Mar 04 2013

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.

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62 responses so far

62 Responses to “CAM Practitioners as Primary Care Doctors”

  1. Flailon 04 Mar 2013 at 9:05 am

    I’ve heard plenty of anecdotes from people that swear by chiropractors helping to treat issues with back pain or range of motion issues. I know that there are chiropractors that push much crazier ideas (like treating asthma or other issues). The chiropractor my wife goes to gives her an adjustment, and then “prescribes” stretches or other exercises she can do to help with her issues.

    My question is this: are there issues that chiropractors can legitimately help with? Is there any data showing they are effective at their more plausible claims (such as the back pain or range of motion issues)?

  2. eiskrystalon 04 Mar 2013 at 9:14 am

    What does a naturopath/chiropracter know about referring to medical specialists? You may as well include the massage therapists in there for primary carers as well. At least they will “do no harm” unlike the chiropracters and their back-cracking…

    Frankly this will backfire badly for them too in the long run. At the moment they are neither mainstream nor getting many people with serious ailments. They are also not going to be able to charge a comfortable sum or be able to spend as much time with the patient while doing primary care as part of the larger medical system.

  3. eiskrystalon 04 Mar 2013 at 9:20 am

    I’ve heard plenty of anecdotes from people that swear by chiropractors helping to treat issues with back pain or range of motion issues.

    You will probably get the same anecdotes related to massage and sports therapy for such injuries. A bit of exercise, massage and stretching can have an impressive effect sometimes.

  4. Ori Vandewalleon 04 Mar 2013 at 9:37 am

    Flail: I have no expertise in this matter, but what I’ve heard from someone training to be a physical therapist is that effective chiropractic treatments are identical to what physical therapists do, whereas ineffective chiropractic treatments are unsupported pseudoscience.

  5. jester700on 04 Mar 2013 at 11:05 am

    Just noting a repeated typo – shouldn’t it be “CCO” above instead of “COO”?

  6. Steven Novellaon 04 Mar 2013 at 11:21 am

    Oops – fixed, thanks.

  7. pdxstoneyon 04 Mar 2013 at 12:09 pm

    What drives me nuts about this is Kitzhaber used to be a practicing emergency room physician.

    http://www.oregon.gov/Gov/Pages/about.aspx

  8. sonicon 04 Mar 2013 at 1:01 pm

    I wonder if an opportunity isn’t being missed here-
    I am assuming that about 70% of people going to a doctor’s office or emergency room are not actually sick. (I don’t have any stats, this is just based on my experience, so my premise might be false in which case the argument fails.)
    It seems if this is true, then 70% of the people going to the doctor would do well with a ‘placebo’ treatment. (“Take two aspirin and call me in the morning.”… :-) )
    It seems that some of the CAM people might be willing/ able to learn enough to know when they should send a person to a different doctor (I had the term ‘real doctor’ here, but that’s not the way a CAM guy would view it now. is it? ) :-)
    Anyway, I’m wondering if it isn’t possible that with some training many of the current CAM people might make excellent ‘gate keepers’, ‘triage specialists’ or ‘specialists in referring people to the proper doctor’ or some such thing?

  9. Enzoon 04 Mar 2013 at 2:08 pm

    sonic,

    I get what you are trying to say, but yikes!

    First, by “with some training” you really just mean…Medical training, don’t you? It isn’t like CAM people are taking blood and checking for high cholesterol. How would they really even distinguish which patients are asymptomatic and which would require medical intervention?

    Second, CAM practitioners are more than happy to treat perfectly healthy patients.

    Lastly, if you let CAM practitioners be the gatekeepers, you just increase the likelihood that referrals will be to other CAM practitioners. Oh, you’re really sick. You have this full body rash with blisters. I know a great herbalist for that!

  10. Enzoon 04 Mar 2013 at 2:23 pm

    Actually, bad example in the first point. Some naturopaths will order blood work and apparently some chiropractors as well. I don’t know the full range of indicators they check.

  11. DevoutCatalyston 04 Mar 2013 at 2:27 pm

    CAM practitioners believe they have something far better than conventional medicine, can’t see them as gate keepers. Unlikely they’d make appropriate referrals when their MO is to stab MDs in the back.

    Enzo, chiropractors have xray machines. You can give a monkey a mass spectrometer, doesn’t mean he knows what to do with it.

  12. BillyJoe7on 04 Mar 2013 at 3:26 pm

    sonic:
    “isn’t possible that with some training many of the current CAM people might make excellent ‘gate keepers’, ‘triage specialists’ or ‘specialists in referring people to the proper doctor’”

    I’m not sure why you ask this question, because it has already been answered:

    Steven Novella:
    “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”

  13. sonicon 04 Mar 2013 at 4:26 pm

    Enzo, et. al.,
    Certainly there are CAM practitioners who would not be good for the position I’m envisioning.
    It would require the person to recognize his limitations and to have enough training to be able to discern between ‘obviously not really sick’ and ‘maybe something wrong’.
    They would also have to be willing to tell people to go to the hospital when they see a person who might benefit from that.

    I know the ‘triage specialist’ at a rather large hospital. She is an RN. She makes ‘life and death’ decisions fairly regularly in emergency situations.

    I’m thinking more along those lines….

  14. kvsherryon 04 Mar 2013 at 6:38 pm

    Sonic-

    As an RN, the ‘triage specialist’ that you refer to has had medical training throughout nursing school to understand the medical reasons and treatments for disease. Additionally, this role in any emergency room goes to an RN that has completed specific training from the Emergency Nurses Association giving guidance about the decisions that need to be made, who goes in what order, it’s called the “Emergency Severity Index” and gives clear guidelines. The triage nurse is also a nurse who has significant experience in the Emergency Room setting and can rely on her observational skills to determine the ‘life and death’ decisions. This nurse is also working off of standardized protocols that the hospital’s medical team has come up with to tell her what tests to order for what presenting complaints.

    Finally, I hope this does not come off as too sensitive, but it sounds like you are comparing nurses, trained members of the healthcare team, to pseudoscientific CAM practitioners.

  15. rezistnzisfutlon 04 Mar 2013 at 7:12 pm

    Whether or not CAM proponents have the best intentions, basing treatments off of little more than placebo, making baseless claims about treatments, taking money from those who are credible, or worse, giving the credible a false sense of treatment, is not a good thing. Furthermore, much of the CAM philosophy is derived from perceived inadequacies of science-based medicine and some even go as far as claiming that SBM is harmful, planting seeds of distrust and pseudoscience that can only serve to cause harm (see the whatstheharm.net).

    Unfortunately, CAM proponents don’t just stop at lifestyle care and pain management, they go further to make medical claims that, at best, have no evidence of being true, or worse, have evidence to the contrary. They often charge out the nose for their “services” and take advantage of those who are vulnerable. Why many of these practices are still legal is beyond me.

  16. Davdoodleson 04 Mar 2013 at 8:36 pm

    “Chiropractors and naturopaths would like to be your primary care physician.

    My local auto mechanic is probably better-qualified to be a “physician” then either gibbering cohort of no-nothings.

    While he’s probably as partial to my loose change as the charlatans, at least I’ve never heard the auto mechanic claim that he could treat my flat tyre with eye-of-newt, or that my headlight bulb is broken as a result of a subluxation of my carburettor.
    .

  17. sonicon 04 Mar 2013 at 11:18 pm

    kvsherry-
    And I would suggest that anyone doing that job should have that training.
    And that would include the CAM guys.
    And that is the opportunity I see here-

    You want to be a ‘gatekeeper’? (I’ll use that term instead of physician as I don’t think that should be applied to the job I have in mind). Then do this training like everybody else. No need to discriminate- just have a training for people who want that job.
    And make the CAM guys do the training- no discrimination.
    Then if a person elects to have a CAM guy as his primary, then the CAM guy knows enough to refer someone who is truly sick. Further, the CAM guy could be made to inform his patients that his role is to help them with ‘self-limiting’ problems and to refer them to other doctors when needed.

    This is politics, not medicine or science. ;-)

    Davdoodles-
    Sounds like you are getting better medical advise from your mechanic than I get out on the golf course. Where do you take your car? :-)

  18. daedalus2uon 04 Mar 2013 at 11:41 pm

    Sonic, there is a disconnect between the reality based community that recognizes that acquiring skills and knowledge takes effort and training and CAM magicians who just make stuff up and fool themselves and defraud their patients.

    The CAM guy can’t know when someone has a self-limiting condition unless the CAM guy has the training, expertise and knowledge to do a differential diagnosis and recognize it. A few months, or even a few years at CAM skool isn’t going to impart a science based medical conceptualization that matches the real world.

    There are homeopaths who have let their children die of infections while “treating” them with homeopathy. How could they possibly recognize something that their magic water won’t cure?

    If CAM practitioners become PCPs, won’t they need to have malpractice insurance?

  19. kevinjearlyon 05 Mar 2013 at 10:25 am

    Kitzhaber is a former emergency room surgeon. I sort of doubt the that he holds the sentiment attributed to him in that Washington Times quote.

    Now if you will excuse me, I’ve got to call my dowser: the electric is on the fritz and my toilet is clogged.

  20. Murmuron 05 Mar 2013 at 11:02 am

    This topic made me shudder. As well as the usual “what’s the harm” mumbo jumbo they would also sell their remedies for any number of ailments I might have. A quick internet search and I found homeopathic pills for £4.50, (I felt dirty looking at the site so didn’t look up dosage)… which I would be recommended for a headache. I can get ibuprofen or paracetemol for under 50p a pack of 16 at Tesco… even the branded ones are at most £2.50 (though, don’t get me started on people spending stupid money on branded medication). Obviously Big Pharma are trying to rip me off once again!!!

    As an aside, a random thought; has anyone done any studies on how often people visit CAM practitioners and how often people who like to be treated by qualified medical professionals visit their doctor? Are CAM patients more susceptible to hypochondria?

  21. sonicon 05 Mar 2013 at 11:17 am

    daedalus2u-
    I’m suggesting that in order to become a PCP or ‘triage specialist’ one would do the training for that position– no discrimination.
    If someone wants to be a homeopath and not do the appropriate training, then they don’t get the position that requires the training.
    No discrimination.

    There are always some people who remain incompetent even after training.
    Perhaps a larger percentage of CAM people would remain incompetent after the training than people from another group.
    Perhaps.

    There is a means of removing an incompetent person from such a position– is there not?
    And how would this be a bad thing– if it were demonstrated that the CAM people remained incompetent even after training? And if they didn’t remain incompetent, then how is that a bad thing?

  22. ccbowerson 05 Mar 2013 at 12:16 pm

    Sonic,

    The training you are advocating for already exists, it is called medical school and residency. So, if a CAM practitioner decides to go to medical school to become a primary care physcian, then great. Otherwise, I’m not sure what you are advocating for.

  23. sonicon 05 Mar 2013 at 1:56 pm

    ccbowers-
    I’m not sure the training I’m advocating would require med school and residency.
    Certainly triage specialists don’t have that training now.

    I’ll give a real life example-
    A friend of mine went to an acupuncturist. After stating his complaint she said, “You might have appendicitis. You should go to a hospital immediately.”
    This may have saved his life.

    What I’m advocating is that this sort of thing become the norm.

  24. sonicon 06 Mar 2013 at 12:40 am

    What I have proposed might be a horrible idea.
    However, I have come to realize that it rests on at least two premises-
    1) about 70% of people going to a doctor ‘for something’, ‘have nothing’.
    and
    2) the system is now run by politicians.

    Premise 2) is the nasty one to me. Politicians don’t care about science or medicine- they want to get elected. Currently the politicians use the health care system to make promises about care and so forth that they have no means of keeping. They do this to get votes.
    I don’t think it will not be politically feasible to keep CAM out of medicine.
    This is one reason I would advocate keeping politicians out of medicine- but everyone tells me that the government is going to run health care, so…

    If politics is going to be about health care, then health care is going to be about politics. While it might not be possible to keep CAM out of medicine, I do believe it might be possible to get the CAM people trained.
    Politicians love to talk about education and such.

    Perhaps I’m overly pessimistic about CAM and medicine.
    Perhaps my distrust of politics is coloring my thinking. No, that’s a certainty :-)

  25. Mlemaon 06 Mar 2013 at 4:25 am

    I don’t really know much about this.
    from the American Association of Naturopathic Physicians:

    “Licensed naturopathic physicians must fulfill state-mandated continuing education requirements annually, and will have a specific scope of practice defined by their state’s law.”

    But it looks like currently licensed naturopathic physicians can practice as PCP in Washington state and have training in diagnostics and can do minor surgery.

    I tried to examine the coursework that the accredited schools require, and it looks fairly extensive. At least as extensive as an advanced degree in nursing, if not medical school (a doctor could judge that better) It does seem weird to see homeopathy as a course. (maybe that should be: use of placebos in treating gullible hypochondriacs) If we are facing a shortage of PCPs, it does seem like those physicians could fill the gap, especially if licensed and thereby accountable for their practice. If not, what do we do? Maybe poor folks just have to get at the end of a very long line?

  26. Mlemaon 06 Mar 2013 at 4:32 am

    to continue: my thoughts are there are a lot of people right now who don’t get even basic medical care because they can’t afford it. If they become able to afford it: who will provide it? I think another alternative to allowing NDs, for example, would be to make training affordable for more physicians and PAs. In reality, there are plenty of capable young people who would love to be doctors, but the schooling is too expensive, and too selective due to lack of seats. Medicine has remained a rather elite profession in this country and i don’t think it needs to be that way.

  27. Murmuron 06 Mar 2013 at 4:37 am

    Sonic, you are not getting the key point, to be able to successfully be a “triage expert” as you put it, the person would need to go through medical school and be well versed in medicine. Your anecdote only shows that sometimes they get it right, and even assuming your figure of 70% is correct, you are then condemning the other 30% to substandard care.

    As for politically, I think you will find if you give CAM a finger they will claim an arm and there is simply no room to negotiate. Distrusting politicians is a good thing and I would argue coming from a pessimistic view of them don’t even give them the wiggle room, because they will take it and twist it. The idiocy of their ideas needs to be stated and presented to them smack bang in the face for there to be any hope.

  28. Murmuron 06 Mar 2013 at 5:06 am

    So Mlema, you would condemn poor folks to having their PCP have “At least as extensive as an advanced degree in nursing”? This is assuming the Homeopathy module does not detract too much from any other legitimate medicinal modality. You are condemning your beloved poor people to substandard care, as nurses, as wonderful as they are, are not doctors and are not trained in being a PCP.

    You are also assuming they would cost less in the short term and in the long term. As I said above, a quick look on the internet showed me that Homeopathic remedies were MORE expensive than other remedies and it has been proven that most of the CAM rememdies (if not all) are only as effective as a placebo, so these genuinely sick poor people would then need to take more fake medication at a higher cost in order to get sicker.

    Would you rather wait 4 hours in a hospital emergency for your child to have a life saving anti-biotic or tetanus jab or would you rather he be given a magnetic bracelet after being seen right away? If there are issues with the medical profession, cost of entry, lack of available appropriate young minds, then I think the problem should be addressed head on rather than trying to fill the gap with quacks and witchdoctors.

  29. Thadiuson 06 Mar 2013 at 5:50 am

    If these CAM scammers are allowed to practice as PCP, and the political climate concerning evidenced based medicine does not change, an unlikely hero may be our last line of defense. I of course am talking about trial lawyers. If Naturopaths begin treating patients as PCP’s, they will make mistakes and kill people, not just because there entire philosophy of medicine is based on magical thinking but because it happens to real doctors as well. We can only hope that some particularly nasty trial lawyers will take up these cases and use the misfortune to ruin Naturopaths and Chiropractors as well as the politicians who allow them to become PCP’s w/out proper training.

  30. BillyJoe7on 06 Mar 2013 at 7:02 am

    Not mentioning any names, sonic and mlema, but the naïveté of some posters is breathtaking.

  31. daedalus2uon 06 Mar 2013 at 8:08 am

    The problem with CAM practitioners isn’t that they don’t know enough, but that they “know” stuff that is false in addition to not knowing enough. A person with zero knowledge would do better.

  32. sonicon 06 Mar 2013 at 10:27 am

    Murmur-
    A ‘triage expert’ doesn’t go through medical school now.
    Your premise is false.
    I’m guessing that much of your reasoning is based on this misinformation, so I will allow you to rethink given that your basic premise for the discussion is false.

    Thadius-
    My thinking exactly- if someone does a good job, then there isn’t a problem.
    If someone does a bad job, well that is a problem we have been dealing with all along.
    If CAM people all do a bad job– we call that exposure.

  33. Murmuron 06 Mar 2013 at 11:12 am

    Sonic,

    Can you please explain what you mean by ‘triage expert’ then, I was not aware that they already exist and do not require medical training? If this is not the person that someone would see when they first get sick, then I am sorry, I was mistaken in implying anything about them.

    My point is, no matter what you call them, ‘triage expert’, PCP, GP, medical quarterback, they will require medical training to be able to do their job properly.

    I am also question the ethics of saying that we should let people make uninformed medical choices by using CAM practictioners as PCPs and causing probably thousands people harm in order prove a skeptical point.

  34. ccbowerson 06 Mar 2013 at 11:37 am

    “A ‘triage expert’ doesn’t go through medical school now.
    Your premise is false.”

    Sonic, this ‘triage expert’ term you are using is misleading, because we are really talking about primary care physicians and their offices/staff and the role they play in healthcare, and unless you are arguing that they are not needed, this CAM discussion is way off.

    Even if 70% of visits are not necessary, it does not follow that the skills needed and care received during a visit does not matter. Whether further evaluations or treatments are needed (which must be evaluated for 100% of patients by the way) the person evaluating this needs a broad understanding of medicine and healthcare in general.

  35. sonicon 06 Mar 2013 at 12:02 pm

    Murmur-
    Here is a sample from the CDC for ‘field triage’.
    http://www.cdc.gov/mmwr/pdf/rr/rr6101.pdf

    I think most triage people (the only one I know) are RNs. But EMT’s need to make these types of decisions as well.
    The guy driving the ambulance probably didn’t go to med school. :-)

    There is a difference between medical training and going to medical school.
    And I have suggested the position would require training.

    As to ethics-
    You assume the outcome before the experiment is run.
    You assume that the situation would be different than it is now. How many people use CAM guys as PCP now? Perhaps not acknowledged, but I’m betting those that would choose a CAM guy are actually using one for the purpose now. I know people who contact their naturopath or chiro or whatever first now.
    Don’t you?

    ccbowers-
    Politics.
    You say they demand ‘x’, I say offer ‘y’.
    Now we compromise– the CAM guys get trained and inform their patients that their role is to deal with ‘self-limiting problems’ and to direct them to other doctors for other problems. If they don’t want to do that, then they don’t get the position.

    See the opportunity?

  36. ccbowerson 06 Mar 2013 at 1:40 pm

    “See the opportunity?”

    Sonic, I see huge problems with what you are proposing, and I’m sure I’m not the only one. These are problems not only in theory, but in practice as well. If medical school and residency were truly a waste and inefficient way to have primary care in this country, then I am open to alternatives being proposed and evaluated, but they better at least make sense on paper before we start testing them in real life. Your CAM proposal does not seem to accomplish anything positive.

    Your proposal doesn’t even work in principle because (as people have pointed out above) CAM practitioners are not only lacking in specific training and education, but many are also trained and educated in incorrect information. So its not just a matter of specific training, but it is far more complicated than that. We cannot destroy very basic standards in this way, and I don’t think we will do this. I also see “the opportunity” for a slippery slope once that door is cracked open (and not the fallacious type of slippery slope), in that it will be politically easier to expand this scope (and subsequent harm) until its a big mess.

  37. daedalus2uon 06 Mar 2013 at 1:49 pm

    The problem with non-experts doing triage means that they will make mistakes and people will die.

    I am reminded of an incident reported in a blog where a PCP (in the UK), diagnosed someone with an aortic dissection that was about to burst, ordered an ambulance to take him ASAP to the hospital. Unfortunately the EMTs in the ambulance were “trained” to go through a certain protocol for a “heart attack” to see if the trip was “necessary” and did not think of themselves as glorified transporters of patients as dictated by other medical authorities. So the ambulance stopped and did the work-up that their protocol required, the aneurism burst and the patient died.

  38. BillyJoe7on 06 Mar 2013 at 3:45 pm

    The problem we have here is non-experts thinking that can make a useful input into the questions raised here that can only be usefully answered by the very experts that they are arguing against.
    Dunning-Kruger and a song by Joni Mitchell come to mind.

  39. Mlemaon 06 Mar 2013 at 7:11 pm

    murmur, you are twisting my words. Why don’t you find an accredited school for naturopathic physicians, look at the coursework, compare it to medical school (find out what the course content is if you can – that’s why I said a doctor could do that) and then pronounce your judgment. I contributed to the conversation the observation that in Washington state right now NPs are acting as PCPs. If you feel that is a horrendous violation, then my observation gives you an opportunity to explore the ways that it doesn’t work in real life. From what I could find out (as I said: “I don’t really know much about this.”)
    NDs are trained in many of the same way MDs are, minus surgery rotations and some other stuff I don’t know about because I didn’t go to medical school (although I did my graduate work in medical school at Johns Hopkins). It looks like NDs to a more extensive history/evaluation, probably something similar to a functional MD eval. They appear to have more extensive training in nutrition/possibly environmental factors/ and maybe counseling, and focus on preventative health, but I really don’t know. Why don’t you check it out and give us your educated opinion?

    I agree w/ daedalus2 that “The problem with CAM practitioners isn’t that they don’t know enough, but that they “know” stuff that is false in addition to not knowing enough.” You have to question the orientation of someone who would believe that homeopathy is grounded in science. How would that affect their decision tree?

    sonic, I get what you’re driving at I believe, but PCPs aren’t triage. The physical human is incredibly complicated. In many, if not most, sorting out a presenting problem requires long years of training.

    Right now, promptcare self-pay type services for uninsured people don’t typically offer most walk-ins any expertise beyond physician’s assistants. If insurance gives these people a PCP who will get to know them and their history and personality (which is so important for delivering good medical care)
    where do we get these PCPs? They will need to be qualified and tested for the knowledge and skills that any PCP should have. Maybe that’s only MDs – maybe not, I don’t know. But we can bitch about people who don’t have the training trying to claim that they do (don’t get me wrong, that’s very important) but who will these people be? how do we train them/test them/assign their role. If that is well-regulated, it will prevent quackery.

    to me it sounds like an exciting opportunity to increase the number of educated and qualified health care providers, including doctors. Let’s put the money into the education system, hire professors, grow medical school admissions, etc. As medicine gets more and more complicated as the science advances, maybe there are more intermediary roles for providers, like somebody between a PA and an MD? This will be great for the economy, and we might be able to reduce the nation’s burden of diseases like diabetes, which cost us untold millions, and has a higher incidence in the poor.
    http://deepblue.lib.umich.edu/bitstream/handle/2027.42/51444/Everson%20SA,%20Epidemiologic%20Evidence%20for%20the%20Relation%20between,%202002.pdf;jsessionid=DE0436907840576D2FF15ABC962B9995?sequence=1

    the simple fact that medical care is probably the most expensive purchase that economically disadvantaged make means that reducing that cost can potentially help them a lot

    sorry, didn’t mean to get all socialistic, but really murmer “your beloved poor people”? what the hell?

  40. sonicon 07 Mar 2013 at 1:38 am

    Mlema-
    You bring up the biggest problem I see with what I’m proposing.
    A triage person doesn’t have enough training to do what I’m envisioning.
    Yet I’m not asking a person to be any good at diagnostics, I’m just asking the person to know enough to say– “Hey, you should get that checked.”
    In other words someone between the patient and the PCP.
    (As I recall at least 1/2 the people showing up at the emergency room where I worked did fine with a little reassurance. “If it still hurts in a couple days, come back…”)
    This seems a role that the CAM guys might be able to fill well.

    ccbowers-
    Where I live we spend twice as much on health care as anyone else in the world to get mediocre results by most objective standards.
    Your efficiency argument is not persuasive.

    daedalus2u-
    Your anecdote is interesting.
    Are you suggesting that ‘union rules’ caused a person to die? :-)

    It seems that my proposal could be seen as a means to lower standard of care.
    But health care is unaffordable to many where I live. What might be seen as ‘lowering’ could really be ‘making available at all’.

    If the above statement isn’t true, then my proposal can be disregarded.

  41. Murmuron 07 Mar 2013 at 5:37 am

    Mlema, I did make my argument based on your statement about the coursework and have not looked at it myself. Even if I did, not being a medical professional, I would not know what I am looking at. I will grant you that one as perhaps my reasoning may be hasty in that regard. I still maintain that giving CAM any kind of legitimate foothold is a dangerous thing. (Sorry about the ‘beloved poor people’ comment… just a snitch of sarcasm that wasn’t justified in retrospect)

    Sonic, you have changed the words from ‘triage expert’ to ‘field triage’ and your link refers to emergency situations which are quite different to what the discussion is actually about. While I can see what you are trying to suggest, I think you fail to see the most basic problem here… CAM practitioners will still practice hoodoo at that level and they will be given a legitimate space to push their quackery. Where you might think something through rationally, you have to put yourselves in their shoes and see how they might use the legitimacy to do even more harm. They truly believe that their remedies work, so they will push them as far as they can go.

    Even if they have basic medical training, do you really think a Chiro who thinks Sugarus Placebous X30 will cure someone’s headache will think to pass that person on to a ‘real’ doctor? He will push his modalities. There is a very good chance this could backfire as after taking sugar pills for 7 days and you still have a headache, you might very well have a serious condition and get pushed up the tree… the CAM guy can then say look at all my success… I “cured” 50 patients with my *cough* placebo *cough* and you “real” doctors could not heal even half of the 50 I pushed up to you. Why? Because he has already filtered out the ones who are not actually sick… but he will claim them as “cured”.

    As to the ethics. I am assumig a bad outcome because you were yourself saying that the incompetents would be removed and:

    “If CAM people all do a bad job– we call that exposure” etc.

    If they are doing a bad job then they are giving sub standard medical attention and no matter how you spin that, it is doing harm or has the potential to do harm to a real person. You advocate the legal system to remove them… I am sorry if I assume here that they can only be removed legally if they have done harm or done potential harm. I would assume you would have actually had to have done something demonstrably wrong before you are struck off?

    As to those using CAM practitioners as PCPs, well, that is their choice. Knowing people who do something and legislating for it are two very different things.

    To quote you:

    “What I have proposed might be a horrible idea.”

    I would agree with that.

  42. BillyJoe7on 07 Mar 2013 at 6:09 am

    “my proposal can be disregarded”

    Right.

    I know you prefer not to answer my posts and that suits me fine but, really, you talk such nonsense sometimes. Your proposal can be disregarded anyway. Why don’t you listen to those who know about these things for a change instead of to your untrained mind.

    Anyway, I won’t bother you further, so feel free to continue as you see fit.

  43. ccbowerson 07 Mar 2013 at 9:43 am

    “Your efficiency argument is not persuasive.”

    I made no such argument about efficiency, and that is really peripheral to question we are discussing

  44. sonicon 07 Mar 2013 at 11:34 am

    Murmur-
    I agree with what you say.
    At this point I’d say that my proposal (which clearly needs fleshing out regarding ‘what training?’ amongst other things) is better than the governor’s and perhaps more politically viable than Dr. N.’s

    Where I live we currently spend at least twice as much as anyone else on health care and get mediocre results by many objective standards. Further, the system has become a political tool– numerous political campaigns in my area consist of nothing more than bald-faced lies about what the candidates will do about health care- designed to manipulate people into voting one way or the other.

    I know that this means the actual system will be run for the use of the politician– they will use it to manipulate people into voting for them.
    The worse the system, the more expensive, more draconian, the more we need the politician as saviour.

    This means that notions of ‘science’, ‘outcome’ and ‘expense’ are all terms to be used by politicians to lie and manipulate to the people.
    I would expect the system to get more and more expensive and less and less useful. I believe the correlation between the percentage of money coming from government sources and the value of the system is near perfect– the more money from government the worse the system. I’m talking health care and I believe the history of the situation would indicate the truth of what I’m saying.

    Government in action.

    Anyway, I see that the problems with my proposal are large, I think it is a better proposal than the governor’s (as I understand it, anyway) and I fear Dr. N.’s proposal is politically inviable.

    I hope I’m wrong on both counts.

    ccbowers-
    You are correct. I see the term ‘efficient’ or ‘inefficient’ applied to the system where I live and I have to laugh and I got carried away with a pet peeve.
    You see, where I live the system is the least efficient in the world by far.
    Perhaps I’m more open to changes due to that fact than I should be. After all, the system where I live does have some very good things about it- it would be silly to make it worse on the notion that it couldn’t get worse.
    In fact I think it could get worse– I believe the politicians will demonstrate it can be made much worse over the next couple of years.

    I believe it was Shakespeare who advocated ‘killing all the lawyers’. That would take out most of the politicians too.
    Guy was ahead of his times. :-)

    (And no, I don’t really advocate killing anyone).

  45. daedalus2uon 07 Mar 2013 at 12:32 pm

    Sonic, it wasn’t “union rules”, it was the unfortunate outcome of an attempt to reduce cost by rationing care by using insufficiently trained and insufficiently supervised (and hence cheaper) individuals to make medical decisions beyond their expertise.

    The “worried well” don’t have anything wrong with them, and the reassurance of someone who sounds like they know what they are doing might be all they need. But someone with something wrong needs what ever is wrong to be identified and treated.

    The problem is that putting someone with insufficient knowledge and training in a position where they are supposed to sound knowledgeable and reassuring is dangerous if they start to actually believe that they are knowledgeable. CAM practitioners are already there. All CAM practitioners have dangerous levels of ignorance and hubris regarding medical care. If they didn’t, they wouldn’t be CAM practitioners.

  46. Mlemaon 07 Mar 2013 at 2:46 pm

    Sonic, Murmur, I think these online conversations are hard. A lot of friction seems to be from the simple fact that we think we’re talking about the same things when we’re not. I think we all agree that ideally: everybody have a physician who cared for them throughout their lives. A “family doctor”. Most people had those when i was a kid, before the health insurance industry became a massive corporate block and everything was deregulated. (yeah, I’m old) I think it’s important to have training, evaluation, licensing and oversight. But as Sonic points out, the reality of what’s happening out there in many places is so far below the ideal. i think it’s important to keep CAM out of our SB medical system. I will reserve my further comments on CAM – because as a huge descriptor it lumps together many things that I’m not entirely averse to. It’s all about defining and patient education.

    sonic, I really want to know where you live. is it Texas?

  47. sonicon 08 Mar 2013 at 12:28 am

    daedalus2u-
    One of the features of my proposal is that the CAM people get training.
    I guess I have some faith that at least some of them would become better heath care providers with better training.
    I can appreciate that you might not have that same faith. And it is faith on my part, so I have no logical argument for it.

    I agree that people who are really sick need to be treated.

    Perhaps a difference in attitude exists in that I don’t see the system where I live as ‘working’. Perhaps this is why I would be willing to take some chances that others wouldn’t. Certainly if I thought this system was working I would not suggest what I have.

    BTW- I am not attached to this proposal at all. I just think it is interesting and I am glad to see that it is possible to have a rational discussion about the proposal without any emotional baggage or name calling. I think your points about the difficulties of training are exactly the problem that would make this proposal worthless–
    thanks :-)

    Mlema-
    A family doctor? Is that term still defined anywhere? :-)
    Where is there SB medicine now? The hospital I go to sends people to Chiro’s, sells homeopathic remedies at the pharmacy…
    The insurance companies run the hospitals and so they offer what people will pay for. They get more people to sign up by having more services covered. That’s how it works here.

    Last time I didn’t have health insurance when I needed some help I learned something very cool.
    I was sent to a number of different places for various tests- x-ray, ekg, blood work…
    (This example is representative)– when I went to get the x-ray, I was told what it cost and I would be waiting for about 45 minutes. When I said I didn’t have insurance but I had cash, the price was immediately cut 35% and I could move to the front of the line if I wanted to.

    So I knew how to cut my medical bills by 35%– just don’t have insurance and pay cash. This is something that I could work with.
    But that’s not going to be an option much longer, I don’t think.
    It seems the public bought the notion that having insurance would lower the cost. I don’t know how having more people handle your money lowers the cost, but it sells for the politicians. (I have insurance now– don’t worry). :-)

    I had no idea how much my love of all things political ;-) effected my thinking on this subject.

    I live in California- or at least that is where my body is currently located.
    Hablamos spainish. Me gusta spainish, pero yo no lo entiendo muy bien.

    Where my mind is seems to be somewhat questionable– I’ve been told many things about where that is… :-)

    (I agree ‘CAM’ is overly general but when in Rome…)

  48. BillyJoe7on 09 Mar 2013 at 7:33 am

    Sorry but I can’t resist…

    BJ: “you talk such nonsense sometimes”

    Case in point….

    S: “I guess I have some faith that at least some of them would become better heath care providers with better training. I can appreciate that you might not have that same faith. And it is faith on my part, so I have no logical argument for it.”

    S: “I am not attached to this proposal at all”

    You have no understanding so you pull a proposal out of thin air (based on faith? What the f…?), but you are not attached to this proposal at all?
    The question is why are you even bothering?

    S: “I just think it is interesting”

    What on Earth is interesting about and untrained brain spouting nonsense?

    S: “…and I am glad to see that it is possible to have a rational discussion about the proposal without any emotional baggage or name calling”

    They are way too generous of their time, patience, and consideration.
    I prefer to call a spade a spade.
    You have no idea what you are talking about, sonic, and your faux intellectual, meandering posts do not fool me at all.

    (Sorry, I promised not to comment further, but there is a limit)

  49. sonicon 10 Mar 2013 at 12:07 pm

    BillyJoe7-
    If the statement read, “I have faith that the argument- ‘these people can’t be trained’- will not work politically where I live,” that would be a more accurate statement of the actual thought.
    Thanks for pointing to that.

    As to “why would I mention this proposal” – why not?
    That’s not meant to be facetious. I really can’t imagine a reason why not. Please enlighten.

    As to being a spade, I’m not sure what you are referring to: my skin color, the shape of my forehead, my use in a garden,… And that is meant to be facetious. So there. :-)

    I understand if you think I’m a bit off about what the politics are like where I live.
    But it is worse than anything I’ve said.

    And I’m not really attached to that proposal either, but…

  50. BillyJoe7on 10 Mar 2013 at 6:05 pm

    sonic,

    Seems we are still friends.
    Well, otherwise, why would I bother, and why would you respond.

    However, you do talk nonsense.

    As to the spade?
    I doubt your head resembles a spade, but I’ll bet you’ll always try a shovel where a spade is required.

  51. Murmuron 11 Mar 2013 at 6:21 am

    Mlema:

    “Sonic, Murmur, I think these online conversations are hard. A lot of friction seems to be from the simple fact that we think we’re talking about the same things when we’re not.”

    Yes, this is very true and context and tone can be read into so many ways via text conversations.

    BJ:
    “You have no idea what you are talking about, sonic, and your faux intellectual, meandering posts do not fool me at all.”

    To be fair, I have seen a lot worse.

    Sonic:
    You have to understand that throwing an idea out there that you claim to not really support and having leading comments like “And I’m not really attached to that proposal either, but…” is just the kind of thing a conspiracy theorist or quack would do if they were trying to sneakily make a point on this blog.

  52. sonicon 11 Mar 2013 at 3:14 pm

    Murmur-
    I didn’t really understand that about being sneaky. I see what you mean.
    If it seems I’m getting sneaky in the future- please call me on it – I would prefer to be obviously clear if possible.
    If it seems I’m a conspiracy nut or a quack, well that’s for you to decide- my opinion on that matter isn’t going to be very objective, I’m afraid. :-)

    Mlema,
    You asked about Texas–
    A story for yawl.
    Last time I was driving through Texas was during an election. I listened to the guy who was running for Congress on the radio. He was talking about what a beautiful place he owned where they hunted. He wanted the DJ to bring his daughter out to the party he was having in a week. He was hoping she would be dressed in a provacative manner like she was last year. It seems that at some point during last year’s festivities the girl slipped in the mud and ended up looking like a female mud wrestler.
    And wouldn’t it be nice if she would do something like that again?

    The DJ interrupted, “How is the campaign going?”
    “I’m endorsed by the NRA, my opponent by the Sierra Club. I predict a landslide victory.”
    “Did I tell you what a fine looking daughter Joe Smith has? She’s a cheerleader. They will be at the hunt next week. Bring your daughter, we’ll have a barbeque and fireworks…”
    He won as he had predicted.

    For that campaign tactic to work where I live, the guy would be better off if he were talking that way about young boys. :-)

    BillyJoe7-
    Such nonsense you say. There is no job for a spade that can’t be accomplished with a shovel and some elbow grease. :-)
    More seriously–
    The post was about a political response to what is now becoming a completely political situation where I live. It might, therefore, be appropriate to take my rant apart piece by piece.
    Perhaps there is a particular statement that you find particularly nonsensical.
    Perhaps not.

  53. BillyJoe7on 11 Mar 2013 at 11:55 pm

    S: “There is no job for a spade that can’t be accomplished with a shovel and some elbow grease”

    Try digging post holes with a shovel. ;)

  54. Bill Openthalton 12 Mar 2013 at 8:28 am

    Sonic –

    So I knew how to cut my medical bills by 35%– just don’t have insurance and pay cash. This is something that I could work with.
    But that’s not going to be an option much longer, I don’t think.
    It seems the public bought the notion that having insurance would lower the cost. I don’t know how having more people handle your money lowers the cost, but it sells for the politicians. (I have insurance now– don’t worry).

    Insurance doesn’t lower the cost, it spreads the cost and the risk over a large number of people. As long as you have enough cash to pay for the procedures you need, you are better off self-insured, but if the procedure is too expensive for your pocket-book, you are out of luck.

    Our society believes people who need medical care should get medical care. The most efficient and effective way to deliver medical care based on need, is through universal medical insurance. The care providers will be paid, the patients and their families will not be ruined, and with good actuarial management, the cost to each of us will be the lowest. Of course, there are ideology-related decisions to be made — should the treatment be free, or should costs be refunded, should the premium be linked to the income, should all treatments (no matter how expensive) be covered, should life be extended at all cost, etc.

    The simple fact remains that many European countries provide on average better health care for more people at a lower cost (in terms of GDP) than the USA. The flip side is that for cutting-edge care, the USA still rules, and that healthy people spend a lot less on health-care in the USA than in Europe.

  55. sonicon 12 Mar 2013 at 3:31 pm

    Bill-
    Before we get too far into this please understand-
    I have been the guy with no money, and no insurance before– (no address either…)
    This doesn’t make me an expert in anything- but please don’t think I don’t know or care about people in that situation. OK?

    I agree that insurance doesn’t lower cost. It is most efficient and effective to have the person getting a service to pay for it directly.
    I believe that is a fact.
    You then say that ‘universal insurance coverage’ is the most effective and efficient method of delivering a service.
    I believe that is conjecture.

    It appears the conjecture is in direct conflict with the fact.
    I believe that needs to be addressed before sensible communication can occur.

  56. BillyJoe7on 12 Mar 2013 at 4:44 pm

    sonic,

    It is not conjecture.

    Come down to Australia if you want your eyes opened.

    We have universal health cover paid for out of taxes, with those being able to afford private health insurance but choosing not to take out private health insurance having to pay 5% extra in tax.
    No one goes bankrupt paying medical bills and the country spends 9% GDP on health for a much better return than the 19% spent in the USA.
    In the last few years, my mother has had a total hip replacement and had a colon tumour removed and is on the waiting list for another hip replacement. She is unable to afford private health insurance and she is on a pension, so the cost to her is nil.

    What we don’t have is an influential group of libertarians telling us this is wrong.

  57. sonicon 13 Mar 2013 at 11:40 am

    BillyJoe7-
    It is nice that your mother is being taken care of so well.

    The question was about effective and efficient- your response doesn’t mention either– nor does it compare the system you are touting to one in which each person who receives a service pays for that service.
    So I’ll file it under ‘interesting anecdote’.

    BTW–
    Where I live there are currently zero (none, nil) libertarians elected to our federal government. (none in the State or local either).
    As our system is one based on votes- one can see the libertarians have zero votes when it comes to determining how anything in this country is run. Zero votes.
    I am amazed at how many people believe any disfunction that exists in our government could have anything to do with libertarians.

    I have noticed that it is not unusual for a group to blame many bad things on the member not present.
    I try to avoid that behavior.
    I’d never make it as a politician here. :-)

  58. BillyJoe7on 13 Mar 2013 at 4:20 pm

    My mother’s case is not anecdotal, it is representative of what happens with universal health cover in Australia. Or do you think the system treated my mother differently to others? If so, why would she be treated differently? She is just pensioner with no influence. She is, in fact, an example of the general case.

    Regarding effectiveness and efficiency of universal cover vs user pays.
    First of all, I did compare the two. Before the recent changes, the USA spent twice as much of their GDP on health care without achieving universal coverage; and patients went bankrupt if they didn’t have sufficient financial reserves and developed a major illness. This just does not happen in Australia. The only problem in Australia is waiting times for non-urgent surgery, but this is better than not getting the surgery at all.

    Regarding libertarianism.
    Perhaps I didn’t follow it closely enough, but it seemed to me that the big opposition to the recent reforms in the USA was based on libertarian ideology (minimal government; anti-social security; pro user pays). I am willing to concede this point though if my impressions can be shown to be incorrect.

  59. sonicon 14 Mar 2013 at 12:02 pm

    BillyJoe7-
    I did some research.
    Your government borrowed about 44 billion dollars 2011-2012.
    That’s about $1,945 per person, right?

    I’m guessing you are a tax payer- and that many people aren’t– for example children, elderly, students, lower wage workers…

    I’ll make a wild guess here– I did the other math, you can check this– but I think you probably pay tax for between 4 and 10 people–
    So if your tax bill was $8000 to $20,000 higher, then you would be actually paying for the services you are currently getting.

    Check that for me would you, it really is a pretty wild guess on my part.
    If I’m right, I’m thinking you might realize to what extent your government has been giving you a false impression as to what is actually going on.

    We do not have a system in the US where the person getting the service pays for it.
    That went out in the late 70′s– And with it the expectation that each person would be able to pay all the doctor bills he got over his lifetime.
    Imagine that– it was only about 40 years ago when the normal person in this country without any form of medical insurance was fine– they could pay every medical bill– just like most people can afford food, clothing, shelter, haircuts, water, electricity,…

    We opted for a system where it is normal that nobody can afford it– well it seems there are about 1% who can afford it. :-) .

    How it is here-
    When the Senate and Congress and President were all of the same party they couldn’t pass a budget.
    They blamed the parties that could not possibly have anything to do with the inability to run the government in a legal manner on this utter failure to govern.

    Check out the meaning of the word ‘anecdote’– “a usually short narrative of an interesting, amusing, or biographical incident”

  60. BillyJoe7on 15 Mar 2013 at 6:55 am

    sonic,

    Check out the meaning of the equivocation fallacy.
    The word “anecdote” on this blog refers to the use of personal experience as evidence or proof of something. That’s the way you used the word in your first reply to my post as a way to denigrate it (please do not deny the obvious!). But, in fact, I was using my mother’s experience, not as proof or evidence of anything, but as an illustration of the effect of universal health care on people without private health insurance in Australia. That’s more in line with your second use of the word. The difference is that my mother’s experience is clearly generalisable to the population as a whole (she is not special; she is treated like everyone else in a similar situation), whilst an anecdote, as that word is used on this blog, is not generalisable.

    Also where did I say that the system in the USA is, or was ever was, “user pays”. I was clearly saying that that is what libertarians would like it to be, which is why that were hell bent in opposing the recent reforms. It was further away from their preferred situation of “everyone for themselves”.

    Finally, I do not view tax as me paying for ten people. I view tax as paying for infrastructure, education, health, social security, defence etc, with everyone paying according to their level of income/ability to pay. This is a fair and equitable system when those who can do so find loop holes to avoid paying their share of tax. It is also the system that is most conducive to internal harmony and peace amongst the population. So I do not accept your spin.

  61. BillyJoe7on 15 Mar 2013 at 7:05 am

    apart from when those who can do so find loop holes to avoid paying their share of tax.

  62. Doctorrickon 07 Apr 2013 at 12:08 am

    Not sure if anyone still following the thread, but saw a major point above (to me at least). “Family Doctor” does indeed have a quite specific and meaningful definition. Family Medicine (or Family Practice) is a specific specialty of medicine. It requires a 3 year residency in an accredited program, with a laid out course structure. In addition passage of a board certification exam. While the term is used loosely by lay people, it is quite firmly defined.

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