Practice Drift: Osher Team Explores Risks of MDs Exceeding Scope in Integrative Practices

Practice Drift: Osher Team Explores Risks of MDs Exceeding Scope in Integrative Practices

The movement from the wild-west of “alternative” medical practices into mainstream respect and inclusion is typically a process of standard-setting, self-regulation, and then governmental action. Two principals in the Osher Collaborative for Integrative Medicine recently asked whether – with the chaotic and rapid expansion of the field — its time for integrative medical doctors, in particular, to consider additional, proactive steps.

The recommendations touch on an integrative medical doctor’s responsibilities to patients, to self, to their still newly emerging field, and, interestingly, to complementary providers. The Osher Center leaders propose, perhaps most significantly, that it is time for the Federation of State Medical Boards to “revisit the Federation of State Medical Boards 2002 “Model Guidelines for the Use of Complementary and Alternative Medicine in the United States.”
The commentary, co-authored by Melinda Ring, MD, FACP, and Sandy Newmark, MD, FAAP and published in JACM-Paradigm, Practice and Policy Advancing Integrative Health (The Journal of Alternative and Complementary Medicine), is entitled “Practice Drift: Are There Risks When Integrative Medicine Physicians Exceed Their Scope?
Ring and Newmark note that it is a common scenario among all medical professionals to move “outside [their] medical training and its implicit scope of practice to incorporate new approaches to healthcare diagnosis and treatment.” But, they add: “It seems particularly prevalent in the practices of medical doctors who have chosen to enter into complementary and integrative medicine.”
The authors’ vantage point is 25 years after a survey of public use prodded mainstream institutions toward the integrative era.¬† Ring, an integrative clinician who directs the Northwestern Osher Center, and Newmark, the holder of an endowed chair at the UCSF Osher Center, are employed at institutions that are among the 70 members of the Academic Consortium for Integrative Medicine and Health. Ring is a member of the board of the American Board of Integrative Medicine, the highest standard of recognition in the USA for integrative medical doctors. They are quite aware of and sympathetic to the multiple zephyrs and storms that produce the drift into integrative practice:
“A growing number of medical doctors are drawn to new approaches, which are perceived as personalized and preventative and expand non-pharmacologic options for patients. Beyond the philosophical movement toward healthcare rather than disease-care, other driving forces include frustration with the time-crunch demands in insurance-driven medicine, decreasing compensation; and professional burn-out. In response to the growing number of providers seeking a new practice model, individual clinicians, educational organizations, and businesses are increasingly providing trainings and certifications in areas such as functional medicine, anti-aging medicine, regenerative medicine, and integrative medicine. These trainings are typically offered as brief in-person courses or online modules. Some are promoted as profitable, turn-key sources of revenue.”

To bring the generalizations to life, the Ring-Newmark team offer specific examples:

 

  • a psychiatrist who takes some functional medicine training, explores integrative Lyme disease strategies and re-positions as an expert in a field where endocrinologists would seem to be the likely specialists;
  • an integrative gynecologist who expands a bio-identical hormone-oriented practice to include treatment of children and men on “with hormones, pharmaceuticals, and dietary supplements”; and
  • a primary care doctor who “has done some self-education, takes a week-long class and re-brands as an integrative consultant.”

This list will not shock anyone close to the field. Most can point to at least one of each, and then quickly offer a half-dozen other exemplars. The targets are profession neutral. Naturopathic doctors, chiropractors in many states, acupuncture and Oriental medicine practitioners and others continuously explore new modalities as they engage their passions for integrative practice then, not infrequently, re-position themselves and their businesses to draw new types of patient.

 

The freedom to explore and change one’s core clinical interests and approaches is essentially viewed as a birthright in the integrative community. Old line holistic doctors invented their early integrative practices by including therapies and approaches outside their training. The trade off for no employment security in large medical organizations is the potential for more frequently exciting their clinical curiosity. A part of the integrative medicine formula for beating the practice burnout that is behind the 4th “practitioner satisfaction” component of the Quadruple Aim is to know you can shed a skin, shape-shift, and re-emerge into your community with a different sort of clinical focus and perhaps a new business model.
Major academic health centers and delivery organizations such as Ring and Newmark represent are famously cultures of fear. Issues of safety and liability have gained a continuous shoulder perch. The concerns are warranted given the data on medical errors.  While medical death is rarely an issue in integrative care, concerns are real. Most in the integrative medicine field can immediately point to professionals whose newly acquired integrative clinical confidence appears to be running a few leagues ahead of their frosh-level competence.
The authors add an additional reason for concern over rapid practice shifting. The field of integrative medicine, despite recent growth, still faces “doubt and criticism.” The most vociferous, antagonistic voices are those of academic medical colleagues: “When [integrative] providers treat outside their scopes, negative judgement could generalize to negative impressions of the entire field of integrative medicine.” This shifting landscape of exploration, uptake and rebranding raises “questions that need to be considered and addressed by the medical field.”
The recommendations from Ring and Newmark don’t jump to a call for new formal regulation. Their goal is to help create “a clinically responsible and ethical framework for the changing field.” They spread responsibility around.
  • Integrative doctors need to be transparent with their patients about the extent of their training.
  • Patients need to be “empowered to move past implicit trust” of their practitioners. Patients should be given accessible resources “to understand the nuances of training.”
  • Educators and professional organizations that provide certificates or other formal courses in integrative modalities should consider adding ethics and scope of practice modules.
  • Perhaps professional organizations should create peer networks for chart review.
  • And as noted, the Osher Center leaders propose that it is time for the Federation of State Medical Boards to “revisit the 2002 model guidelines.”
The authors make clear that the purpose of the commentary “is neither to censor any particular group of providers nor to advocate for unreasonable restrictions on integrative practices.” In fact, the Ring-Newmark commentary includes an unusual level of interprofessional respect. One of the risks from medical doctors’ rapid uptake of new modalities is to “alienate complementary providers” who may have completed years-long professional education in areas where medical doctors may have 300 or fewer hours of training.
The very thought of this self examination may disturb many integrative practitioners to a reflexive, jealous guarding of their freedoms. Don’t restrict my rights to the cornucopia of emerging modalities and global healing practices and traditions!
This commentary is a level-headed call to stop Рat this point of growth for the field Рto look, and to listen. Canadian researchers Nadine Ijaz and Heather Boon may offer help toward an optimal framework. They recently  suggested that Western regulatory models may be a misfit for traditional practitioners Рa disrespectful, and even a colonial imposition on differing models and paradigms. The broad-reaching suggestions of Ring and Newmark may be the beginning of shaping a respectful context for looking after health and safety amidst the continuing maturity of the integrative medical field.
Note: The commentary is available on open access through September 4, 2018.