10 July 2019

Are we being too hard on integrative doctors?

Complementary Evidence Based

The Medical Board of Australia’s inbox has never been so full. As of mid-June, the board had received around 8,000 emails about its proposal to regulate doctors who use unconventional medicine.

The board is having to invent new ways to de-identify and publish the submissions because there are just too many to go through manually.

“We love to hear from people; it’s great that there have been so many submissions, but I hate to think that people are really worrying because there really isn’t any need,” Dr Anne Tonkin, the chair of the Medical Board of Australia, tells The Medical Republic.

Most of the submissions are from patients who are really upset that the board is trying to shut down the alternative or integrative medical practice they like to go to.

This was never the intention of the board, says Dr Tonkin.

“The purpose of the draft guidelines is to keep patients safe. So, if their practitioner is going to use something that’s not in the usual run of medical practice, they will be told and they will be given information that will help them to decide whether to go ahead with it or not,” she says.

“So, it really should be really reassuring for patients.”

The board started work on the guidelines a few years ago because it saw a spike in the complaints being made against doctors who practised outside the realm of conventional, Western medicine.

“My dad chose integrative medicine for his prostate cancer treatment instead of oncology,” one AHPRA complainant told The Medical Republic. “His doctor’s advice possibly hastened his death.”

The complainant’s father was diagnosed with prostate cancer around 2001. Initially, he was treated by a GP and a urologist, which kept his cancer under control for over a decade.

Over that time, he was befriended by an integrative doctor who took charge of his primary care.

In 2012, when the cancer had metastasised, the integrative doctor discouraged the patient from seeing an oncologist, instead recommending chlorophyll, ultra-heat treatment, infra-red treatments, vitamin C infusions and fasting.

“Dad genuinely believed it was going to save him, but the cancer just got worse and worse,” the complainant said.

“He must have spent hundreds of thousands of dollars. His treatments got in the way of him enjoying his life, cut short holidays and dominated his thoughts.”

Eventually, the patient saw a private oncologist, but he died within six months in 2015.

In 2016, AHPRA received a complaint letter from Associate Professor Ken Harvey, who is now the president of Friends of Science in Medicine. This letter named 21 integrative medical practitioners whom Professor Harvey alleged were practising medicine inappropriately.

A quick online search reveals that, three years on, many of these doctors are still promoting unproven and potentially harmful treatments on their websites.

There are integrative GP websites that advertise homeopathy as a treatment for depression and fibromyalgia. (Homeopathy does not work for any medical condition, according to the RACGP.)

Insulin potentiation therapy (IPT) and low-dose chemotherapy are being supported by integrative GPs online. (There is no evidence for use of IPT as a treatment for cancer, according to the Memorial Sloan Kettering Cancer Center in the US.)

Many integrative GP websites advertise the elimination of mercury and lead through oral and IV chelation. (The American College of Medical Toxicology strongly advises against using chelation for anything other than heavy metal poisoning. Chelation therapy can have serious side-effects, such as renal failure and hypocalcaemia.)

One integrative GP clinic states on its “educational” website that “regular use of sunscreen is associated with an increase in the development of the most forms of skin cancer”. (Sunscreen doesn’t cause skin cancer; Cancer Council Australia advises people to apply TGA-approved sunscreens to reduce their risk of deadly melanomas.)

Interestingly, five out of the 21 integrative medical practitioners listed in Associate Professor Harvey’s letter had previously been reprimanded or penalised by various regulatory bodies for: inappropriately administering intravenous vitamin C treatment to a patient with renal disease; failing to refer a morbidly obese patient dying of cancer to a weight-loss clinic; advertising inappropriately online; requesting and accepting loans from patients; and over-charging Medicare.

The Australasian Integrative Medicine Association (AIMA) has its own set of guidelines, developed in collaboration with the RACGP, which emphasise treatments with the “best available evidence” and advise doctors not to delay conventional medicine when needed.

Dr Tonkin says these AIMA guidelines “are really very good” and cover the same sorts of issues as the board’s draft guidelines.

The integrative medical practitioners who don’t follow AIMA’s or other medical bodies’ guidelines may be small in number – but we just don’t know.

“Integrative medicine isn’t a recognised specialty,” says Dr Tonkin. “So, we don’t keep any stats on which doctors who are having complaints made about them call themselves integrative or not.”

AIMA currently has 3,000 people on its database, but not all of these are doctors.

Surveys indicate that around 30% of all GPs self-identify as using some form of complementary or integrative medicine, says AIMA president Dr Penny Caldicott.

“There are a lot of doctors who are interested in further study in integrative medicine but are not sure where to start,” she says.  “Doctors frequently come to AIMA asking how to train in integrative medicine, they are often nervous about the way forward as they see that the medical climate is not very friendly or supportive.”

AIMA is launching the AIMA Endorsed Pathway towards the end of the year to help standardise the training process, she says.

What is clear is that consumer demand for complementary and alternative medicine is very high.

A survey published in Scientific Reports last year found that 63% of around 2,000 Australian adults used complementary therapies. Almost half of respondents used vitamin or mineral supplements. Many practised meditation or saw massage therapists, chiropractors or yoga teachers.

That so many patients sprung to the defence of their medical practitioners by writing submissions to the Medical Board of Australia suggests that these treatments are highly valued in the community, even if some of them are no more effective than a placebo.

The tsunami of anxious letters from patients might also be due to negative publicity and misinformation about the proposal, says Dr Tonkin. “Sadly, I think a lot of the patients who have put in submissions haven’t really understood the purpose of the consultation and they are really not addressing the guidelines at all,” she says.

The draft guidelines, which were released in February and are open to public consultation until 30 June, describe fairly basic principles of good medical practice, such as not misleading the patient about the known efficacy, costs or side-effects of treatments.

But an open letter by vitamins mogul Marcus Blackmore called the proposed guidelines “Draconian” and said that “the proposal would see a split between conventional doctors and integrative medicine doctors” and “has the potential to severely restrict the use of integrative medicine in Australia”.

After meeting with Dr Tonkin in March, AIMA’s Dr Caldicott wrote a letter to the board formally requesting a retraction of the proposed guidelines.

She said the guidelines were unnecessary, had a poorly defined scope, amalgamated three disparate groups into one definition (integrative, emerging and unconventional medical practitioners), and that there was a lack of procedural fairness in the development of the guidelines.

“The proposed guidelines place a burden of proof and bureaucracy on integrative doctors beyond that required of all doctors through the Good Medical Practice Guidelines,” she says. “This is interesting because integrative medicine interventions are generally very low risk, so why would there be an imperative to have more proof and oversight?”

Dr Caldicott says the 11 cases of misconduct listed by the medical board in its discussion paper do not demonstrate the need for new guidelines as they have all been identified and dealt with under the current Good Medical Practice Guidelines.

“This shows that the current system works,” says Dr Caldicott. “If the system works, why do we need new guidelines?”

In conversation with The Medical Republic, Dr Tonkin addresses each of these criticisms in turn. 

Firstly, it is the responsibility of the board to try to prevent complaints through better regulation, not just react to complaints as they arise, she says. The board does this by drafting guidelines that relate to “hot spots” in complaints data. 

The board has done this a few times before, once in 2018 to clarify sexual boundaries in the doctor-patient relationship, and once in 2016 to better regulate cosmetic surgery, she says.

Secondly, the guidelines are not holding integrative doctors to a different standard as other doctors because the guidelines apply to all doctors equally, says Dr Tonkin.

“I’m a medical practitioner,” she says. “If I wanted to give somebody something unconventional, I’d have to abide by these guidelines just like everyone else does. We are absolutely not setting up a two-tiered system. Everybody should perform to the same level.”

Thirdly, in response to the suggestion that the complaints ‘system ain’t broke so don’t fix it’, Dr Tonkin says the current system “is obviously not working well enough”.

“And it seemed to us that given that the Good Medical Practice Guidelines aren’t everybody’s favourite bedtime reading that maybe if we gathered everything together in the one place and make it really clear about what applies in this kind of situation that that might help people practise to the level that we are expecting them to keep the public safe,” she says.

To the accusation of procedural unfairness, Dr Tonkin says the board doesn’t do pre-consultations before drafting guidelines because it would be unfair to invite only a few stakeholders to participate.

Finally, the board believes strongly in the patient’s fundamental right to make their own medical decisions, says Dr Tonkin. “We don’t wish to interfere with that at all,” she says.

The board will never ban particular alternative or complementary treatments or dictate under which circumstances treatments can be given,  Dr Tonkin says.

“Can you imagine how complicated that would be?” she says. “It would also make a lot of doctors very annoyed… We certainly don’t want to restrict what people are doing as long as it’s safe.”

THE CASE FOR THE DEFENCE

The term “integrative medicine” started to gain popularity about 40 years ago in Australia with the founding of the Australasian College of Nutritional and Environmental Medicine (ACNEM) in 1982 and the formation of AIMA in 1992.

It’s since become recognised as a legitimate style of medicine by more than 70 universities in the US, including prestigious institutions such as Harvard University and Stanford University.

Integrative medical clinics are now found in all cities and even some country towns in Australia, and can charge a $62 to $290 gap fee.

At its best, integrative medicine looks outside the box at what environmental, nutritional, behavioural, infectious disease or gut microbiome factors could be causing or exacerbating a patient’s symptoms.

Integrative medicine generally doesn’t put complex patients with chronic, unexplained symptoms in the “too hard” basket.

It’s persistent, patient and willing to take a trial-and-error approach, tweaking nutritional or environmental variables until the patient feels better.

Integrative medicine is somewhere that patients with chronic fatigue syndrome, IBS, fibromyalgia, chronic pain or mood disorders can turn for guidance and support when conventional doctors tell them they’ve hit the end of the road with treatment.

It’s a style of medicine that tends to value the patient as a partner, understands the importance of continuity of care, and is happy to try low-evidence interventions that other doctors might turn up their noses at, such as placebos, acupuncture, hypnosis, vitamins, minerals, hormones, herbs and naturopathy.

The best integrative doctors aren’t anti-vaccination and they don’t offer mystical practices, such as energy healing.

They usually believe in the same hierarchy of evidence as conventional doctors, and support the GRADE approach. But they also feel that it is sometimes unethical to wait for high-level evidence before trying a treatment, given that the process of gathering data is slow, expensive and often riddled with conflicts of interest.

After visiting an integrative medical practitioner, the patient might receive a full workup of the environmental, social and emotional factors that might be affecting their health, and discover that they actually have food intolerances, or that they’ve brought an intestinal parasite back from overseas or they are allergic to the mould in their carpet.

What does this look like in practice?

Harry (not his real name), a patient from Perth with an inflammatory bowel condition called ulcerative colitis, says integrative medicine gave him back his life.

For four years, Harry was passing blood when he went to the toilet, which could be up to 12 times a day. His symptoms of extreme anaemia, constant stomach cramps, fatigue, depression and aching joints left him unable to exercise.

“I used to do a lot of running, you know, 10 to 15km,” he says. “Got diagnosed and bang, that was it. It was like being hit with a steamroller.”

He was put on several medications by a gastroenterologist and only had brief periods of remission. When he experienced a flare in December last year, Harry was told by the gastroenterologist that if the drug of last resort didn’t work, he’d be looking at colon surgery.

And so, Harry went to see Dr Nadine Perlen, a board member of ACNEM and an integrative medicine GP. 

Dr Perlen did a sweeping set of food allergy and food intolerance tests, including skin prick tests and the controversial IgG food antibody blood test, and advised Harry to avoid walnuts, shellfish, gluten, pork, chicken, most grains, dairy and eggs.

(The Australasian Society of Clinical Immunology and Allergy states that “There is no credible evidence that measuring IgG antibodies is useful for diagnosing food allergy or intolerance”.)

After adopting this strict diet, Harry’s disease went into remission for several months. He lost weight and is “starting to feel human” again, he says. Now, he’s doing more exercise and “starting to get back into doing something that other people would class as normal”.

Harry has not yet re-introduced any foods because he fears a relapse. Dr Perlen put him on some supplements, including vitamin D, probiotics and fish oil.

“The blood results that I had on Tuesday were fantastic,” he says. “All normal. My cholesterol is down.”

Harry went back to see his gastro specialist and told him how well the dietary intervention had worked.

“It was literally dismissed within 10 seconds: ‘Oh, yeah, great’ and pushed to one side. Now, let’s talk about what drugs,” says Harry. “So, cynically, you say, ‘Is it because the pharmaceutical industry is driving it? Or is it just an ignorance or lack of interest?’

“The difference with Nadine is that she has the ability to sit there and look at it from both sides and just it’s the alternative, let’s see if this works, let’s see if this helps. And, in my experience, it’s had a dramatic effect.”