Is the Medical Board of Australia attempting to suppress the use of complementary medicines by lumping them into the same category as "unconventional medicine and emerging treatments"?
Today we are joined by Prof Stephen Myers, a respected academic in complementary and integrative medicine, who shares his educated opinion on this recent move by the Medical Board of Australia.
Covered in this episode
[00:20] Introducing Prof. Stephen Myers
[01:16] Medical Board of Australia - new proposed guidelines
[07:36] Is this a deliberate act of suppression?
[11:10] Those using complementary medicine are keeping up with current evidence
[13:26] What are the future implications?
[15:56] Does this consultation meet COAG principles?
[17:58] Is complementary medicine more dangerous than orthodox medicines?
[22:05] Proactive complementary medicine use saves money from the public purse
[27:02] Tackling the critics of complementary medicine
[30:26] Complementary medicines pose a low adverse event risk
[34:22] Who and how to respond to this consultation paper?
[35:49] When is the close of submissions for this consultation?
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Professor Stephen Myers who's the director of the NatMed Research Unit based at Southern Cross University New South Wales. He's one of Australia's leading academics in natural, complementary, and integrated medicine. He has qualifications in naturopathy, western medicine, and pharmacology. He's raised over $8 million in research funding, managed over 50 clinical trials looking at the pharmacology of natural products in a wide range of conditions. He's supervised 17 higher degree research students, authored 3 books, 10 book chapters, 93 peer-reviewed research papers, and numerous papers for the professional press. He's also acted as a consultant to industry, government, and academia across a broad range of issues. Welcome to FX Medicine, Stephen. How are you?
Stephen: I'm good. Thanks, Andrew.
Andrew: Now, Stephen the Medical Board of Australia, the MBA have put out a proposed guideline. Can you take us through what this is, please?
Stephen: Well, it's a consultation paper that, certainly on reading it, I actually found it to be very strange I think is probably the appropriate word to use first. What it actually does is to group three groups of medical practice under one umbrella and you have to actually ask why? The background within the consultation paper says, "Feedback has been received from stakeholders that additional guidance for medical practitioners is needed in relation to the practice of complementary and alternative medicine by medical practitioners."
And I find that very interesting that the medical board has received feedback from stakeholders. Who those stakeholders are, they don't actually tell us, it's not transparent. But I can tell you that the stakeholders aren't the Australian Integrative Medicine Association which is the peak professional body, and it's not the Australian College of Nutritional and Environmental Medicine which is the peak educational body for doctors. These groups were not consulted. It would appear that none of my colleagues in higher education who have got a medical background and an understanding of complementary and integrative medicine were consulted.
So there seems to be no widespread consultation within the field of integrative medicine but they’ve have put a consultation paper together because they've had feedback from stakeholders. So I'm very concerned about the providence of this paper and its lack of transparency. It clearly targets complementary and alternative medicine and literally, they make a case for risk that's actually only there because they include these other medical groups in an amalgamated definition.
Andrew: What do you mean by an amalgamated definition?
Stephen: Well, what they actually do is they put complementary medicine, unconventional medicine, and emerging therapies into one definitional framework. And I've got great concern about that because generally when you define something, you're doing it because those things have things in common. Now, the only thing that those three things have in common are the fact that the Medical Board considers them to be outside the province of conventional medicine which is one of the things that the actual definition refers to.
So the definition actually states, "Complementary and unconventional medicine and emerging treatments, include any assessment, diagnostic technique or procedure, diagnosis, practice" which they define and I'll come back to, "medicine, therapy, or treatment that is not usually considered to be part of conventional medicine whether used in addition to, or instead of conventional medicine. This includes unconventional use of approved medical devices and therapies."
So it's a wide-ranging definition that merges these three things together. So, firstly, we have to say what's unconventional medicine? So unconventional medicine would be a medical practitioner prescribing a known pharmaceutical drug, not only sort of off its claims but in a way that would not be able to be understood by other conventional medical doctors. So that's unconventional medicine. Emerging therapies are things like stem-cell therapies. Now, integrative medicine doctors who practice complementary medicine don't prescribe medical drugs off their, the claims that are made for them because they're actually interested in the best therapy for patients and they're not going to be unconventional in that way and they don't use stem-cell therapy.
So why you have to actually ask are they putting these three things together? And the only reason that I can actually come up with is that the definition is political and not scientific. It actually concerns me that there have been times in history that people round up different groupings of people and the only reason that they actually round them up is the fact that they hold views that are considered to be antithetical, that they're actually not considered to be doing the right thing. So this is a political definition it's not scientific because they are failing to say that it's a political definition. I'd actually go so far as to say that it's a piece of pseudoscience and, you know, let me define pseudoscience. Pseudoscience is somebody who's attempting to do something scientifically where science isn't involved and it's for other purposes. And that's what I believe the Medical Board is doing, that they are actually putting these three groups together so that they can make a case against complementary and integrative medicine which is unfounded.
The risks that they talk about, the only risk that they can find for unconventional medicine and for emerging treatments, they quoted deaths from stem-cell therapy. That's got nothing to do with the practice of complementary medicine by integrated medical practitioners whether they be specialists or whether they be general practitioners. So to try and make a case against complementary medicine by putting it in with a bunch of other practices is unfounded. It's not scientific, it's not evidence-based, and it's very inappropriate.
Andrew: Yes, it actually smacks to me like of suppression and indeed I was following on from what you were talking about the strange use, if you like, of drug therapies. I remember hearing about one sports doctor who was using low-dose antibiotics not for acne and not because it was below its minimum inhibitory concentrations (MIC), for an antibiotic use. Indeed, he was using it in sportspeople for its inhibition effects of interleukin 1b so that they could play while having a cold. And so that to me is off-label. Not off-label but a very strange use of a drug which isn't followed by any science whatsoever. But that's a drug, that's a pharmaceutical. What I'm picking up here is that by including integrative and complementary therapies, it's actually suppressive of any investigation whatsoever into researching these to see if they can help.
Stephen: Well, I mean, that's actually an interesting topic to actually take up because the way that the Medical Board defines practice is actually quite frightening. It says that, "Practice is not restricted to the provision of direct clinical care". So I'll repeat that, “Practice is not restricted to the provision of direct clinical care”. It also includes using professional knowledge in a direct, non-clinical relationship with clients, working in management, administration, education, research, advisory, regulatory, or policy-development roles, and any other roles that impact on safe, effective delivery of services in the profession.
Now, I actually am concerned that if we actually would take this to our civil libertarian friends that they're actually infringing upon the civil liberties of doctors that educate, research, and advise about complementary medicine. The way that this is actually written, legally, if I was to actually put up an alternative to what I consider to be an unsafe delivery of a medical service that might affect the delivery of that medical service, I would actually be in breach of researching, advising, or advocating something that was considered to be inappropriate for orthodox medicine.
That smacks to me of thought police. It smacks to me of a situation where we want to not only suppress the people that actually undertake these roles but we want to make sure that they can't talk, they can't research, they can't advise, they can't engage in policy development. It's bizarre, I mean, to actually go that far with such an all-encompassing definition of practice. I consider it to be an invasion of my civil rights and my academic independence.
What I research should be up to a human research ethics committee duly constituted under The National Health and Medical Research Council that actually decides what's ethical research, not The Medical Board of Australia deciding something is actually not within the area that they consider to be appropriate for conventional medicine.
Which brings us, actually, on to another, you know, delightful part of this definition is that the primary comparator they're using is conventional medicine. Now, the interesting thing is that they don't define conventional medicine. And what do they mean by conventional medicine?
You know, given that it's estimated that 30% of Australia's general practitioners, about 10,000 of them, use complementary medicine in one form or another as a component of their clinical practice. I know I have used integrative medicine as part of conventional medical practice. Is conventional medicine something that is, you know, a defense of the walls of medicine by an old guard, you know, for medicine as they remember it? It may not necessarily mean medicine as it is today. You know, is conventional medicine a decision by an elite within medicine? Is conventional medicine a democracy? Is conventional medicine something that's scientifically-based? And if it is, does it move with evidence?
All of those questions are sort of unanswered in regard to comparing somebody who practiced complementary medicine with conventional medicine. And, again you know, I've actually argued that a lot of the doctors who practice complementary medicine as part of medical practice, they're actually reading the literature. They're seeing what is actually evidence-based and they're incorporating it into their practice. They're expanding their therapeutic options. They're following The Australian Medicine's Guideline and what's called the Quality Use of Medicine (QUM) concept where at any time you think of picking up a prescription pad, you need to consider all of the options, you need to communicate all of the options to your patient, and then allow your patient to choose what is the appropriate option for them in consultation with you. And I'd actually say that the doctors who are practising integrative medicine are much more on top of what patients' options are than many of the people that are practising what you'd call 'conventional medicine'.
Stephen: Well, the thing that the consultation paper ends up with is a set of guidelines to govern the practice in this particular field. And I think the thing that I would say is that and, you know, I believe that all of my medical colleagues practising integrative medicine would agree that there should be one set of Good Practice Guidelines for all doctors. There shouldn't be one set of guidelines for one group of doctors and another set of guidelines for another set of doctors. There should just be one set of guidelines. Otherwise, we create arbitrary fields in medicine and you'll probably end up with a two-tiered medical system, you know, those people that are, you know, the good children that actually do the right thing and those that are the wayward children. And the minute that you create those sorts of tiers, inevitably people will come along and expand those divisions in various ways.
You know, if this was done properly, if the Medical Board had have actually decided to consult people in the field and let's see if we can actually tackle, you know, these 'concerns' that they got from stakeholders in an appropriate way, they might have had a discussion with AIMA and ACNEM about creating a GP specialty in integrative medicine which would actually be worthwhile. But creating a set of guidelines that actually defines people practising in this field as different from the Good Practice Guidelines for other doctors is not the way to actually travel.
Given the fact that this definition has been cobbled together politically and not scientifically, we are calling for The Medical Board of Australia to actually withdraw this consultation, to go back to do their homework properly, to talk to the peak medical groups that are actually involved in this area, to engage with academics that are actually working in this field, and to come back and do this exercise, if it requires being done, in a way that's much more conciliatory, that's much more engaging, that, you know, follows the concepts of COAG.
Stephen: COAG is The Council of Australian Governments and they have principles for Best Practice Regulation. Now, the medical board believes that they are actually following these principles but I think that that's actually open to fairly wide interpretation. So one of the COAG principles is whether the proposal is the best option for achieving the proposal's stated purpose and protection of the public? Well, the public doesn't need to be protected by doctors who practice complementary medicine. They may need to be protected by doctors who practice stem-cell therapy and they may need to be protected by doctors who practice unconventional medicine but they don't need to be protected by doctors that practice complementary medicine.
As I pointed out, you know, you can't make an argument about safety if you were to actually just look at complementary medicine alone. And so it had to cobble these things into one definition to be able to 'protect the public.' So I think if you look at the COAG principles and realise that this is a construct that has no basis in science, then it can't possibly meet the COAG principles because it's actually a construct that's been put there for political purposes that isn't actually setting out to either do what they think it's setting out to do, or to actually protect or inform the public. And, you know, one of the COAG principles is, you know, basically that they are doing so in a way that the cost and the understanding of the benefits achieved are understandable to the public and the people that it set out to affect. And I have to say if you read this document and if anybody in the public were to read this document, they would not be able to understand what they're setting out to do especially if you've got a general grounding in what complementary medicine is.
Andrew: You mentioned adverse effects before and these get widely publicised in the media. But when you actually look at adverse effects from complementary medicine versus orthodox pharmacological medicines, they pale into insignificance. So why is this raised as such an issue with complementary and integrative medicine?
Stephen: Well, there are lobby groups that have actually have made it their life's purpose to actually try and suppress complementary medicine. And, you know, one of the things that I find, you know, and I guess at best I find amusing, but at worst I actually find it, you know, disturbing, is that there are medical doctors who are spending their lives trying to stop complementary medicine where it's hard to point at bodies. You know, it's hard to actually find where there's any significant safety impact of complementary medicine.
Yes, we can point to the potentiality of drug-herb interactions, etc., but the reality is that they're relatively rare in the community and we actually have a good handle on some of the ones that really need to actually be looked at. And then when you compare that to iatrogenic disease which is, you know, disease actually caused by doctors either by practising negligently or because of the fact that medicine actually has substantive risk associated with it, we're talking about, you know, 40,000 deaths a year in the hospital system and greater when people start to look at this. And why these medical doctors who, you know, are generalists in their own field, aren't focusing to get their own house in order and decrease the amount of morbidity and mortality caused by doctors practising medicine, I find stunning.
You know, part of the whole concept of complementary medicine is try a gentle option where the cost-risk analysis is far less than, you know, a prescription drug or a surgery, where appropriate. You know, and I have to emphasise where appropriate. One of the things that's, you know, very clear is that each individual needs to be triaged and treated, you know, on the basis of where they arrive in the medical system, whether it's to see a general practitioner or a hospital emergency department. But, you know, there's evidence that actually suggests that if somebody that comes in and they've got mild depression, let's give them some John's Wort first up and see how they go before they're prescribed an antidepressant that has significant side effects. You know, let's give them acupuncture for their pain before we fill them with opioids.
You know, there's evidence to actually suggest that there are ways of actually dealing with common conditions, both acute and chronic, that actually are well evidence-founded and better for the patient in the long run if they actually work. Why you would want to attack that, you know, with all the fervor of your being, I don't understand. You know, when there are so many things in medicine that need to actually be, you know, looked at and argued against, you know, the unnecessary surgeries that are taking place in obstetrics, in orthopedics, the unnecessary prescriptions of drugs that are off-indication that occurs across multiple fields within medicine. There's lots of fodder for people within the medical fraternity to actually look within to get their house in order. Why they set up to attack complementary medicine, I don't know. I don't understand their motivation.
Andrew: Indeed, this was recently highlighted in JAMA Internal Medicine 2019. I was reading about in Aus Doc (Australian Doctor), I think it was the end of February. There were seven procedures that do more harm than good and this was an assessment of patient records in New South Wales hospitals. And I just think it's staggering that there's this suppression of, as you say, not just the practice, but also the inquiry into what works. And, look, if it doesn't work, it doesn't work but you can't tell it doesn't work if you don't do the inquiry.
Stephen: Well, I think the thing that's actually interesting is that there's a body that actually lobbies against complementary medicine courses in universities. And all they achieve is when those courses get closed down is that we lose another bunch of researchers. You know, at the same time they say, "Oh, we're all in favour of research," but they've probably done more to actually suppress research than they've ever done to encourage it.
Andrew: And this is my concern is that if you suppress research, you suppress those investigations which may actually be helping our ailing and aging population in a cost-saving measure. This has been shown in The Alfred Hospital, for instance, where, by a very simple inclusion to cardiac surgery patients, they were saving $2,300 per patient episode per hospital stay. That's money-saving for the Australian government.
Stephen: Yes, well, The National Institute for Complementary Medicine, (NICM), did some work a number of years ago that showed significant cost-savings associated with a number of evidence-based complementary medicine practices. So not only do we actually have the evidence that a number of interventions within complementary medicine are effective but they would actually save significant amounts of money if they were actually implemented. So rather than this constant attack in the field and the, you know, the sensationalism that actually occurs within the media, it's about time that complementary medicine got invited to the table for a rational dialogue. You know, one of the things that I’ve been calling for is to actually have a level playing field where we start to actually have a serious discussion about how complementary medicine and conventional medicine can actually work effectively together for the health of all people.
Andrew: I totally agree with you. Indeed, in the U.S., many universities are now embracing integrative medicine and including them in their core structure and they're talking with orthodox medicine, I would ostensibly think, because of this need for cost-saving. So I don't get why there's an attempt to suppress it in Australia.
Stephen: I completely agree with you, Andrew. I don't understand it either and, you know, there are moves of course in the United States for broader recognition of medical practitioners that work in this area, you know, that you can actually get a recognised medical qualification for having a specialty in lifestyle medicine, for instance, in the United States, something that's vitally needed in Australia. You know, there should be some way of recognising the doctors that have actually trained in aspects of integrative medicine that actually acknowledge the work that they've actually done, you know, rather than actually, you know, frightening their cotton socks off.
You know, one of the things that a psychiatric colleague pointed out to me last night is that this paper is akin to institutional bullying.
Stephen: You know, we already, in Australia, have an incredibly high suicide rate among medical practitioners. There are immense amounts of stresses that are on top of them and rather than come out and consult with the field, to come out of nowhere with a consultation paper that puts complementary medicine in with fringe practices has caused a lot of concern amongst integrative doctors in this country. And its pressure that was unnecessary, it's pressure that's actually inappropriate, and it's also pressure that's not rational. You know, it's not based on any real safety concerns. The thing that I keep coming back to in regard to this paper, is that it’s the amalgamation of complementary medicine in with other forms of medicine that do have risks associated with them that allow them to make a case against complementary medicine. You know, I challenge them to make that case outside of this political definition that they've actually made.
Andrew: What about the concept that's been thrown around by the people that wish to suppress complementary medicines that complementary medicines both A, are dangerous, and B, don't work? How can you have that juxtaposed action?
Stephen: Well, you know, I think we need to actually look at this in a much more sophisticated way than what they're actually saying. So to actually say that they actually don't work needs to be stacked up against a very large body of scientific evidence to actually say, "Well, the evidence is there that they actually do work." And, secondly, a lot of complementary medicines, especially things like herbal medicines, are based on a tradition of use. And when that tradition of use is put to the test, we find very high scientific concordance. And, you know, that's, you know, potentially a topic for another day is the value of the traditions that underlie a lot of complementary medicine in terms of what they find.
One of the concerns by detractors is that they take away from following standard medical care. But this medical board paper is dealing with individuals who've got a standard medical degree that are in clinical practice that are actually trained to actually ensure that they're not giving a complementary medicine out when somebody needs to actually be referred to a specialist because of a given problem, they need to have a diagnostic test because they've got a given problem. So those things are less likely to occur by integrative medical practitioners. So that's another argument that actually falls by the wayside.
When they say they're unsafe, where's the evidence? You know, and I have no doubt that somebody can point to a body somewhere and somebody can point to, you know, somebody who's actually done something that's inappropriate. And, you know, I would acknowledge that those things happen on both sides of medicine, you know, that there are potentially, you know there are people who practice bad medicine. And, you know, unfortunately, while I would love to say there are none in the field of integrative medicine, I'm sure that there are a couple. But the reality is that it's very hard to make a safety issue against complementary medicine.
Somebody who actually, you know, specialises in determining risk actually did a thing called the bubble graph and if you could actually, you know, imagine a bubble the size of one those balls that they have in gyms on a page, the individual found it very difficult to put complementary medicine on the same graph. They had to put a single dot and they had to actually acknowledge that they had actually expanded it because the risk of complementary medicine is virtually negligible in comparison to the risk of conventional medicine. So I'm not sure where they, you know, get this argument that it's actually unsafe, because it's unfounded.
Andrew: It only takes a very quick investigation of the DAEN, the Database of Adverse Event Notification. You can do your own search. You can search whatever drug you want, whatever nutrient or herbal supplement that you want, and those notifications are comparable, sorry, are able to be compared. And, as you say, they pale into insignificance once you look at them on like a bubble graph. Why do you think they're harping on about safety?
Stephen: Well, look. You know, I have written about safety and I've written about toxicity but I actually also need to actually put that into context. There are safety issues that we need to be aware of. There are toxicity issues that we need to be aware of but the reality is that these things are significantly safer than the standard therapies that are widely used by my medical colleagues. And the reason for that is that they're generally much gentler interventions. And when somebody actually really does need a prescription drug or a surgical technique of some sort, their condition has progressed to a point where the risk of the condition is such that the physical risk of the intervention is significantly less. And, you know, doctors have to make these risk decisions on a daily basis within our hospital systems, and I fully acknowledge that.
I fully acknowledge the appropriateness of those sorts of risk decisions. But if you actually, you know, do the risk decision about complementary medicine, you'd have to actually say that in terms of its comparators in drugs and surgery, it's a much, much safer form of therapy, which is one of the reasons why the public are attracted to it, and it's one of the reasons why integrative medical doctors have taken it up in the first place because it offers a softer, safer option. It's not the whole story but it's a softer, safer option for many people, and for many people with chronic conditions where conventional medicine doesn't have the answers.
I think the concern about these guidelines is that they're actually trying to set up an "us" and "them." And I don't think that that's actually appropriate. They've done so, they say, because stakeholders have actually communicated to them that these things need to happen. It seems to me to be absurd that if you've got somebody making a complaint that you don't go along to the people that the complaint is made about and actually ask them, "Do you think these complaints are warranted?"
Instead, what they've done is come out with a consultation paper that's actually merged complementary medicine in with a range of other types of practice that have risks associated with them, and that the only way that they can actually justify complementary medicine being there is because these other practices have risks associated with them. You know, I would join with other doctors, with AIMA, The Australasian Integrative Medicine Association, in calling for the medical board to withdraw this consultation paper, to actually consult the groups who they believe they need to actually work with and undertake this process in a much more collegiate way.
Andrew: Now, it's not just you and AIMA and ACNEM, but what about integrative medicine practitioners out there? I'm assuming that this is going to be restricted to medical practitioners who, MBBS in Australia, because we're dealing with the Medical Board of Australia, correct?
Stephen: Well, I think the Medical Board of Australia are calling for submissions. So I think the first thing that the public and other practitioners need to actually respond with is that the definition is pseudoscientific and political, that complementary medicine shouldn't be linked to unconventional medicine or emerging therapies, that no case can be made for there being a significant safety issue, and that the Medical Board should actually retract the paper. That's the first thing.
The second thing is to actually deal with this consultation as though it's viable, and answer the questions, and the reality is that the Medical Board basically gives you two options. One option is status quo and the second option is to actually implement these new practice guidelines. Well, if we're only given two options, at the moment we would say, "Let's stay with the status quo and let's work collegiately to actually develop additional guidelines to the practice guidelines for all doctors."
Stephen: The official closing date for feedback to the Medical Board of Australia is the 12th of May.
Andrew: It's a very important time for the health of all Australians and those who care for them. Thanks for taking us through these critical points today, Professor Stephen Myers.
Stephen: My pleasure, Andrew.
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook.