuncturists who trained at Calif Acu College which is the school in point.

        “dated info” With this Report ACCAHC aimed to represent itself as a leading think tank on CAM in healthcare. In fact, prior to this report ACCAHC was staunchly opposed to “integrative medicine” on any terms other than their own which, as pointed out, requires equal recognition and regard for their “medicines.” These ideas have been vetted elsewhere for 3 to 4 years prior to this dated report.

        “up-to-date information” IMO at least some of the leadership involved with ACCAHC is out of the loop in healthcare. For example, the statement that LAcs in Calif are primary care providers is wrong. All one need to is read the Legislative Intent (section 4926) of the practice act in Calif. “individuals practicing acupuncture be subject to regulation and control as a primary health care profession.”

        “CAM providers as PCPs or functioning in a primary care role” Let’s pick up this discussion in 12 months when the ACA is teetering on collapse from a lack of providers.

        I like Richard Dawkins quote “There is no alternative medicine. There is only medicine that works and medicine that does not work.”

        I also like a quote about the reality of medical training (in this case not limited to MDs) which I attribute to a colleague: “that’s why they call it medical PRACTICE.”

      2. cowboybill says:

        Re NOMAA – your reference was partially correct. NOMAA attempted to win DOE recognition as an alternative ACAOM, the only DOE recognized accreditation for stand-alone acu schools. NCCAOM is a non-profit 501(c)6 group that tests all acupuncture schools grads EXCEPT for those in Calif which must take the Calif licensing exam. NCCAOM has shown no interest whether LAcs work in primary care. A 501(c)6 is a non-profit category under IRS code for groups that promote a business or industry. Every state other than Calif defers testing to NCCAOM. The ACCAHC report did write the “oddly” statement as you indicated. There is a question is whether they understood the point.

    2. WilliamLawrenceUtridge says:

      When alternative medicine is proven, it ceases to be alternative medicine and simply becomes medicine. The difference between the herbal remedies you are citing, and the herbal remedies promoted by CAM practitioners, is proof (plus, the ability to control the dose extremely precisely, understand the pharmacokinetics, modify the molecules to be better processed by the body, reduce adverse effects and more). If a plant molecule has an effect, the same molecule from a steel vat will be a better, more reliable source.

      The difference between a doctor and an herbalist, in addition to superior molecule, is one assesses the evidence for treatment before providing it, the other doesn’t. Not a trivial distinction, particularly considering the potential for severe side effects like kidney failure.

      I can never see the promotion of alternative medicine as anything but unethical (and often arrogant, not to mention riddled with fallacies; and smug. Sooooo smug).

      1. “I can never see the promotion of alternative medicine as anything but unethical (and often arrogant, not to mention riddled with fallacies; and smug. Sooooo smug).”

        You have never had to care for someone who has suffered the adverse effects of a foul medication. or persuaded a patient from suing a foul medical doctor.

        IMO the fallacy is in the mind of the idealistic person who believes science so precise and sincerely that you find it acceptable to poisoning someone just because of the data. I’ve been doing this for 30 yrs and have following all the rules and have made countless patients ill and hospitalized due to adverse reactions. Thanks scientist!

        Not anymore … I have my “voodoo tools, blood letting and a couple of herbs and spices and a lot of common sense. I have to say this model get good results without liver, renal or hematologic toxicities.

        OH … Patients love this new paradigm.

        1. Carl says:

          Yeah, I’m sure they feel great when you feed them some BS about a couple magic herbs and tell them they don’t have to make any difficult decisions or balance any risks.

        2. WilliamLawrenceUtridge says:

          I bet patients love your approach. You tell them that they have a condition that can be treated, then give them an incredibly dramatic treatment. Do you see a lot of acutely ill patients, or mostly patients complaining of vague symptoms like fatigue, muscle pain and poor sleep?

          What kind of doctor are you?

          1. s. sap says:

            This is so typical of the AMA and MDs trying to flex their muscle. Its all out of fear. Kind of like what happened with the DO’s they were a threat to you and if you couldn’t beat em you had to join em. While I don’t agree that Chiripractors or Acupuncturists should be PCPs Nathropaths who have gone to an accredited school have an 8 year education plus a residency. In fact they take the same science boards that MDs do. How much do you remember from the hour long lecture in nutrition you got in med school? The body is an amazing thing it has the power to heal itself. MDs are responsible for killing over 100,000 people every single year. Trash talking NDs saying they don’t know when or who to refer pts to that is just plain ignorant. These Doctors believe in first do no harm. Patients all over the country are tired of being just another number in your office. In our office we know people on a first name basis. We spend more than 3 minutes with them, our priority is about healing. We treat the person, not the symptoms. Bastyr University puts out the “Harvard equivalent NDs.

  8. TBruce says:

    The best information that I can find is that medical malpractice insurance costs ~10 to 40 times more than chiropractic insurance.

    I looked into this question and in Canada,at least, the rates for malpractice insurance for chiropractors and GPs with primarily an office practice are about the same. High-risk specialties (neurosurgery, obstetric etc) have considerably higher fees, however, they shouldn’t be considered in the comparison.
    I don’t know what the comparative fees in the US would be.

  9. Art Malernee dvm says:

    There is a veterinary office in my neighborhood that advertises acupuncture>>>>

    Two state veterinary schools teach acupuncture to young students. Florida and Colorado :(

  10. Ben Kavoussi says:

    @ Jann,

    Excellent post. One comment about the status of acupuncturists in CA. Indeed, they have a status equivalent to primary care providers in the state. However, they are prevented from claiming that they “cure any type of disease, condition or symptom.” Look at this page on the CA Acupuncture Board:

    http://www.acupuncture.ca.gov/consumers/consumer_faqs.shtml

    Two-thirds down the page, it reads:

    Q. DO I NEED A REFERRAL FROM MY REGULAR DOCTOR TO SEE AN ACUPUNCTURIST AND WILL MY INSURANCE COVER ACUPUNCTURE TREATMENT?
    A. An acupuncturist is considered a primary care provider and a referral may or may not be required for insurance purposes. Many insurance companies do cover acupuncture treatment. For more information on insurance, please contact either your insurance company or an acupuncture association.

    But there questions down, it also reads:

    Q. I READ AN ADVERTISEMENT WHERE AN ACUPUNCTURIST CLAIMS THE ABILITY TO CURE MY DISEASE. IS THIS LEGAL?
    A. No. Pursuant to California Code of Regulations, Title 16, Section 1399.451(b) it is improper for an acupuncturist to disseminate any advertising which represents in any manner that they can cure any type of disease, condition or symptom.

    Let me reiterate this to highlight its asinine absurdity: acupuncturists are primary care providers that cannot can cure any type of disease, condition or symptom! This is something I had expected to find in a fairytale, not in CA law.

    So what are the 10,000 CA licensed acupuncturists doing? Well, to keep themselves gainfully employed, they are treating disease that do not exist: like the running piglet syndrome, damp-heat in the lower burner, or liver fire blazing upwards (I am not making that up!); and they are treating these mind-boggling absurdities with procedures that do not exist, neither, like sedating the rising yang, or dispersing the heat in the liver meridian. again I am not making that up!

    I am at a loss for words: is this charlatanism or schizophrenia?

    1. I can tell you for certain … none of these Acupuncturist will put someone in the hospital for an overdose, under-dose, mis-dose, mis-prescribed or wrong pharmaceutical medication fiasco!

      Traditional Acupuncture has it’s place … we have to check the egos and make the decision.

      1. Carl says:

        Well, maybe you can tell us for certain that those specific things won’t happen. But how about these things?

        “perforation of the lungs by needle insertion is one of the most common and serious complications of acupuncture treatment”
        http://www.ncbi.nlm.nih.gov/pubmed/14568778

        Acupuncturist gives patients hepatitis B while trying to perform some improved acupuncture garbage:
        http://news.bbc.co.uk/2/hi/health/1024753.stm

        “Quebec calls 1,200 people for HIV tests, acupuncture clinic reused needles”
        http://usatoday30.usatoday.com/news/world/2004-03-15-canada-hiv-tests_x.htm

        Oops, that’s some nasty side effects for a treatment which is good for nothing but a false sense of ease when you convince the patient that your practice isn’t a load of crepe.

  11. Oh, with my new understanding of how Acupuncture truly works (2013 version) I would modify some of the ancient protocols they use and bring them into this decade.

    1. WilliamLawrenceUtridge says:

      You consider 1930-1950 CE to be ancient? The use of filiform needles dates to the 1930s, and the specifics of point locations were formalized by the Chinese Communist Party in the 1950s. You should read Kim Taylor’s remarkable book, Chinese Medicine in Early Communist China, 1945-63; A Medicine of Revolution, where you will find many of your current practices invented. Not very ancient indeed.

      What kind of doctor are you?

  12. JesusR says:

    [Off topic]
    Any thoughts on the Cochrane review that concludes that influenza vaccine has a low efficacy (100 people need be vaccinated to avoid 1 case)? I’ve search here and found some brief dismissals, but not a proper assessment.

    “The results of this review seem to discourage the utilisation of vaccination against influenza in healthy adults as a routine public health measure”

    http://summaries.cochrane.org/CD001269/vaccines-to-prevent-influenza-in-healthy-adults
    Full text: http://www.whale.to/v/2010+coch+adult.pdf

    There was also a recent article on BMJ questioning the public policy on this topic:
    http://group.bmj.com/group/media/latest-news/expert-questions-us-public-health-agency-advice-on-influenza-vaccines
    http://www.bmj.com/content/346/bmj.f3037

    1. WilliamLawrenceUtridge says:

      Jefferson’s influenza griping has been criticized here several times, but you’ll probably have to wait until the fall to see much discussion of the ‘flu and its difficulties.

      The influenza vaccine is a tricky, tricky question for so many reasons – hard to make a good one, less dramatic than so many other diseases, and its lethality is extremely labile; most years it’s not that bad, but Spanish Influenza killed hundreds of millions. Public health authorities can’t win.

      Not helped overall is the knee-jerk questioning and rejection of vaccines in general. If people contextualized the vaccine properly (yeah, it probably won’t save your life, but there’s essentially no risk and you are spared several days of miserable bone-grinding pain, not to mention protecting those around you) and just got the damned shot, life would be better for many.

      John Barry’s The Great Influenza is a fantastic book covering the Spanish ‘Flu, I highly recommend it.

  13. David Morgan says:

    Thanks Jann for sharing this great article with us. I fully agree with andrey that biopsychosocial model of health always differs with biomedical model. Thanks again.

  14. Ben, thanks for this. I will certainly reference it at some point in the future. Particularly since I am planning on returning to California (assuming I match there, of course) for my graduate training next year.

  15. W Bruce Milliman, ND says:

    Why don’t we talk clinical care, you and me…not just all of these opinions, biases and theories. I’m available. To reach me quick, call (206)734-0419…If I don’t pick up, leave me times and numbers of your availability.

    W Bruce Milliman, ND
    Seattle Healing Arts Center
    6300 9th Ave. NE, 2n Floor
    Seattle, WA 98115
    (206) 522-5646 x 1004

    Speaker, House of Delegates
    American Association of Naturopathic Physicians

    1. weing says:

      What have you healed?

    2. Chris says:

      Cool, tell me how effective you are at things that I have encountered as a parent could be on the list. Stuff like ear infections, strep infections, nurse’s elbow (it gets out of joint), seizures, warts, migraines, obstructive hypertrophic cardiomyopathy, chicken pox, and on and on

      Just give me the PubMed indexed study that shows your methods are actually effective. And do it here, not by phone. Explain very well how you would deal with an infant who is in full convulsions. Do you tell the parent to bring the child in, or do you tell them to call 911 and get the child to a an emergency department with real doctors?

      Otherwise, the blatant ad was very bad form.

    3. WilliamLawrenceUtridge says:

      What do you heal with homeopathy?

  16. Woo Fighter says:

    Weing:

    Probably nothing.

    From Mr. Milliman’s website, below. Just a sample of what he sells, along with reiki, CST, “quantum touch,” unani medicine and of course homepathy. There are many mentions of “chakras” and “qi” all over his website.

    SOUND HEALING

    A form of therapy that uses sound to balance and align the physical body and its energy centers (chakras). It works on the premise that everything in the Universe is energy in vibration, and that using various types of sound, healing can occur when the body is realigned to its natural frequencies of vibration.

    Practitioners may use intuition, intention and visualization to select appropriate sound healing frequencies, and therapy might include human voice, tuning forks, tonal sounds or music to help release pain and stress, and align unbalanced areas of the body.

    Acutonics Healing

    Acutonics is an energy-based treatment that is similar to acupuncture. Precision-calibrated tuning forks are applied to specific meridian points to access the body’s energy systems. The sound waves of the forks vibrate and travel deeply into the body along energy pathways, affecting human physiology and reaching places not easily accessed by traditional medicine. Applying the forks stimulates and balances the body’s physical and subtle energy field to promote healing and inner harmony.

  17. dr. jc smith says:

    Have you all forgotten that America is in the throes of a healthcare crisis–leading the world in every category of disease at the cost of trillions–all due to the medical mismanagement?
    Have you also forgotten the recent BMJ editorial that found 2/3rds of medical care is “ineffective, unproven, or too risky to use”?

    The Washington Post published a recent article to this effect: “Surprise! We don’t know if half our medical treatments work” by Sarah Kliff who reported on an article in the British Medical Journal.

    The following pie chart is shocking considering it shows nearly 2,000 of 3,000 medical treatments studied fall into these categories:

    “Unlikely to be beneficial”,

    “Likely to be ineffective or harmful”,

    a “Trade-off between benefits and harms”, and

    half are of “Unknown effectiveness.”

    I suggest you medical chauvinists get off your high horse and admit the failings of medicine. If you believe in free enterprise, let the marketplace determine what treatments work best rather than the medical cartel that has exploited Americans for decades.

    Indeed, let’s talk facts rather than discriminatory and unscientific gobbledygook.
    regards,
    JCS

    1. weing says:

      @jc,
      Don’t get your knickers in a twist. I subscribe to BMJ’s Clinical Evidence. It includes chiropractic manipulation for various conditions also, it’s not just conventional medical treatment.

    2. WilliamLawrenceUtridge says:

      Hello “Dr.” Smith, from the website “Chiropractors for fair journalism”.

      What does the alleged failing of medicine have to do with whether or not CAM practitioners can be PCP? If medicine is less than optimal, that means we should improve medicine. Why should it mean “lower the bar further so CAM can slouch over it”?

      I’ll also note that all you are doing is highlighting areas where medicine is attempting to address its own failings. You are pointing to a very important fact – medicine knows it is imperfect and has an ongoing, internal, eternal quality improvement program in place (it’s called “science”). Medicine, far from being on a high horse and refusing to admit to its failings, routinely publishes critcisms of current practice, the need to update practices in the face of new evidence, and uses continuing education credits, tools like up to date, conferences, consensus guidelines and systematic reviews to ensure as best possible that changes in medical best practices are advertised and shared widely.

      So claiming medicine is flawed is correct. Claiming the answer is CAM is wrong, and hypocritical. I don’t believe I have ever seen a homeopathy journal say, bluntly, all they do is give patients a sympathetic ear, or a chiropractic consensus statement that says “all we can help patients with is back pain, but that is accompanied by a risk of cervical artery dissection”. Where are your criticisms of acupuncturists who puncture lungs, or give their customers AIDS? Where is your acknowledgement that naturopathy can be deadly? Where do you shout about the complete lack of science behind nearly every CAM belief system?

      Perhaps you should give your speech to CAM proponents, they seem to need it more.

      1. Dave says:

        An example of the above is a recent article in the Mayo Clinic Proceedings, August 2013 issue, entitled “A decade of Reversal: An Analysis of 146 Contradicted Medical Practices”.

        It’s general advice to entering medical students that much of what they learn will turn out to be revised as more knowlege becomes available in the future.

    3. windriven says:

      @jc smith, not a doctor

      “Have you all forgotten that America is in the throes of a healthcare crisis–leading the world in every category of disease at the cost of trillions–all due to the medical mismanagement?”

      Really? Polio? I thought Syria had that title. Aortic aneurysm? Malaria? You flap your jaws and we’re supposed to believe every flatulence forthcoming? Let’s have some citations there ‘doc’.

      “let’s talk facts”

      Yes, let’s. Let’s all agree that chiropractic is sometimes useful for the treatment of low back pain. Period. End of story. Let’s admit that medicine understands its limitations while it works tirelessly to expand the horizons of medical science..

      Then let’s match up the contributions of medicine to those of quackery. I’m ready, one for one supported by quality citations in meaningful peer-reviewed journals. Up to the task there “doctor”? Wanna tell us what chiroquackery has to match ridding the planet of smallpox? Wanna tell us naturopathy’s success rate curing lymphomas? How about all of the contributions of reiki to medical imaging?

      You are a blabber-mouthed fool, full of your own nonsense. Put up or shut up. What are the top ten therapies offered by your quackery that have transformed the human condition, accompanied by meaningful citations proving your claims?

      1. s. sap says:

        NDs are not allowed by state licensure to treat lymphoma. They can only support the immune system. Many work with MDs who have a brain and have the patients best interest at heart. A great deal of those patients who have the compliment of Eastern and Western medicine in their treatment survive.
        After reading these posts it is sickening to see the things you have to say. You obviously are ignorant to Naturopathic medicine and its teaching, the requirements of a person to even get into this program. One of the greatest gifts these doctors have is love and compassion for their patients. You have a God complex you want to be right and you are oh so wrong. Next time you step in the ring know your opponent a little better. A wise ER doctor once told me, when you dont get bothered by things any more and when you dont care about the patient’s its time to get out of medicine. It sounds like you just want to be right, you don’t care about what is best for the patient. You cant stand the competition because a lot of the NDs out here are damn good doctors. I would trust any of them next to you any day. You only care about the letters after your name.

  18. Dave says:

    Many of the problems which place America low in health care categories are due to social factors rather than the health care industry per se. Poverty and unemployment is prevalent in inner cities and on Indian reservations. The problems we have with gun related injuries and due to other social ills such as drug and alcohol abuse, homelessness, and poor eating and exercise habits are less prevalent in some other countries. In addition, a percentage of the population, about 15-20% in the places I’ve practiced, have historically had no insurance and little access to ongoing health care and utilize emergency rooms for crises. The ACA, for all its many faults, is designed to address this last problem but wont fix the social problems which led to such a high uninsured rate.

    We do not have a “health care system” in the US. A patient who goes to Kaiser Permanente gets much different care than someone living in inner Detroit. The best way to improve the health of a country is to improve the socioeconomic status of the citizens, which generally leads to better health behaviors.( How can you exercise when it’s dangerous to walk outside your apartment?) Many of the countries the US is being compared to have a universal system, so people get basically the same access to care, and they have less economic disparity than in this country. I dont pretend to know the solutions to this, I’m stating a fact that people with a higher income and standard of living are generally healthier and live longer. If you have a high socioeconomic status and good insurance you can get very good health care in America. You will pay a lot for it.

    I am under the impression from reading the BMJ that America does pretty well in some disease categories, such as cancer care, but cant cite statistics.

    A universal payor system inevitably leads to savings. As an example, in the US, the VA system with its large bargaining power, gets medications MUCH cheaper than the rest of the nation. When Medicare part D was pushed through some people wanted to allow Medicare to negotiate drug prices like the VA does – that failed politically. I know people who get their medications from Canada because of the price difference. A universal system or public option was not even on the table when the ACA was put through. You would not believe the overhead costs of a medical practice with an entire tier of employees dedicated to coding, billing, wrangling withvarious insurance companies about preapprovals and which drugs are on what formulary, etc rather than to assist patient care. That’s one reason why more doctors are adopting a concierge type practice, which practices by their nature include only patients able to pay the upfront costs and therefore fairly wealthy .

    That said, I agree the costs seem to me to be excessive for what we are getting. But the reasons are complex and only partly the fault of the “health care industry”. And this has nothing to do with science based medicine.

    1. WilliamLawrenceUtridge says:

      I dont pretend to know the solutions to this

      My certainly glib solution would be an actual federally-funded health care system. Obamacare isnt’ a health care system, it’s a health insurance reform scheme. There’s a big difference. I feel sympathy, in fact pity for Americans, lacking as they do a genuine health care system, and I don’t understand opposition to it. Health care is awesome, and I am incredibly happy my taxes pay for it.

      I am under the impression from reading the BMJ that America does pretty well in some disease categories, such as cancer care, but cant cite statistics.

      And I would guess that it is only certain slices of the citizenry who do pretty well, I’m guessing a lot of people with the comparable cancer simly die of it.

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