After publishing on challenges the Accreditation Council for Continuing Medical Education (ACCME) is presenting to the integrative and functional medicine continuing medical education (CME) providers, I sent links to Graham McMahon, MD, MMSc, the organization’s president and CEO to request an interview. Multiple integrative CME providers with decades delivering integrative CME have lost or are facing potential loss of recognition. They have shared serious questions of transparency and intent on ACCME’s part. Some efforts to connect with ACCME have been rebuffed. Is integrative medicine being targeted? In my request for an interview, I provided McMahon some background on concerns. McMahon responded immediately, and affirmatively. We spoke for over 30 minutes via zoom on February 5, 2020. His responses included a surprising assertion that he believes the present ACCME is aligned with integrative medicine principles and practices. He committed to open dialogue in ACCME’s move “from cop to coach.” He underscored that the new proposed language is yet open for comment. I assembled our exchange in the following interview format and sought his edits and written replies to additional questions, then secured his approval prior to publication.
McMahon has been in his post since 2015. The announcement of his hiring captured his background: “A medical educator, researcher, and practicing endocrinologist, Dr. McMahon joins the ACCME from Harvard Medical School, where he serves as Associate Dean for Continuing Education and Associate Professor of Medicine. He teaches extensively at Harvard Medical School and at Brigham and Women’s Hospital in Boston, serves as Editor for Medical Education at the New England Journal of Medicine, and as Executive Editor for the NEJM Knowledge+ program.”
Integrator: I was just trolling you online and learning a few things, watching some you-tube of you, the CMEPalooza2.
McMahon: What did you learn?
Integrator: Interesting that you are an endocrinologist, a diabetologist. You should have some sympathy then with research challenges in integrative medical practice knowing that the best care addresses mind and body and thus is personalized and uses multiple modalities and often teams and thus doesn’t fit into an evidence system that evolved in reductive application of pharmaceutical agents for acute symptoms and conditions.
McMahon: As a practicing endocrinologist and diabetologist, I have to address patients’ need for their whole health – through nutrition, stress and sleep management, lifestyle choices, mental health, and use of medications as needed. That necessitates practicing integrative medicine. Many of us in the broader medical and education community share views with the integrative medicine community about the importance of meeting people where they are, patient centeredness, interprofessional practice, and social determinants of health, and focusing on wellbeing and health as our goals, not just the absence or suppression of disease.
Integrator: Let’s leave the sublime for a bit and go to the mundane part in the questions I sent ahead of the interview. One was whether or not, for starters, you have any corrections to my prior writing in the two articles I sent.
McMahon: First, much of this is not new. “Content validity” has been part of our work since 2002. These things have been in our FAQs and guidances. We are clarifying and elevating these requirements, putting them in places where they can‘t be missed. We want to remind our community about the importance of ensuring education content is accurate and does not include clinical recommendations that might put patients at risk. The changes are now just proposals. We have asked for feedback.
ACCME and integrative and patient-centered care
Integrator: Yet there is language that is much more prominently highlighted. In particular, the clarity that ACCME would not grant CME for content that is not “generally accepted” if its goal is to teach clinicians how to do something clinically. This is a key issue issue. This is what most of the integrative medicine and functional medicine CME programs are seeking to do: provide tools for practice change for medical doctors and others to more salutogenic practice models. The whole framework of salutogenesis is not “generally accepted.” The move toward “health creation” that Don Berwick [MD, former CMS administrator] and others are supporting is still rare in regular medicine while the core of the integrative impulse.
McMahon: The content validity standard applies across the entire spectrum of clinical care. It is not specific to integrative or alternative medicine. It is about making sure that education is based on evidence and supports optimal health. We want to avoid faculty making claims in accredited educational activities that are not in the best interest of patients. It’s important to generate the outcomes and the quality of care that our patients deserve, and relying on science to ensure we do no harm. We strongly support integrative and patient-centered care. We are promoting medical education on inter-professionalism, on cultural sensitivity and team care. We are promoting competencies in these areas. You mentioned in your note that Harvard moved toward well-being and health in its new mission statement, and this is reflective of how the profession and continuing education are moving to a health enhancement approach.
Integrator: Fascinating. I did not expect to hear such affirmation of the integrative model amidst the very deep concerns that most of the integrative medicine CME purveyors seem to have. To the extent that there is alignment, or potential alignment, we seem to be ships passing in the night.
McMahon: We accredit a whole variety of organizations that offer CME on integrative medicine and we have positive relationships with them. We have a similar view about what matters — promoting patient-centered, culturally sensitive care focused on health, anchored among clinicians who have mutual respect, and collegiality. It is important that we stay true to these values and do what’s right by patients.
Integrator: I know from my interview with him that you have told Rick [Hecht, MD, chair of the Academic Consortium for Integrative Medicine and Health] and have told me since that this language about not accrediting CME for clinically oriented how-to programs that don’t meet the “generally accepted” evidence threshold is not targeting integrative medicine. If you would give me examples of areas of CME with what you believe are clinical overstatement not supported by evidence that are not from the integrative world, that would be useful. What is another non-integrative clinical context that is provoking this change, and where this restriction could be applied?
Limited examples of non-integrative “controversial” areas
McMahon: Well, there is medical marijuana, and injecting stem cells into various tissues or joints, for two examples. There are many legislatures that have passed laws that allow the medical use of marijuana; yet just because it is legal does not mean that there is sufficient evidence to justify clinical care recommendations. In many cases the use has stepped well ahead of the evidence. We do want to support dialogue and debate about what we do know but that’s different than teaching how to without the evidence that justifies that recommendation. Even if a legislature has approved medical marijuana, recommendations given in accredited CME need to be based on the evidence.
Integrator: The problem I see with these two examples is they are both therapies that many integrative medical doctors would consider classically “integrative”. Integrative-oriented doctors are more likely to use or recommend medical marijuana, which is after all an herb, and stem cell injections, than are conventional medical doctors. What is another example of a long-time CME purveryor – not by name of course, but by content – where recently they’ve had their recognition dropped under this emerging requirement? What’s an example from regular medicine, so I can show better how integrative medicine is not targeted.
McMahon: Well it applies across the board. The example you mentioned of a program or speaker promoting off label use of drugs without evidence – the same principles would apply there. We are reminding faculty that they have a responsibility to remain anchored in patients’ well-being, and to our role as trusted advisors that are rooted in science. It’s not specific to integrative medicine. It’s about basing CME content on evidence and supporting patients in optimizing health.
Why now? not answered
Integrator: A question that comes up is timing. There doesn’t seem to have been any safety issue about integrative medicine behind this recent closure – especially in the context of 250,000 medical deaths a year from the regular practice of medicine. So the question is why now? What or who motivated this? Many of these folks have been granting CME that has been helping people learn to clinical re-shape their practices for 10 or 20 years. Suddenly one major program has CME pulled, then another, now a third. Why now? The field certainly has evidence to believe or feels that it is being targeted.
McMahon: Most of this in our standards is not new. If there is evidence, there shouldn’t be a problem. And what is new in our proposal is open to comment.
Integrator: I will urge readers to participate in responding. Yet the relationship to “generally accepted” evidence raises problems that may not be immediately known to you. For instance, this field proposes that if there is low risk, high evidence of safety, then lower levels of evidence should be accepted for making suggestions of clinical and practical value. Especially given the structural-economic challenges to getting research funded on non-patentable approaches, practices and products. And the whole person approaches often come from a view that multiple small effects working with the whole person is the way to shift to health. There are few dollars available for examining such whole systems of research and “generally accepted” systematic review and meta-analyses are not often available. Yet as a diabetologist, you will know that whole person, personalized and often team care is the best way to go.
McMahon: It is not our intention to constrain conversation. We want accredited CME to promote intellectual discourse about novel, interesting developments. When it comes to treatment recommendations, we say that the content must meet the generally accepted threshold. This does not mean the evidence has to be RCTs or systematic reviews. It has to be based on science. The purpose is to separate accredited CME from the equivalent of charlatanism. We don’t want recommendations based on anecdote or self interest. We want patients to be the beneficiary.
Recent consulting with integrative leaders
Integrator: I wonder have the ACCME’s views about integrative medicine been formed based on consulting with any leaders in the field? Did you bring any in to explore perceived problem areas? The American Board of Physician Specialties through which the American Board of Integrative Medicine is recognized is not part of ACCME governance. So there is not even a direct line of communication and participation at that level. Where have you been getting your expert advice on integrative medicine?
McMahon: I’m interested in dialogue and openness. We’ve been connecting with the integrative medicine community and the entire medical community at meetings around the country and the world, to leverage the power of education to transform the lives of clinicians, people and communities.
Integrator: Here’s perspective. The integrative CME programs that we are talking about have been sponsored by major academic and clinical centers. I hope you appreciate that what is going on in these institutions with integrative medicine over the past 25 years is you have front-line academic colleagues in now 75 academic health centers and health systems seeking to move to salutogenic models of practices. They have been using these methods and teaching to them, and educating others how to do so in CME approved programs for 10-20 years. ACCME’s actions appear to be effectively putting up a road block to this movement toward practice change, toward salutogenic models. If medical doctors want to transform their practices – learn how to practice differently – if there is no ACCME accreditation, their institutions won’t pay for it. They will have to pay cash if they want to learn. ACCME is effectively putting up a barrier to such practice change. The ACCME would be in the position of being in the way to advance salutogenic models.
McMahon: It’s not in any way our idea to limit the ability of people to talk about new approaches – we don’t want to constrict conversation. And it’s a big jump to go from a couple of stories from individuals to concluding that we are opposed to salutogenic models. As I have shared, we support them. We actively are promoting CME that helps to produce patient-centered, interprofessional, team-based models.
Integrative content considered “controversial”
Integrator: Well with whatever over-arching alignment that may be there, the experience of many integrative medicine CME purveyors is that integrative medicine certainly seems to be viewed by ACCME as a “controversial” area. Can you share integrative medicine content or themes that are particularly hot-button or red flags, where you feel overselling and charlatanism is a problem – that you consider “controversial”?
McMahon: Not specifically. I’d just remind the community that we have a system of regulatory oversight over products, devices, and services that are appropriate to ensure that patients aren’t taken advantage of. That system relies on the process of scientific inquiry and discovery, sharing insights, and growing an evidence-base. Our duty to patients is to offer diagnostic approaches and therapies to them that have met a threshold of demonstrated efficacy and safety.
Integrator: Would you be willing to provide a webinar or conference call with interested parties in the integrative field? They are looking for clarity and transparency. Can they expect any written guidance from you? I know from the webinar I was watching that your mission at CME is to move “from cop to coach.” Many in the field feel like they’re being profiled and strip-searched. Coaching would be good.
McMahon: In the last few weeks and over the last months I have had collegial calls with Rick [Hecht, MD] and the Consortium and with others in integrative medicine. We have discussed with the Consortium the prospect of having a session with them at one of their meetings. I was particularly happy to be able to speak with Rick. I was able to puncture rumors he or others may have heard. I am happy to rectify misunderstandings. I think it is clear that we have an open door and are transparent. Our new proposals are just that – proposals. They are open for comments.
Integrator: An issue though that I discuss in my interview with Rick is that, unlike the Consortium, where their main conference is for researchers, the other CME purveyors focus on clinicians, on medical doctors who come to conferences to learn how they can better the care of their patients on the Monday after. And 2021 seems a very long way off. More clarity, less darkness and more coaching now would be good.
McMahon: We have educational materials on our website, and offer live and online educational events, and we plan to continue to do so. Anyone with questions or concerns can reach us at firstname.lastname@example.org.
The shift to “Accredited Continuing Education” from CME
Integrator: Well an online event on these topics could be very useful. Getting close here to the end. A general question about ACCME’s future, to close. I noted in my questions ahead of time to you the proposed change to “Accredited Continuing Education (ACE)” rather than “Continuing Medical Education (CME)”. Such a change suggests both the accent on “accredited” thus distinguishing it from that which does not have the ACCME seal of approval, of course. You are also dropping “medical” which suggests perhaps you’d like your influence to extend more broadly than continuing education for medical doctors. Any comments?
McMahon: We are using the term “accredited” to explicitly differentiate between accredited and non-accredited education. We are using the term continuing education, rather than continuing medical education, to be inclusive of all health professions. Continuing medical education usually refers to education for physicians. While the ACCME acts as steward of the Standards, many different health professions use the Standards and we wanted the terminology to reflect that broad application. The use of the term “accredited continuing education” does not reflect any change in our accreditation system.
Additional Comments: When I shared with my integrative physician spouse some frustrations I had with the short time frame I had for my interview with McMahon – given the agenda I’d shared with him – she named the interaction well: an attempt to fit into a 30 minute visit an integrative first office call for a patient who is was relatively integrative-naive, not in the office on their own initiative, and who needs to be acculturated into what is different, both for doctors and patients, in this new, salutogenic environment. The interview was a learning experience, with more questions remaining open than answered. McMahon’s expressed support of integrative models didn’t specifically include specific therapeutics, especially the controversial areas relative to natural pharma in integrative and functional practices. I suspect my colleagues in integrative CME will not find much of this satisfying.
Still, I appreciate the time McMahon took for the call which expanded to 45 minutes and then involved additional time to review the draft, expand on comments and add additional responses. (I will be back at him next week with a couple of specific questions for a promised piece on the conflict of interest issues related to integrative CME.)
Clearly, it is time for the field to take seriously McMahon’s expressed commitment to coaching and transparency and engage relationship building. I invite any who are rebuffed or believe they have been treated disrespectfully by the ACCME going forward – as indeed has been the experience of many to date – to share the experience with other colleagues and with me. If there continues to be a felt pattern, it will only be discovered through continuous sharing. Credit to those who are fostering such collegiality. Meantime, the field can tighten it’s own evidence ship, while also reaching out to help McMahon keep ACCME from being a barrier to the transformation of practices toward whole person and whole system health and healing models. If indeed both parties are promoting such integrative care, collaboration is in order to make sure that medical doctors and others seeking to transform their practice can get credit for optimal, evidence-informed learning.
Prior articles in this series: