The easy access by medical doctors to accredited continuing medical education in integrative medicine is an engine of the field’s growth. So as stories emerged of what was believed to be an Accreditation Council on Continuing Medical Education (ACCME) clamp down, I engaged a series of interviews and reports. I reported direct and indirect assurances from ACCME’s CEO Graham McMahon, MD, MMSc that integrative medicine is not being targeted. Yet a recent commentary from leaders of the Osher Collaborative for Integrative Medicine raised the question again. I decided to review evidence to this date. I cannot but conclude that integrative medicine is, in fact, at the center of the bullseye in ACCME’s recent push for new standards of “content validity” regarding “controversial areas”. Here is the evidence.

Evidence from the Osher Collaborative for Integrative Medicine commentary

The March 2020 issue of the peer-reviewed JACM-Paradigm, Policy and Practice Advancing Integrative Health (The Journal of Alternative and Complementary Medicine) published a commentary entitled “Keeping Integrative Medicine Continuing Medical Education on the Cutting Edge – and Compliant”. The authors, Melinda Ring, MD, Iman Majd, MD, MS, LAc and Darshan Mehta, MD, MPH, are each a leader of a separate institutional member of the Osher Collaborative for Integrative Medicine. Their goal was both to educate and guide the integrative community around what can seem an ACCME minefield. They provide useful history. They share, for instance, that the ACCME was formed and is governed by representatives of the 7 entities that together constitute the governing board for the dominant school of medicine: AMA, AAMC, and etc. (See visual at the bottom of this article.) They conclude with 7 recommendations for the field.

Of particular note for our purposes here is this statement:

ACCME leadership has verbalized during meetings and conversations that diagnostic and therapeutic strategies common in integrative medicine (e.g. natural products, manual medicine, acupuncture) fall in the category the ACCME designates “controversial topics” which they define as “…topics in the field of medicine that remain experimental, unproven and/or unconventional.”

Neither this statement nor any other comments from the commentary’s authors assert that integrative medicine is ACCME’s only target. Not on the table is whether antipathy toward integrative medicine or any evidence regarding integrative practices directly stimulated the ACCME’s proposed changes. The authors merely report that ACCME is targeting these kinds of integrative practices.

“Use your gut” – AIHM reports comments from the 2019 ACCME annual meeting

The soup thickens when one considers comments submitted by the Academy of Integrative Health and Medicine (AIHM) regarding the ACCME’s proposed rule change. The submission, which AIHM executive director Tabatha Parker, ND shared, describes comments from McMahon and his staff at the 2019 ACCME Annual Conference that an AIHM staffer attended. AIHM is a leading provider of integrative medicine CME through its well-attended annual conference, its Fellowship in Integrative Health and Medicine, and other programs.

The ACCME session was entitled “Bringing Educational Leadership to Controversial Topics: Managing CME About Medical Marijuana.” Following the formal presentation, AIHM’s representative asked whether ACCME has a list of “controversial topics”. McMahon responded that there was no definitive list.

McMahon then off-handedly suggested that CME providers that want to remain accredited “use your gut” to decide what is “controversial”. It is worth noting that McMahon did not say “use the science”. This of course should be their standard. He might as well have said use your prejudices and preconceived opinions.

Then McMahon and his colleagues proceeded to list a set of topics they considered and assumed everyone else’s “guts” would deem controversial. These were “medical marijuana, stem cells, alternative medicine, chiropractic care, homeopathy, naturopathy and psychedelics.” This was a response to a room of CME providers of all kinds. The message was, if you are smart, walk gingerly or stay away.

The set of topics noted are in two categories relative to “integrative medicine.” Some are practices that are wholly in the “integrative” realm and some are subjects that are more common among integrative doctors than most conventional physicians – and thus pretty close. The latter category includes medical marijuana (“integrative pain treatment”), stem cell injections (“integrative orthopedics”) or psychedelics (“integrative psychiatry”).

The ACCME’s use of the umbrella “alternative medicine” term opened an extremely broad catchment. Massage? Botanical medicines? Dietary supplements? Mindfulness? And never mind for a moment how retro the ACCME’s language is. One would be hard-pressed to find the term “alternative medicine” advertised in an accredited CME program over the last 20 years. Is ACCME stuck in the 1990s when it comes to integrative CME? As reported elsewhere, the ACCME does not appear to have any in house integrative expertise.

As notable was the absence of reference from McMahon or his staff to any “controversial topics” related to conventional drugs or procedures or to any other specialties. Are there really no “controversial” evidentiary themes in a conventional field in which a third of what is done in regular medicine is unnecessary and much of that harmful? The set of ACCME subjects being targeted begins to have concentric circles around it.

Credit AIHM for already carrying out Recommendation #6 from the Osher Collaborative commentary: “Be involved with and closely monitor ACCME policy making.”

Evidence from the Integrator interview with ACCME’s McMahon

I had both communicated with Ring and heard of this exchange between McMahon and the AIHM representative at the 2019 ACCME meeting before my February 8, 2020 interview with McMahon. Like Ring et al, my interest was not to drive polarization.

I’d heard via a prior interview with Rock Hecht, MD, the chair of the Academic Consortium for Integrative Medicine and Health that McMahon had assured him and his Consortium colleagues that integrative medicine was not being targeted. Mixed signals, at best. Non-transparency would be a kind way of describing the worst.

I directly invited McMahon to help heal the apparent rift by reassuring members of the integrative field that they were not alone in being targeted. Would he name non-integrative content and practices that were “controversial areas” that provoked ACCME to propose their new rules?  McMahon responded by mentioning medical marijuana and stem cells. I explained that both of these are commonly viewed as integrative practices. McMahon shared nothing else without being provoked. One would think that if a lot of other areas were on the table that some might have been close to mind.

Given that integrative medicine CME is at least among ACCME targets, I asked McMahon why ACCME has this new focus. Were recent ACCME actions due to evidence of safety concerns? Where these related to physicians using integrative medicine therapies they may have learned about in the years of ACCME-approved sessions? McMahon provided neither evidence of safety problems nor a statement of such concern. Instead, he reiterated that the ACCME is not targeting integrative medicine CME.

I will add here that in private discussions, ACCME has talked vaguely of there having been “complaints”. No direct evidence has been provided by the ACCME. Might the complaints be from academics who still hold that there ids no evidence for acupuncture and chiropractic and the Hecht’s Consortium is “quackademic medicine”?

Restraining trade?

This is all deeply troubling. In each case, McMahon and colleagues effectively drew a bullseye on the integrative CME providers. They drew it on no other content area. Nor has ACCME provided evidence beyond hearsay as to why CME programs that have been sponsored for 10 or 15 years by ACCME accredited institutions should suddenly be in ACCME’s cross-hairs now. No doubt then: integrative CME is definitely being targeted.

In truth, the ACCME can chose to target integrative medicine CME. But if so, why not just say it? Dodging the facts stokes concerns. Is the ACCME intentionally putting the brakes on a field that has made significant advances in recent years. Witness the inclusion of integrative practices in chronic pain policy guidance and integrative oncology guidelines. Witness the adoption of integrative philosophy and practices in 55 medical centers in the Veterans Administration.

In war terms, accreditation is a narrows of a river. Control the narrows and one can manage the flow of commerce both upstream and downstream. Through the 1970s, for instance, the AMA sought to stop chiropractic’s growth by closing out the ability of chiropractors to be accredited to send their patients to hospitals for imaging at hospitals. (The AMA lost after the 10-year Wilk vs the AMA anti-trust case led the judge to conclude that it was restraint of trade and a part of “a long history of illegal behavior” by the AMA.

As the Osher Collaborative team pointed out, close access of interested medical doctors to accredited courses on integrative clinical practice and the ACCME dampers change options for medical doctors. In doing so, the ACCME also cuts off more whole person, health focused, integrative clinical treatments to countless patients. The ACCME effectively puts a stake in the ground for continuing with the pharma-centric business as usual of the dominant school of medicine. The ACCME is effectively retraining trade on the one while fostering it for the other.

Given the historic adversity of American Medical Association to integrative practices, one cannot help but conjure the frank image, immediately above, of all the organizations whose representatives constitute the board members to whom McMahon is responsible:

American Medical Association – American Board of Medical Specialties – American Hospital Association – Association of American Medical Colleges – Association for Hospital Medical Education – Council of Medical Specialty Societies – Federation of State Medical Boards

In this context, a recent class action lawsuit against one of the organizations represented on McMahon’s Board merits mention. In Mannis, M.D. et al v. American Board of Medical Specialties et al, three California doctors filed a proposed class action, anti-trust lawsuit “in which they allege the American Board of Medical Specialties (ABMS), the American Board of Anesthesiology (ABA), and the American Board of Emergency Medicine (ABEM) have for years abused their positions within the American medical community by illegally obtaining revenue through anti-competitive means.”

Sadly, a reasonable person must assume presently that these ACCME actions relative to the “controversial” new integrative ways to practice are deliberate acts of war. Don’t use your gut. Use the evidence.  The ACCME has provided no good reasons for starting its targeting of integrative CME relative to “content validity”.

The best start in responding to the ACCME is a campaign of diplomacy with an assumed adversary. Follow the seven recommendations from the Osher Collaborative and above all #6: “Be involved with and closely monitor ACCME policy making.” If relationship building doesn’t bring actual transparency, more respect, diminished prejudice, and inclusion in their decision processes, consider other measures.

Prior articles in this series:

Is Integrative Medicine Continuing Education Threatened by Proposed ACCME Guidelines? Part 1 “Content Validity”

Reflections from Rick Hecht, MD on Academic Consortium Meeting with ACCME President Graham McMahon, MD, MMSc

Is Integrative Medicine Being Targeted? Interview with ACCME CEO Graham McMahon on New CME Proposals

In-Office Supplement Sales, Conference Vendors and Potential Conflicts: ACCME’s Proposed Continuing Medical Education Standards, Part 2