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Defining what a “physician” is

The very concepts of “complementary and alternative medicine” (CAM) and “integrative medicine” (IM), the former of which “complements” science-based medicine with quackery and the latter of which “integrates” pseudoscience-based with science-based medicine are all about slapping a veneer of scientific legitimacy onto something that has failed to achieve such legitimacy through actual basic, translational, and clinical science. The reason I start out by saying this is to emphasize that CAM/IM is all about using language to persuade that pseudoscience is actually science-based. It’s far more about marketing than accurately communicating concepts. In CAM, everything is “holistic,” and doctors “care for the whole patient,” while “Western medicine” is “reductionistic” and “allopathic.” At the very heart of this language is a false dichotomy: That you must either embrace pseudoscience or that you somehow can’t provide care as compassionate and caring as what the quacks supposedly provide, nor are you able to provide for the emotional needs of your patients. There are two false dichotomies, actually, in that there is also the not-so-subtle implication in CAM that you can’t be truly “holistic” without—you guessed it—embracing the pseudoscience that is at the heart of many CAM/IM modalities.

This use and abuse of language for propagandistic purposes in CAM/IM is not limited to just these examples. In fact, the misuse of language infuses the whole enterprise of CAM/IM to the point that its adherents, not content with being mere “practitioners,” are trying to claim the very title of “physician” for themselves. I learned this from John Weeks, the main force behind the Integrator Blog, a blog dedicated to issues of CAM and IM. He’s the one who first let me know about Andrew Weil’s attempt to put together a board certification in IM. In particular, his reporting on the reaction of CAM/IM practitioners, both physicians and non-physicians, to this initiative by Andrew Weil was most illuminating to me. What was most telling was how further propagandistic use of the language focused on “dominance” by MDs, which in this case struck me as actually being closer to the truth than the usual CAM-speak is. In any case, Dr. Weil’s initiative does indeed appear to be more about taking control of CAM for physicians, his high-minded language about “establishing standards” notwithstanding.

This time around, Weeks has provided me with an education about how alternative/CAM/integrative practitioners now covet the title of “physician”. In the process, he also uses and abuses language in the same way that Andrew Weil and CAM/IM advocates do. This time around, it’s all about co-opting the title of “physician” for non-physician CAM practitioners. It’s bad enough to me when actual physicians are seduced by the pseudoscience of CAM, but this effort appears to be an intentional strategy designed to confuse the public by proclaiming as physicians practitioners who lack the essential skills to be a physician, such as acupuncturists, chiropractors, homeopaths, and naturopaths.

Weeks begins with the story of a non-physician (i.e., non-MD, non-DO) practitioner of CAM who distinguished chiropractors, naturopaths, and acupuncturists from physicians. To me, of course, that’s an utterly appropriate distinction (it’s not for nothing, after all, that I frequently refer to the naturopath’s ND title as meaning “not a doctor”), but to Weeks it’s “stepping into a militarized zone”:

A doctor level, non-MD academic friend from a conventional medical school who has expertise in complementary and alternative medicine inadvertently stepped into a militarized zone the other day. On a conference call with a multidisciplinary group of practitioners, he wished to make a distinction. He first offered a generalization about the roles of “chiropractors, naturopaths and acupuncturists.” Then he distinguished these from what he called “physicians.”

All of us knew that this studied academic was referring to licensed medical doctors, a.k.a. the kings (and queens) of the hill in U.S. medicine. At the same time, many of us were acutely aware by his comment that, while common and even professional usage of the term “physician” may connote MDs, legal realities are shifting. In fact, trends suggest that one endpoint of the movement toward integrative medicine is that “physician” will increasingly umbrella a rainbow of disciplines.

It turns out that there is a conscious effort under way by promoters of CAM/IM to appropriate the title of “physician” for themselves or, at least, to dilute it down so that it can mean either MDs or any of a number of other types of health care practitioners. Surprisingly, they’ve apparently even had some legislative and regulatory success. Weeks reports that the United States Department of Labor recently published something called O Net Online which replaces the Department’s Dictionary of Occupational Titles and that in that online dictionary there is reference to “naturopathic physicians” and “chiropractic physicians.” Worse, if you look under the sample of reported job titles for chiropractors, a synonym for chiropractor is apparently just “physician.” I also couldn’t help but notice that the descriptions of these jobs are pretty funny in a morbid sort of way, for example, listing one of the functions of a naturopath as administering “treatments or therapies, such as homeopathy, hydrotherapy, Oriental or Ayurvedic medicine, electrotherapy and diathermy, using physical agents including air, heat, cold, water, sound, or ultraviolet light to catalyze the body to heal itself.” Yes, it’s depressingly accurate, but it’s funny in that there is no recognition that homeopathy is quackery, as is much of what naturopaths do.

Even acupuncturists are apparently getting in on the act, trying to claim the title of “acupuncture physician” and even proposing an abbreviation of AP to describe themselves. In Florida, for instance, acupuncturists are legally entitled to work under this title, although “not through accredited, doctoral-level educational means.” Of course not. Acupuncturists are not physicians, nor should they ever be referred to as physicians unless they also have an MD or a DO degree. (And in that case I’d seriously question whether a physicians who has become an acupuncturist and practices acupuncture deserves the title of “physician” any more.) Somehow, apparently acupuncturists managed to get the legislature to give them the right to refer to themselves as “physicians,” and boy do they take advantage of it! Indeed, during my visit to Florida last week to present Grand Rounds at the Florida State University College of Medicine, Jann Bellamy and I discussed this very issue.

But it’s not just acupuncturists. Naturopaths have been getting in on the action, too. Indeed, naturopaths in 15 of the 16 states that license them are allowed to call themselves “physicians.” (Apparently California is the only holdout willing to put its foot down.) But in the case of naturopaths, it goes far beyond that. Besides wanting licensure in as many states as possible, naturopaths are pursuing in these licensing laws the right to be able to practice as primary care providers (even though they have zero expertise in primary care) and even as highly specialized practitioners, such as naturopathic oncologists, the latter of whom tack the abbreviation FABNO, which stands for ““Fellow of the American Board of Naturopathic Oncology.” Meanwhile, a couple of miles away from where I practice, across the border, Canadian naturopaths keep trying to get the right to be able to prescribe real medications, either as an admission that their woo is mostly useless or because they want to be considered “primary care physicians.” Maybe a little of both. Be that as it may, naturopaths in other states, such as New Hampshire, are clamoring for laws mandating that health insurance plans pay for their services:

Republican members of the House Commerce Committee bucked their leadership Thursday and voted 15-5 to endorse a health insurance mandate requiring insurance companies to cover people who use naturopathic practitioners as primary care physicians.

If the bill is approved, the insurance companies of patients of some 60 practices throughout the state will have to reimburse the visits.

“Patients have been begging us to push for this legislation,” said Dr. Jaclyn Chasse, president of the New Hampshire Association of Naturopathic Doctors. “We couldn’t be happier.”

I can’t help but notice how the New Hampshire organization is called the “New Hampshire Association of Naturopathic Doctors,” much as the national organization is called the American Association of Naturopathic Physicians (AANP), not to be confused with the American Academy of Nurse Practitioners. I also can’t help but note that a typical nurse practitioner is far more able to provide primary care services than any naturopath. Yet naturopaths keep trying to wrap themselves in the mantle of the term “physician.”

Weeks is shockingly (to me, at least) honest about the reason for this push by promoters of unscientific health care modalities to be able to call themselves “physicians,” using as an example chiropractors:

Success in claiming the physician title, linked to privilege, status and particularly third party payment – some insurers will only cover certain services if provided by a “physician” – figured heavily in an October 2, 2009 mailing to members from the American Chiropractic Association (ACA). The ACA credited its hard work for insuring that the title stayed in the language defining the Federal Employee Benefit Plan. Blue Cross Blue Shield, which manages the plan, attempted to demote chiropractors to a status as “other health care providers.” (6)

As I’ve said before, it’s all about the status. Chiropractors, acupuncturists, naturopaths, and other specialties of woo crave the respectability that comes with being a physician. They also have delusions of grandeur in thinking that they can do what physicians do, namely provide primary care services, even though none of them have adequate training in the administration of drugs or the science-based screening for cancer, heart disease, and other common diseases to function as primary care doctors, among other functions of primary care. Nor can they deal with common diseases, such as diabetes, hypertension, coronary artery disease, or others, at least not using science- or evidence-based guidelines. Unfortunately, this delusion of grandeur leads them to want to blur the line between real physicians and practitioners of pseudoscientific medicine.

Not surprisingly, Weeks is very unhappy at even quite reasonable attempts by physicians to protect the title of “physician” by opposing the licensing of naturopaths, as if it were a bad thing to prevent the state from putting its imprimatur on specialties that are not based in science and evidence. He also confirms something that I’ve always suspected about the near-obsessive use of the word “allopathic” to describe conventional MDs and DOs:

Then again, the AMA leaders in keeping “physician” out of reach of other professions are probably not as comfortable with the additional 2008-2009 language: “MDs are also known as allopathic physicians.” The modifier “allopathic” is a hole in the dike through which may flow naturopathic physicians, chiropractic physicians, perhaps more acupuncture physicians, and the first through, osteopathic physicians.

In other words, modifiers are the way to go, as far as letting non-science-based practitioners claim the title of “physician.” If physicians who practice science-based medicine are described not just as “physicians” but “allopathic physicians,” then they are lowered and other woo peddlers claiming the title of physician are elevated to approximate equality. Then you have various flavors of “physicians,” including “allopathic,” “naturopathic,” “chiropractic,” and “acupuncture” physicians. I do give Weeks credit, though, for mastery of deceptive language on par with the best propagandists. After all, if osteopathic physicians are now equivalent to MDs, even though 50 years ago they were viewed with extreme suspicion, then why not naturopathic or chiropractic physicians?

I’ll tell you why not.

The reason that DOs are now generally considered on par with MDs is because the way that osteopathic physicians (DOs) practice medicine, at least in the U.S., is usually indistinguishable from the way that MDs practice medicine. In essence, DOs became the equivalent of MDs by changing their education and practice to become like those of MDs. They now do the same residencies, are subject to the same standards and board certifications, and are licensed in the same way as MDs. In most osteopathic medical schools, osteopathy has been deemphasized to the point where it’s now, more than anything else, a historical vestige that continues to be taught more because of tradition than because of any continued enthusiasm for osteopathy. Indeed, very few DOs actually ever use it or practice it anymore once they graduate. Most, in fact, are rather embarrassed by these reminders of the chiropractor-like beliefs that used to be central to osteopathy. We can only hope that naturopaths go that way, but it’s highly unlikely, given the sheer extent of woo practiced by naturopaths, who are not only not embarrassed by their woo but downright proud of it. Remember, homeopathy is still considered an integral part of naturopathy, so much so that it is a major part of the curriculum of every school of naturopathy whose curriculum I’ve ever examined and is also a requirement on the naturopathic board examinations. (Don’t get me started on the very concept of a naturopathic board examination.)

Be that as it may, if you want to get an idea of how far Weeks and presumably his non-science-based holistic cohorts are willing to go to redefine what a “physician” is, look to the last part of Weeks’ post, where he actually invokes Webster (as in the dictionary) to convince his readers that physician should mean what he wants it to mean. He lists various definitions of “physician” that he’s found in different versions of Webster, picking the ones he likes, the ones that are seemingly most inclusive. In other words, he exercises one of the lamest arguments known to humankind. When you’re reduced to arguing based on dictionary definitions, you’ve sunk about as low as you can go.

My amusement at such lame arguments notwithstanding, I can’t resist pointing out Weeks’ one last envious broadside at physicians:

The physician term is power. Professions so denominated stand at the top of the hill, waving about highfalutin reasons why their recognition as such is in the public good. The sub-text includes the know motivator that the title lands one on the road to the bank.

I must conclude by saying again that I’m pleasantly surprised at just how honest Weeks is about the motivation for trying to redefine the term “physician” to include quacks. It has nothing to do with improving patient care, nor does it have anything to do with quacks being able to provide primary care that is equivalent to that provided by real physicians. Rather, it’s all about power, money, and prestige, and the quacks want as much of all three as physicians have. Never mind that they haven’t actually earned such prestige and power through proving the value of what they do to society and through validating their contributions to health care though science. They want it all anyway. Unfortunately, they appear to be succeeding in co-opting the term “physician,” diluting its value to the point of meaninglessness and in the process contributing to the corruption of language, all in order to achieve their goal of more power and prestige.

At least Weeks is pretty honest about his motivation.

But what about the argument that “naturopathic physicians” or “chiropractic physicians” or “acupuncture physicians” can function as primary care practitioners? What sort of argument against this nonsense might actually resonate among not just real physicians but legislators and the public? I can think of one. Just consider the effect on vaccination rates of letting naturopaths, chiropractors, acupuncturists, and all the other non-science-based specialties, the vast majority of which tend to be profoundly anti-vaccine, were allowed to claim the title of “physician” and to function as primary care physicians. Now that’s a truly scary thought.

Posted in: Chiropractic, Homeopathy, Naturopathy, Politics and Regulation

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