- Whether IM really offers the best of conventional medicine and CAM.
- Whether IM produces better outcomes.
- Whether IM is effective in the area of prevention, including obesity and cardiovascular risk.
- Whether IM has anything to offer preventive medicine.
- Whether future IM research will yield beneficial results.
- Whether IM has a positive impact on utilization clinical preventive services, smoking cessation, diet, and physical activity.
- Whether IM is cost effective.
We don’t even have a working definition of “integrative medicine,” although experience tells us that incorporating diagnoses and treatments with insufficient evidence of safety and effectiveness is an acceptable element of integrative practice, as is rebranding “conventional” practices as “integrative.”
Normally, these substantial deficiencies would get in the way of declaring that IM is anything like a real specialty in medicine. Indeed, as David Gorski has pointed out, IM is more of a brand than a specialty. Yet, as we do know, integrative medicine considers itself exempt from the rules. Thus, a few years ago, Andrew Weil, MD, an early adopter in incorporating pseudoscience into medical practice, announced his desire to create of a board certification in integrative medicine. No doubt aware that IM couldn’t fulfill the requirements of the American Board of Medical Specialties (ABMS), he turned to the American Board of Physician Specialties (ABPS), whose requirements for Board recognition are more forgiving. For example, the ABPS is willing to credit work experience as a prerequisite to board certification, as opposed to residency and fellowship training. Sure enough, a few years ago, the ABPS formally accepted board-certification in IM via the ABPS’s recognition of the American Board of Integrative Medicine (ABOIM).
Board certification is not required for medical practice in any state. However, some hospitals and insurance companies do require it as a credential. State medical boards, which regulate the practice of medicine in the U.S., also have rules on which recognizing agencies they approve. The oldest (est. 1933) and most prestigious is the American Board of Medical Specialties, whose 24 boards and 147 subspecialties, covering 750,000- physicians, are universally accepted by state medical boards, hospitals and health insurers. (Statistics are from 2010.)
The American Board of Physician Specialties started its board recognition program in 2005. In 2010, the ABPS recognized 16 certifying boards, representing 5,000 physicians. According to its website, there are now 20 boards recognized by the ABPS. Some, like orthopedic surgery, family medicine, and emergency medicine, have competing boards, one recognized by the ABMS and the other recognized by the ABPS. Others, like urgent care and disaster medicine, have only ABPS recognition. The ABPS has encountered some difficulties in gaining state medical board approval as a recognizing agency, centered on the lack of requirement of formal training in a specialty for board certification. There is a third recognizing agency, the American Osteopathic Association, which has 18 certifying boards representing about 25,000 osteopathic doctors. (Again, 2010 figures.)
Most, but not all, state medical boards, allow a physician to advertise an ABPS-recognized board certification or are neutral on the subject. (California, for example, does not.) However, because the First Amendment protects truthful advertising statements, as long as there is nothing misleading or false in claiming board certification, state medical boards can’t prevent a physician from stating he is board certified even if the recognizing agency doesn’t have board approval, although some states, like Florida, require the physician to post a disclaimer stating that the specialty certification is from a private agency and is not one approved by the medical board.
Interestingly, there is nothing to prevent a medical board from approving some, but not all, of a recognizing agency’s board certifications. Thus, even in states where ABPS boards are otherwise recognized, the state medical board could refuse to recognize a particular board that did not meet its criteria. For example, the Florida Board of Medicine has imposed additional requirements on holding oneself out as a board-certified dermatologist, even though it recognizes both the ABMS and ABPS, each of which has its own dermatology board certification.
Because the American Board of Integrative Medicine has no publicly available standards for board certification in IM, and, indeed, we don’t even know who runs the ABOIM, state medical boards should not allow physicians to claim they are board-certified in IM, at least without a disclaimer. From what little information is publicly available about the ABOIM’s requirements, we can conclude IM does not warrant state-sanctioned board certification.
Who controls the ABOIM and what are its standards?
In the first place, who are these people? The American Board of Physician Specialties has a staff list, but does not reveal who its officers and directors are. We are told that the ABPS is
composed of the Chair of each of the governing specialty boards, the President, President-Elect and Secretary/Treasurer of AAPS [American Association of Physician Specialists] and up to two public members.
But we aren’t told who they are. We are also given this rather cryptic chart.
We know even less about the American Board of Integrative Medicine. According to the ABPS website:
Complete eligibility requirements, application and examination information are available at www.aboim.org.
But if you enter that URL you are simply directed back to the ABPS website. Thus, we have no clue as to who is actually on the board of the ABOIM or who its officers or staff members are.
We also learn from the ABPS that
Each specialty board establishes its own standards although the ABPS oversees proposed changes in standards for appropriateness and adherence to standards to which all Boards must comply. All proposals by specialty boards regarding organization, structure and certification standards are first reviewed by the ABPS and then forwarded to the AAPS Board of Directors for final approval.
So, what are the ABOIM’s standards for organization, structure and certification? We don’t know. Nothing on the ABPS website tells us.
Compare this to the American Board of Medical Specialties, which tells us not only who is on its Board of Directors but also gives us links to all member specialty board websites, each of which has information on governance and standards.
Integrative Medicine is, until December 31, 2016, one of the ABPS-approved board certifications which doesn’t require formal training, except for having completed a medical residency, which can be in any specialty. Until a few days ago, the deadline was December 1. However, the ABPS just announced that
In response to the overwhelming interest for the ABOIM Limited Time Eligibility Option, ABPS has extended the deadline to submit applications to the end of the month [Dec. 31, 2016].
The E-Z way to IM board certification will cost you another $200 in addition to the regular $750 fee, which was itself bumped up from the original $500 fee if you waited until after Oct. 15 to apply.
Thus, for all its lip service about patient-centered care, holism, and the like, physician specialists who rarely come in with an actual patient (radiologists, pathologists) are nevertheless allowed to sit for the board exam in integrative medicine. All they need is to be board certified or board eligible in anything, have a license to practice medicine, and rack up 500 points of “documented training and experience,” which has to include at least one year of clinical experience in integrative medicine. Clinical experience is worth up to 250 points, depending on how long one had been practicing IM. The rest can be gotten by taking continuing education courses.
Clinical practice can be documented with a couple of letters. One is to verify, from an independent source (like a partner or office manager), the number of years the physician has been practicing IM. The other
will be needed to document the integrative elements of the practice. This letter should be about 1-2 pages and should provide details about the integrative practices regularly used with patients.
(What we would give to see these letters!)
Apparently, there is some concern among potential applicants about just what constitutes practicing integrative medicine for purposes of the point system. After all, as best I can tell, there are no criteria provided for what does and does not count as IM for purposes of claiming that mantle via the E-Z route. Given the fact that IM regularly purloins elements of “conventional” medicine and just as regularly discounts evidence of effectiveness as a criterion, we must imagine the list of what was acceptable as IM practice is quite liberal. Nevertheless, this confusion called for guidance from ABPS, which, unhelpfully, basically tells applicants to take a stab at it and see what happens:
Q: Can I submit documentation to ABPS staff to see if it qualifies as Integrative?
A: Unfortunately, only the Board can judge if the eligibility criteria [whatever they might be] have been met. ABPS staff is happy to provide guidance based on previous board decisions. The Board will not “pre-screen” applicants or partial applications.
After December 31, the ABOIM will require an MD or DO to complete a “fellowship” in IM unless he or she has also graduated from a naturopathic, chiropractic or oriental medical school, in which case he can go straight to the exam. You can still be board-certified or board-eligible in any specialty. This presents some interesting possibilities. The following combinations would be eligible for board certification under ABOIM rules:
- ND/DO with board certification in anesthesiology
- DC/MD with board certification in radiology
- MD with board certification in pathology who completes an IM residency
The many stylings of IM fellowships
As befits IM in general, which has yet to settle on the basics, the IM fellowships listed on the ABPS website are an odd lot. (Come to think of it, that’s yet another thing we don’t know about IM in medical education: costs and return on investment.) First, it appears there are no common admission requirements. The Santa Rosa Family Medicine Residency and the University of Michigan take only those who’ve completed family practice residencies. The University of Arizona admits non-physician fellows: pharmacists, nurses and physician assistants, and physicians from all specialties are admitted. As we will see below, one fellowship program admits naturopaths, chiropractors and traditional Chinese medicine practitioners along with MDs and DOs.
There is no core curriculum or standard format for an IM fellowship. Arizona has a two-year “distance learning” IM fellowship. The University of Kansas IM program follows the more traditional format of clinical education and research. Stamford Health requires both: completion of the Arizona program a 300-hour acupuncture course as well as providing clinical care in a family medicine and an integrative clinic. The University of North Carolina has a fellowship in research in integrative medicine. I couldn’t find that Ohio State University, which is listed as having an IM fellowship program, offers one.
One program has a connection with questionable medical organizations. The George Washington School of Medicine & Health Sciences Integrative Medicine program advertises that it’s “curricula were developed in collaboration with the Metabolic Medical Institute (MMI).” MMI also claims it is “educationally associated” with George Washington, as well as the University of South Florida Morsani College of Medicine, and the American Academy of Anti-Aging Medicine, or “A4M” as it likes to call itself.
A4M is on Quackwatch’s list of questionable organizations. (More information on A4M here and here.) I ed the University of South Florida by email, inquiring about the claimed link between the A4M, MMI and the USF medical school and providing links to relevant MMI and A4M websites. According to a USF Health Communications representative:
I asked the Vice Dean of our Morsani College of Medicine’s Graduate Medical Education program about this and he had never heard of it.
I sent the same email to George Washington University, whose rep said she would get back in touch with me, but never did.
MMI offers its own self-styled “fellowships” (offered to nutritionists and chiropractors as well) in Metabolic & Nutritional Medicine, Integrative Cancer Therapies (taught by a Florida physician who, according to information he provided to the Florida Department of Health, is board-certified in emergency medicine but does not have any education and training in oncology), and Stem Cell Therapies (uh-oh). Perhaps taking a page from the chiropractic “diplomate” playbook, these “fellowships” are taught in hotel conference rooms.
The newest IM fellowship program, perhaps the apotheosis of the fetishization of alternative medicine by IM proponents, is the Academy of Integrative Health & Medicine Fellowship in Integrative Medicine and Health. The director is Tieraona Low Dog, MD, formerly of Weil’s University of Arizona IM program. The assistant director is a naturopath. The program’s “academic partner” is the Oregon Collaborative for Integrative Medicine, which consists 5 schools, only one of which has a medical school, Oregon Health & Science University. The rest teach acupuncture and traditional Chinese medicine, chiropractic, and naturopathy. The curriculum was developed in conjunction with the Academic Collaborative for Integrative Health, an organization consisting solely of institutions devoted to naturopathy, chiropractic, TCM and acupuncture. It is open to physicians, naturopathic “physicians,” chiropractic “physicians,” TCM practitioners, and acupuncturists, as well as assorted other health care professionals.
We are given only the most abbreviated information about the curriculum, although we do know that it is mostly online. Faculty include “naturopathic oncologist” Lise Alschuler, whose Arizona clinic offers quack treatments for cancer and “detoxification” programs, and Jeffrey Gladd, an MD who prescribes “bioidentical hormones” and sells dietary supplements and other products to his patients. Mimi Guarneri, MD, whose LaJolla clinic offers biomat therapy, cranial sacral therapy, and a “medical intuitive” course taught by a woman who also teaches a course in speaking with the dead, is also on the faculty.
According to the AIHM,
The AIHM Interprofessional Fellowship was unanimously approved by American Board of Integrative Medicine (ABOIM) committee in 2015.
If I were a medical board member considering whether to recognize board certification in integrative medicine, I’d certainly want to know just who is doing this approving and what their standards are.
Given the paucity of information available on IM board certification, state boards might well want to look at what IM clinics affiliated with IM fellowship programs actually offer in the way of treatments. What they will find is an array of pseudoscience and unproven interventions:
- Santa Rosa Family Medicine Residency: treatment of “adrenal fatigue“
- Middlesex Hospital (also here): reflexology and reiki
- University of Kansas Medical Center: IV high dose vitamin C,magnesium and glutathione
- Maine Medical Center: homeopathy
- Harvard’s Osher Center: cranial sacral therapy
- University of Michigan: anthroposophic medicine
- University of Wisconsin (also here): healing touch and heavy metal detoxification
One characteristic these IM fellowships do share is that none are accredited by the Accreditation Council for Graduate Medical Education (ACGME), which requires compliance with published standards for faculty, program content, clinical and research requirements for participants, accountability, and oversight by ACGME-approved institutions, among other means of assuring a quality program.
Conclusion: Definitely cause for concern
State medical boards should be deeply concerned about recognizing a board certification in an ill-defined “specialty” run by unidentified parties with no published standards. Those standards, whatever they may be, are apparently loose enough to allow physicians to simply summarize their practices in a page or two and take CME courses to qualify for the board exam. Or, as of January 1, 2017, complete on-line, unaccredited fellowships offered, in some cases, by organizations of dubious educational provenance. This is the system that brought us Kenneth Woliner, MD, board certified integrative physician, who recently had his medical license revoked by the Florida Board of Medicine after a patient under his care died from untreated cancer. Woliner asserted before the Board that there is a distinct standard of care for integrative medicine practitioners, one that absolved him of the patient’s death. Woliner’s case should serve as a cautionary tale for all medical boards.