Today we are joined by Australasian Integrative Medicine Association (AIMA) president, Dr Penny Caldicott to draw attention to a recent public consultation paper released by the Medical Board of Australia in February 2019 and its potential for negative impact on the complementary medicine industry.
Covered in this episode
[00:58] A breaking issue with Dr Penny Caldicott from AIMA
[03:50] Who does the Medical Board of Australia consultation paper target?
[10:45] Who is the MBA?
[11:19] What are the implications if these guidelines are accepted?
[12:08] Is this a safety issue?
[15:02] Bringing the industry together
[16:32] Where can people find out more?
[17:05] Who does this affect and who can respond?
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Unusually we're discussing a breaking issue, and between the time of recording on the 18th of March 2019 and the time you hear this, things may have changed as things are rapidly evolving. We have Dr Penny Caldicott, president of the Australasian Integrative Medicine Association (AIMA), on the line. Penny, welcome and can you tell us what's happening?
Penny: Thank you, Andrew. Good to talk to you. So, in about two and a half weeks ago the Medical Board of Australia (MBA) put out some new proposed guidelines for doctors practicing what they're calling unconventional, complementary, and emerging practices. And in these guidelines, there are stipulated differences of expectations of doctors practicing these kinds of things.
So the problem that we have as an organisation, the Australasian Integrative Medicine Association, which is a peak body for integrative medicine in Australia, is that we don't really understand what these guidelines are about and who they're meant to be targeting. So we met with the Medical Board last week to try and clarify what is going on here, and what they tried to do was to set up some guidelines for complementary and alternative medicine because, in Australia, we haven't had guidelines for practitioners practising these types of medicine.
And in the process of doing so, they realise that there were a whole lot of other things that maybe they needed to address and so this rationale for these guidelines developed into something a bit bigger than that. But the issue for us is that, in developing this rationale and these potential new guidelines, they haven't had any consultation with anyone who practices this kind of medicine.
So the usual practice in developing a rationale for guidelines is having wide consultation amongst the stakeholders and the stakeholders are normally meant to be the people who are actually practising the kind of medicine that they're looking to propose guidelines for. In the rationale statement, what they said is that there are some stakeholders who've asked for these guidelines which are nobody in the integrative medicine community, but they haven't stipulated who these people are and in the rationale for the guidelines. They haven't actually proven that there is any risk to the community of doctors practicing in this way, and so they haven't really explained why we need these guidelines.
Andrew: So, you said that they haven't stipulated who they're targeting, and that therefore means that it includes all of any practitioner who practices complementary or integrative medicine. Is that correct?
Penny: Well, that's potentially correct. So, in Australia, we know that in a couple of surveys done over the last 10 years, about 30% of GPs, and this is not even including specialists, say they practise some form of integrative medicine, and so potentially this could include lots of people and lots of different practices, but the rationale is so kind of undefined and relatively vague that it would be hard for anyone to know whether these guidelines would include them or not include them.
When AIMA met with the Medical Board, they said that this wasn't meant to target evidence-based integrative medicine and yet AIMA was mentioned three times in the rationale that precedes the proposed guidelines. And so I guess the integrative medicine community is feeling very unsure about what would be included. Rather than bring up any evidence for kind of relative risks of practising this kind of medicine, what they did was bring up a number of cases that a number of cases of doctors that the Medical Board has pursued, and those with cases of people practising kind of not really within the realms of integrative medicine, so things like using anabolic steroids, and stem cell therapies, and a number of other issues like that. And, in fact, interestingly enough those cases did come to light and did get pursued which leads us to think that perhaps the current guidelines are actually sufficient.
Andrew: What perplexes me is what you mentioned there, stem cell therapy and anabolic steroids, are not complementary or integrative medicine practices; they're medical practices and they're an issue of a sanction from a medical board to a medical practitioner.
Penny: Yes, correct. So, the cases that they brought up were I guess we don't think reflective at all of people practicing complementary or integrative medicine.
Penny: And although there's been this kind of attempt to make us feel like we're not included. When you do read through the rationale, it's not so convincing that we wouldn't be included.
Now, what they've said is that the rationale will not be included once the guidelines come out, but what they will do is have a kind of addendum to the guidelines of the things that would be covered by those guidelines and that they'll be guided towards what that should be by the consultation process they're in at the moment which actually means we're having to give comment on guidelines that we don't really know who's going to be included and who isn't. It's just a rather unusual way of doing it.
Now, AIMA went to the Medical Board and AHPRA four years ago, and we had a discussion about integrative medicine, try and say, "This is who we are, this is how we practice, and this is what we do. And by the way, if you're going to write some guidelines at some stage, we'd really like to be involved." And generally that would be the process and has been the process for other kinds of guidelines and regulations that come from the Medical Board, but in this case, it doesn't seem to have been the process.
Now, we all found out about this because someone found out about it, and we all called each other and kind of got on to it. But by the time it came out from the Medical Board in their newsletter, I'm pretty sure there were only about six or seven weeks or less to respond to this. Now, when we met with the Medical Board, we got an extension which is great, so now all the responses are due back by the 12th of May, and we've got some ongoing communication happening with the Medical Board because we're honestly very keen to work with the Medical Board to understand what we're doing and to help them to see that not only are we happy to perhaps have some kind of guidelines around integrative medicine, but we're also a community that is really getting ready and has already put some things in place to help to self-regulate which is what many of the colleges do.
So the good medicine guidelines, which apply to all of us as doctors, really cover pretty much all of the issues that they've brought up in the preamble, and so we think that those guidelines are enough and are happy to work with the Medical Board to help kind of define integrative medicine and help facilitate training programs and pathways.
Andrew: What I don't understand is, in America, you've got Harvard, Stanford, Yale, Brown, top universities, the Ivy League are now embracing integrative medicine, and they're now starting schools in integrative medicine. Indeed, the orthodoxy is now talking to those people who wish to run the integrative medicine schools, and they want to be inclusive in those guidelines. It seems to be exactly the opposite here in Australia. I wonder if this is suppression.
Penny: I mean I think that's what a lot of people are concerned about, and you're right. There are over 70 of the major universities in the U.S. involved in the Academic Consortium of Integrative Medicine & Health, I think it's called now. And the Cleveland Clinic, as many of the listeners may know, was opened up about three years ago, the Integrative Medicine Cleveland Clinic, and has now tripled in size.
So, yes, you're right it's not emerging in the U.S it's definitely emerged. I think there are some issues in Australia. I think that while we've been working really hard on our integrative medicine and our learning, and supporting each other and our patients, I think that we haven't been so proactive in defining who we are and what we're doing, which is what AIMA has been working very hard on. And we've been also developing, to be launched soon this year, an integrative medicine pathway of training and also facilitating teaching practitioners to write letters to each other i.e. naturopaths, nutritionists, and others to be writing and communicating with doctors. So, there is some work being done at the moment, and perhaps this is in a way kind of good timing because we are being proactive and we're really ready to have this conversation with the Medical Board. But we think that these guidelines or these proposed guidelines and the rationale that's associated with them have kind of come out of nowhere without adequate, any consultation. That's where we think the issue is.
Andrew: The MBA is the medical arm of the Australian Health Practitioner Registration Agency which is called AHPRA, which is obviously registered health practitioners. What about non-registered health practitioners?
Penny: Well, I mean AHPRA can't really do anything about non-registered health practitioners. They don't have any authority over health practitioners who aren't registered with them. So, any kind of regulations around non-registered health practitioners can't come from AHPRA.
Penny: Well, I mean as we've already talked about part of the implication is that we actually don't really know what the implications could be. But certainly, there's the potential of creating a two-tiered system. So, one set of guidelines for people practising conventional medicine, which hasn't really been defined, because as we know conventional medicine is always in a state of change. And then one set of guidelines that has potentially an increased burden for practitioners practising anything underneath these guidelines, which again we don't really know who's included in that. But at the moment, it looks like complementary, unconventional, and emerging practices.
Andrew: Ostensibly one would think that this has to do with safety, and yet just recently I read a news article speaking about seven procedures that do more harm than good. How do they propose that you will stamp out these orthodox procedures that do more harm than good while protecting against integrative medicine practitioners?
Penny: Yes, so that's really interesting because, in the preamble to these guidelines, they've talked about off-label prescribing of pharmaceutical medications. Now I mean there are many specialties in medicine that use off-label prescribing routinely, and that would include some pediatric prescribing, definitely prescribing psychiatry and there's numerous other areas with off-label prescribing. And, if anything, the integrative medicine doctors aim to use less pharmaceuticals and, for the most part, I think do prescribe less pharmaceuticals. If you look at the relative risk of death or relative risk of morbidity, then adverse effects in pharmaceuticals is right up the top of the list as is admission to hospital because of all the different things that could potentially happen to you in a hospital or a medical misadventure they talk about in a hospital.
So, when you look at things like herbs and nutritional supplements, we're so far away from that spectrum that the risk associated with the work that we do has been proven in many studies to be very low. So, the relative risk is very low but you see they haven't really talked about risk. They've talked about potential risk in terms of going down a track and using some form of medicine which doesn't allow you to make a proper diagnosis and a proper treatment, or delaying treatment with conventional means if you're doing something that's considered unconventional, or those kinds of things.
But what's interesting to note is that integrative medicine doctors are first and foremost conventional medicine doctors, that's what our training is. And nowhere in our training in integrative medicine are we told that we should throw the conventional away. The conventional comes first, and the integrative practice is how do we understand how this person got to where they are now and how can we help them work their way back towards wellness. That doesn't mean we're not going to do any prescribing. It's not going to mean that we're not going to investigate and exclude urgent things that need to be treated. In fact, that's what we would be doing first. So the relative risk for the kind of medicine that we do is not only potentially but is actually much lower than practising conventional medicine alone.
Penny: I think that's the concern around them. I think that people are worried that it could increase again the vexatious complaints, that people might complain about things that we're doing because they don't understand them which is not really a good reason to complain.
Andrew: Yes, we're not talking about patients here though. We're talking about "people".
Penny: No, so interestingly they say that the complaints are not coming from the patients, which begs us to ask where the complaints are coming from. And, look, I think we should be alert about what we're doing and who we are and how we define what we do. I think that's really important and maybe that alone will help people to understand better what we are doing and we're not some kind, you know, of radical group of people practising some radical form of, you know, unconventional medicine. This is an opportunity for us to do that, and I think the other thing to say is that the integrative medicine community has really come together over this in a way that we've been wanting for a long time and so the positive effect of this is that we're working very closely together across all the organisations in integrative medicine in Australia. We do have some work to do. This is a very serious issue, but I think collectively we can really bring something good out of this situation.
Penny: Yes. So, if you just go to the Medical Board website, you'd be able to find the proposed guidelines, but you can also go to the AIMA website which is aima.net.au. and on the front page, you can find out all about what we're doing in AIMA, what you can do, what are the kind of main issues that you probably need to think about when writing your submission, and we'll be continuing to update lots on the AIMA website.
Penny: So registered practitioners include all doctors and all allied health practitioners, including Chinese medicine practitioners. And all practitioners could potentially put in a submission on this topic, because in fact in the preamble it mentions often health practitioner rather than medical practitioner alone which means that this could potentially have a trickle-down effect for other practitioners through AHPRA as opposed to through the medical board which just represents medical practitioners.
So, on the RACGP (Royal Australian College of General Practitioners) has an integrative medicine special interest group which has about 800 members. So we've been working with the special interest group, but really importantly for doctors and allied health practitioners who can also be full AIMA members, it would be wonderful if you could join AIMA because that way we can really work together not only to build better guidelines but to really take our place in integrative medicine and within conventional medicine in Australia.
Andrew: Dr. Penny Caldicott from AIMA, thank you so much for taking us through this emerging issue in the Australian integrative medicine landscape. We look forward to hearing more good news from you soon. Thanks so much for joining us on FX Medicine.
Penny: Thank you, Andrew.
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook.
Other podcasts with Penny include:
- Dr Penny Caldicott and her journey to Integrative Medicine
- Preventative Medicine: Self Care and Screening with Dr Penny Caldicott