Mar 04 2013
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.
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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