CAM Practitioners as Primary Care Doctors
Chiropractors and naturopaths would like to be your primary care physician. They are tirelessly lobbying to expand their scope of practice, with the goal of achieving full parity with actual physicians. This would be an unmitigated disaster, for reasons I will detail below.
Oregon is setting up coordinated care organizations to help promote improved care at reduced cost. The idea sounds plausible and is a good experiment in how to reduce health care costs. The idea is to set up local groups of health practitioners who work in a coordinated way to take care of the local population, including physical and mental health, with dental health on the way. These CCOs would focus on preventive care with the goal of reducing illness and ER visits.
With any new health care initiative (including Obamacare, and this CCO initiative) so-called complementary and alternative medicine (CAM) practitioners see them as an opportunity to expand their power, reach, and scope. Unfortunately they have been largely successful – they know how to talk to both ends of the political spectrum, and the relevant science seems to get lost or distorted in all the propaganda.
A recent commentary in the Washington Times is a great example of this. The article was written by Peter Lind, a “metabolic and neurologic” chiropractor. Chiropractic neurology is pure pseudoscience, it relates to actual neurology as alchemy does to chemistry, or astrology to astronomy. Lind writes:
Governor Kitzhaber’s philosophy and current Oregon law says that CCOs cannot discriminate against complementary and alternative health providers (CAM) such as chiropractic physicians, naturopathic physicians, licensed acupuncturists, and licensed massage therapists. Governor Kitzhaber has said repeatedly that CAM providers cannot and will not be discriminated against in the new health care system and that chiropractic and naturopathic physicians will act in the capacity of primary care providers for those who wish to practice at the top of their licensure. These providers will help address the primary care provider shortage that is only going to grow when Oregon’s CCOs come fully online.
“Not discriminate against” is code for – abolish the standard of care. There are several political codes which ultimately just mean to get rid of the standard of care, or to create a double standard. “Health care freedom” is another. I have seen such “anti-discrimination” laws in effect with disastrous results. They mean, for example, that insurance companies are forced to pay for useless and sometime fraudulent treatments by CAM practitioners, and then have to write absurd rules (that apply to everyone, including physicians) in an attempt to limit the damage.
Primary care physicians fill the most important role in the health care system. They are often the first point of contact for patients with a new issue. PCPs have to triage such problems, determining which are self-limited and which are likely the beginning of a serious illness requiring workup and treatment.
PCPs are also the “quarterbacks” of the healthcare system. They need to coordinate referrals to specialists, and to coordinate the recommendations and interventions given by those specialists.
For both of the reasons above PCPs need to have a broad understanding of all of medicine. They need to understand what each type of specialist brings to the table, what they do and don’t treat, their strengths and limitations. This is partly why medical training involves rotating through every area of medicine.
Imagine a practitioner in this key position who does not have a broad understanding of medicine and medical specialties. Worse – consider the effects of that practitioner working under a pseudoscientific philosophy of health care.
Hopefully, at least for now, it seems that Lind is overestimating the degree to which CAM practitioners are going to be given the keys to the kingdom. The Oregon CCO webpage makes no mention of CAM practitioners serving as PCPs. Webpages for specific CCOs also make no mention, but do mention that board certification for MDs or DOs is required.
This is no guarantee that sanity reigns, however, as often CAM practitioners expand their scope under the radar. They want to quietly infiltrate all of the institutions of medicine, without transparent debate about what that will actually mean.
The CCO case also illustrates another strategy of promotion by CAM practitioners – since they have been unable to show scientifically that their treatments work, they have shifted to two other strategies: arguing that placebo medicine is good medicine (because their interventions are no better than placebo) and arguing that they are cost effective.
It is true that sometimes their interventions are cheaper than comparable science-based interventions, but because they generally do not work it’s difficult to honestly argue that they are cost effective. Treatments that don’t work are not cost effective – they just hide the true cost. Up front costs may be lower, but the downstream costs of relying on ineffective treatments is difficult to measure.
Conclusion
Making pseudoscientific practitioners primary care doctors would be disastrous, and would be a massive disservice to the public. Politicians owe it to the people they serve to have a transparent debate about such proposals before instituting them, and such debates should be evidence-based as much as possible. They should be informed by high quality science.
Science, of course, is kryptonite to CAM practitioners. CAM is a category that exists solely to create a double standard in medicine – one that is insulated from having to justify itself with science and evidence. This is not good medicine, primary care or otherwise.
All the more sad because Kitzhaber is a physician himself and damn well knows better. Apparently politician first, physician not so much.
Question for medical professionals here… are physicians required by law to have malpractice insurance? If so, this would probably weed out a lot of CAM practitioners from being able to participate in insurance or government reimbursement programs, or at the very least, would keep them confined to the placebo administration industry.
…and then maybe laws will change that will hopefully make CAM practitioners fully liable when patients choose them as a point of entry for their medical care. Since they then would bear full legal weight and financial responsibility for misdiagnosis and treatment they may pass on many patients to actual qualified medical pros.
Unfortunately, a lot of people may suffer before this happens.
CAM practitioners likely won’t need malpractice coverage since their therapies rarely cause actionable harm. That those modalities don’t actually cure anything doesn’t open them up for liability, sadly.
But can a practitioner be sued for not diagnosing something from which I later die? If I go to an acupuncturist with chest pain, presenting all the classic symptoms for heart disease, have a few needles stuck in me and then keel over from a heart attack, would they be liable for not diagnosing the heart disease in the first place?
I think the answer is no, for a few reasons.
First, any legally savvy acupuncturist, or other CAM practitioner, will make you acknowledge that acupuncture, herbal remedies or whatever, are not substitutes for western medicine and will urge you to consult with a medical doctor.
Second, CAM practitioners, for the most part, are not medical doctors, so they don’t have the same duty of care. So for instance, you could ask me (I’m not a doctor) to diagnose your chest pains, but I’m not liable if I say they’re the result of an imbalance of your chi. The answer might be different if an actual medical doctor told you to forego an effective traditional medical treatment in favor of CAM.
Finally, there’s a practical problem. Most CAM practitioners, I would guess, are judgment proof. So even if you got a ten million dollar malpractice judgment against an acupuncturist, you’re likely not going to collect all that much.
This is why, if they do manage to get PCP status in some states,they should at least be required to carry malpractice insurance to the same degree as other PCP’s.
Which is why I imagine, for all practical purposes, CAM practitioners won’t get PCP status, even if they’re able to legally. No insurer in their right mind is going to provide malpractice insurance for someone with no real medical training.
I can imagine an insurance company readily accepting their premiums under the caveat that all of their patients have to read and sign a statement that says :
“This CAM provider’s services are not intended to treat or cure ANY disease or condition”.
I’m certain that this is caused, in large part, by the emasculation of the medical profession.
When I was growing up, Doctors had some form of authority and didn’t couch their diagnosis with “well it maybe”, “it could be” or “I’ll have to refer you”. And there was certainly none of that “Arse-ache medicine #1 may not be for everyone. Symptoms might include arse ache” advertising shite.
Choice in health care is bullshit. If you have something wrong with you – and not the sort of mild cough that causes self medication (which is also a complete load of bullshit) – you want somebody competent and knowledgeable on the case. You don’t want choices, you want somebody “in authority” to make those decisions for you.
That’s what these “woo” merchants do. They offer authority where proper medicine doesn’t.
When people paid for their own medical care (either out of pocket or via insurance), medicine was a private transaction.
Now medicine has been effectively nationalized, which means that all aspects of medicine now and forever will be political decisions, not scientific ones. How big were the Chiropractic Association’s contributions to the Obama campaign?
How big? I don’t know,but why don’t you go do some research,and find out exactly how much they contributed to both campaigns,instead of asking a rhetorical question that assumes the answer that ‘makes’ your point completely free of evidence.
There definitely is some lobbying by CAM practitioners, but for the most part it takes place at the state level. New York passed a bill a while ago that puts CAM practitioners on equal footing with MDs at least for certain purposes. There was definitely lobbying by CAM practitioners, although I’m not sure if there was significant hard money contribution or whether it was in the form of awareness campaigns.
Legitimizing CAM, so to speak, probably has some appeal to both sides of the political spectrum. New Agey types that believe CAM is legitimate medical treatment tend to be on the left. I’m sure there are free market types that see medicine as a private transaction, and believe it should be up to the individual to decide what’s legitimate and what isn’t, whether it’s CAM or evidence based medicine.
Medicine has been nationalized? Do you live in the states? Because here in the states private insurance companies still run the show.
It’s amazing that back when the Heritage Foundation proposed the health insurance mandate, and Bob Dole ran on it in 1994, right-wingers loved the idea.
I could never find a good explanation of what the difference is between regular medicine and chiropraxy/osteopathy as practiced today (not the 19th mumbo-jumbo).
Apparently, people usually go see a chiropractor/osteopath because of back- or knee-pain: What physical therapy do they provide that regular doctors can’t?
In the U.S., Doctors of Osteopathy are considered ‘regular’ doctors. There was a time when that was not the case,but today,the training of an MD or DO is pretty much the same.I have heard that this is not the case overseas however.
DOs are basically people that couldn’t get into “medical school”. I know a DO that basically does the same thing as an MD, just has slightly different training.
In France at least, anyone can practise as osteopath (chiropraxy is virtually unknown).
But I could never get a straight answers from doctors about what osteopaths do that physical therapists (“kinésithérapeutes” as they are called) already provide.
Incidently, the people I know who rely on osteopaths are also usually into homeopathy and afraid of wifi ;-)
Not that long ago Chiropractors had adds about how they could cure cancer. This is nuts.
I think we should be a little more Specific. Discuss Selected Complementary and Alternative Medicine, SCAM for short. This would, unlike the SCAM issues covered, be accurate.
Mr. Novella,
Taking into consideration NCCAM’s definition of CAM as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine”, I understand why the Coordination Care Organization’s (CCO) “anti-discrimination” platform may be a source of anxiety and a cause for worry. As a matter of fact, I completely agree that such attitudes may have the potential to, as you so eloquently stated, “abolish the standard of care”, especially when it is widely acknowledged by both CAM critics and supporters that there is a dire lack of conclusive scientific research in regards to CAM’s impact on health. As a student who has been taught since high school that a lack of experimental data may imply a lack of validity, I too am wary of CCO’s prerogative towards giving chiropractors and naturopathic practitioners the ability to “act in the capacity of primary care providers (PCP)”. I also agree that a PCP’s role in health care are like those of “quarterback”; they hold a great responsibility towards their patients to ” first do no harm” and second, to diagnose, treat and refer accordingly. However, I feel that CAM has potential, regardless of its apparent flaws. In fact, it may potentially be detrimental to disregard all practices that fall under the category of CAM as pseudo-medicine or as you so stated, “not good medicine”.
Let us go back to how CAM is defined. When complimentary medicine and alternative medicine are defined separately, they are two vastly different entities. According to the NCCAM, complimentary medicine is used in conjunction with conventional medicine while alternative medicine is utilized in place of. Although I doubt other branches of medicine can replace the current standard of health care, I do not see there being harm in PCPs allowing patients to utilize complimentary medicine in conjunction with standard treatment. Just as there is lack of conclusive evidence proving complimentary medicine to be useful, there is a lack of conclusive evidence proving it otherwise. Then again, I may be speaking too soon. The new publication of the Journal of Alternative and Complimentary Medicine, the increasing numbers of public access to online resources such as the eCAM or Evidence-Based Complimentary and Alternative Medicine, and the recent application by a Canadian college hoping to teach traditional chinese medicine (TCM) at the university level are all examples of an inevitable shift towards the acceptance and use of both conventional and alternative medicine. It seems as though CAM is slowly evolving to develop a better standard of health care, one that can hopefully be recognized by both the biomedical and non-medical community in time. I do not expect CAM to be universally accepted; such expectation would be rather naive. I do however, in the interest of cultural competence, believe that it would be prudent for both skeptics and doctors alike to understand that patients from different ethnic groups may fiercely cling to their beliefs in culturally-influential practices such as acupuncture, and that in the interest of helping those patients fully recover and adhere to their treatments, it may be best to let them practice their beliefs as complimentary medicine. If their respective practices do not harm or prevent them from healing, who are PCPs to begrudge them those comforts and needs?