Integrative / alternative medicine

[scharnhorst]

Hi
I'm not sure what to make of it but there is a fair amount of pressure in our practices to consult integrative/ alternative medicine therapies in the last yr or so

What is the experience of other MD /DO with these modalities?

Thanks

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[VA Hopeful Dr]

Can you elaborate?

Do you have an integrative department you're encouraged to refer to? Is it patients wanting to talk about alternative medicine with you?

Generally speaking, CAM is at best harmless nonsense. At worst, it can be actively harmful and/or keep patients from seeking appropriate treatment.

 

[AMEHigh]

Yes please expand more.
Where I used to work there was an integrative specialist that I'd run questions by often when patients would ask me questions that I didn't know the answer to. A lot of patients already use supplements, herbs, etc, so it was nice to have someone run questions by.
I definitely think I can learn from things like accupuncture for example, so enjoyed a session we had with an accupuncturist during residency a few years ago.
But no I've never felt pressure about it.

 

[deleted87716]

 

[scharnhorst]

Basically we have a whole panel of practitioners from tai chi to herbal med to acupuncture and we are encouraged to involve them in the care by referrals in appropriate patients
I just dont know what is an " appropriate " time or patient to refer and i don't believe how legit these " practitioner " are

 

[deleted87716]

Basically we have a whole panel of practitioners from tai chi to herbal med to acupuncture and we are encouraged to involve them in the care by referrals in appropriate patients
I just dont know what is an " appropriate " time or patient to refer and i don't believe how legit these " practitioner " are

Then don't refer anyone. Science is on your side.

Be Wary of "Alternative," "Complementary," and "Integrative" Health Methods | Quackwatch

During the 1990s, "alternative medicine," became established as a politically correct term for questionable practices formerly labeled quack and f ...

quackwatch.org

 

[Bacchus]

The patients always seem to come back. I told a patient on upwards of 30 supplements he can see me PRN, yearly isn’t needed because I wasn’t managing anything and he sees an integrated med MD. His Med recc in Epic takes 15 mins alone. Anyway, he refused not to schedule follow up because he likes me to keep an eye on the labs the other guy orders.
They don’t need you until they need science and evidence.

I never refer to CAM unless I have one of our PGYs do OMT.

 

[deleted87716]

The patients always seem to come back. I told a patient on upwards of 30 supplements he can see me PRN, yearly isn’t needed because I wasn’t managing anything and he sees an integrated med MD.

I'd have dismissed him as soon as I found out he had another PCP.

 

[deleted480308]

Basically we have a whole panel of practitioners from tai chi to herbal med to acupuncture and we are encouraged to involve them in the care by referrals in appropriate patients
I just dont know what is an " appropriate " time or patient to refer and i don't believe how legit these " practitioner " are

Never and they aren’t

 

[VA Hopeful Dr]

I'd have dismissed him as soon as I found out he had another PCP.

My approach as well, the exception being VA patients. I can't blame them wanting free medicine but a more organized family doctor.

 

[deleted87716]

My approach as well, the exception being VA patients. I can't blame them wanting free medicine but a more organized family doctor.

Same, but I always have (and document) a discussion at the very beginning about how they basically just want me to be their urgent care doc, and they would be better off using a legit urgent care.

 

[hallowmann]

Basically we have a whole panel of practitioners from tai chi to herbal med to acupuncture and we are encouraged to involve them in the care by referrals in appropriate patients
I just dont know what is an " appropriate " time or patient to refer and i don't believe how legit these " practitioner " are

The only instances I could see utilizing them is if a patient explicitly asks for something (e.g. acupuncture, nutritional, or OMT). Even then, I'd have a discussion about pros (typically minimal) and cons (usually cost among others) and only give them the info of the provider if they still insisted. It does help to know who are actually good at what they do, i.e. they don't try to sell "extra" stuff from their shops and don't try to supplant actual medicine, always telling pts to refer back to me with new complaints.

As far as things like "functional medicine", low T clinics, homeopathy, etc. As far as I'm concerned there are no patients that are appropriate to refer, because I've yet to meet one that didn't do things irresponsibly or misled patients for very clear monetary gain.

 

[yeasports]

Basically we have a whole panel of practitioners from tai chi to herbal med to acupuncture and we are encouraged to involve them in the care by referrals in appropriate patients
I just dont know what is an " appropriate " time or patient to refer and i don't believe how legit these " practitioner " are

Patients will ask but as I take it and I explain it:
A patient is asking me an M.D. for medical advice and not hearsay. If we are in a medical building/office with a doctor patient relationship (vs on the beach with a cocktail) they are asking Medical opinion not personal opinion. I usually say something along the lines of there is no real studies or literature to support (this or that) so I can't go out on a limb and recommend. I also say now this study looks promising (ie some studies for tai chi look reasonable). I will also sometimes state well I don't think something like more awareness or meditation would hurt but I have no studies they cure (this or that). I document this as well. Patients almost always respect and understand and if not they were never really asking a question they just wanted you to confirm their opinion.

 

[Fatalis]

Basically we have a whole panel of practitioners from tai chi to herbal med to acupuncture and we are encouraged to involve them in the care by referrals in appropriate patients
I just dont know what is an " appropriate " time or patient to refer and i don't believe how legit these " practitioner " are

encouraged is not the same as mandatory; this isn't nazi germany. If it ever comes up just say "I cant find a patient that would benefit from it so far..."

 

[Sardonix]

This drove me nuts on the interview trail last year. Like 50% of programs liked to talk about an optional integrative medicine rotation... usually where you could do an online course through Arizona or something. It always took maximal willpower not to damage my rectus muscles by rolling my eyes too hard.

 

[sloh]

This drove me nuts on the interview trail last year. Like 50% of programs liked to talk about an optional integrative medicine rotation... usually where you could do an online course through Arizona or something. It always took maximal willpower not to damage my rectus muscles by rolling my eyes too hard.

Jeez is it really that high (50%)? That’s sad

 

[hallowmann]

Jeez is it really that high (50%)? That’s sad

It's not, my guess is this is very regional. It's been almost 4 yrs, but I encountered only 2 programs that mentioned it at the interview and they were both in southern California.

 

[star.buck]

It's not, my guess is this is very regional. It's been almost 4 yrs, but I encountered only 2 programs that mentioned it at the interview and they were both in southern California.

Interviewed Midwest last cycle, 13 programs, at LEAST 6 had integrative tracks of some sort - but when digging deeper into what they were actually talking about this can also include “integration” of mental health (including DBT, mindfulness, etc), social health, nutritional health, etc... too many confuse integrative care with alternative care it seems. ‍

For the “alternative” medicine stuffs... 2 or 3 in Midwest discussed it during interviews. (Herbal remedies, acupuncture (I’m aware of the science), supplements, etc).

My opinion: as long as patient cares about their own health, and is making choices that aren’t harmful, it’s fine by me if it’s a little quirky. Better than the diabetic that doesn’t give a hoot and comes into the office with a bag of donuts to discuss the chronic ulcer from a nail he walked on for 3 days because he can’t feel his feet anymore.

part of me still WONDERS if the lack of science behind “alternative” and “eastern” medicine is due to lack of funding and cash flow in drinking a special tea you can buy cheap at the local Asian market, or the fact that 15 minutes of meditation a day can immensely improve mental health.

that said: evidence based is still the way to go. 100%.

 

[tealeafexplorer]

Interviewed Midwest last cycle, 13 programs, at LEAST 6 had integrative tracks of some sort - but when digging deeper into what they were actually talking about this can also include “integration” of mental health (including DBT, mindfulness, etc), social health, nutritional health, etc... too many confuse integrative care with alternative care it seems. ‍

For the “alternative” medicine stuffs... 2 or 3 in Midwest discussed it during interviews. (Herbal remedies, acupuncture (I’m aware of the science), supplements, etc).

My opinion: as long as patient cares about their own health, and is making choices that aren’t harmful, it’s fine by me if it’s a little quirky. Better than the diabetic that doesn’t give a hoot and comes into the office with a bag of donuts to discuss the chronic ulcer from a nail he walked on for 3 days because he can’t feel his feet anymore.

part of me still WONDERS if the lack of science behind “alternative” and “eastern” medicine is due to lack of funding and cash flow in drinking a special tea you can buy cheap at the local Asian market, or the fact that 15 minutes of meditation a day can immensely improve mental health.

that said: evidence based is still the way to go. 100%.

I like this. I am interested in integrative medicine but the very traditional people here are very outspoken against it, and tbh there’s stuff in curriculums I’ve looked up that Make me very skeptical as well. Overall I feel as if there are differences in beliefs about what integrative medicine is. To all their own however

 

[hallowmann]

Interviewed Midwest last cycle, 13 programs, at LEAST 6 had integrative tracks of some sort - but when digging deeper into what they were actually talking about this can also include “integration” of mental health (including DBT, mindfulness, etc), social health, nutritional health, etc... too many confuse integrative care with alternative care it seems. ‍

For the “alternative” medicine stuffs... 2 or 3 in Midwest discussed it during interviews. (Herbal remedies, acupuncture (I’m aware of the science), supplements, etc).

My opinion: as long as patient cares about their own health, and is making choices that aren’t harmful, it’s fine by me if it’s a little quirky. Better than the diabetic that doesn’t give a hoot and comes into the office with a bag of donuts to discuss the chronic ulcer from a nail he walked on for 3 days because he can’t feel his feet anymore.

part of me still WONDERS if the lack of science behind “alternative” and “eastern” medicine is due to lack of funding and cash flow in drinking a special tea you can buy cheap at the local Asian market, or the fact that 15 minutes of meditation a day can immensely improve mental health.

that said: evidence based is still the way to go. 100%.

Mindfulness, DBT and meditation is not a CAM. I don't really consider integrative behavioral health models to be truly alternative. They essentially are a way to integrate behavioral health and psychotherapy into primary care settings. There actually are some pretty good studies that investigate CAM, which is why sending someone to a skilled acupuncturist or OMT specialist is something I'm willing to do.

Most of us don't go out of our way to discourage multiple CAM modalities as a supplement or adjunct, because for one thing it takes time and effort to do so, and its not like we really have that. I think the problem is too many of us have had the patient that comes in with relatively straightforward complaints that can be treated quickly and cheaply, but for the last year they've been taking infinitesimal amounts of pancreatic enzymes that cost them $200/mo from their functional medicine doc. If people are motivated for their care, but someone is else telling them that this one panacea is going to solve all of their health problems that will often result in other problems. People delay evidence-based care because of it, and it causes them distress and financial hardship. That is the issue most on here have a problem with, not when their patient goes to an acupuncturist or a chiro once a month.

 

[VA Hopeful Dr]

Mindfulness, DBT and meditation is not a CAM. I don't really consider integrative behavioral health models to be truly alternative. They essentially are a way to integrate behavioral health and psychotherapy into primary care settings. There actually are some pretty good studies that investigate CAM, which is why sending someone to a skilled acupuncturist or OMT specialist is something I'm willing to do.

Most of us don't go out of our way to discourage multiple CAM modalities as a supplement or adjunct, because for one thing it takes time and effort to do so, and its not like we really have that. I think the problem is too many of us have had the patient that comes in with relatively straightforward complaints that can be treated quickly and cheaply, but for the last year they've been taking infinitesimal amounts of pancreatic enzymes that cost them $200/mo from their functional medicine doc. If people are motivated for their care, but someone is else telling them that this one panacea is going to solve all of their health problems that will often result in other problems. People delay evidence-based care because of it, and it causes them distress and financial hardship. That is the issue most on here have a problem with, not when their patient goes to an acupuncturist or a chiro once a month.

Exactly this. Once I've figured out that something isn't acutely dangerous, you can do whatever you want with it: chiro, reiki, accupuncture, Chinese herbs, rhino horn, swimming with healing dolphins. But, actual medicine needs a crack at it first to make sure its nothing serious.

 

[yeasports]

I am all for mindfulness or even for people to pick the wrong thing against medical advice as long as they understand what they are doing (and I document it)
Back in residency I had a patient that stated he became natural and stopped all medications. He was upset because he never felt better but this dang thing in his chest keeps shocking him and it really hurts. (AICD). I told him it only shocked you because you were dead. (vfib) I am not joking he paused for a few seconds (felt like minutes) and said: Oh, is that all it was. (angrily)

 

[deleted87716]

I am all for mindfulness or even for people to pick the wrong thing against medical advice as long as they understand what they are doing (and I document it)
Back in residency I had a patient that stated he became natural and stopped all medications. He was upset because he never felt better but this dang thing in his chest keeps shocking him and it really hurts. (AICD). I told him it only shocked you because you were dead. (vfib) I am not joking he paused for a few seconds (felt like minutes) and said: Oh, is that all it was. (angrily)

Well, death is natural.

 

[Dolphin-Taco21]

Hi
I'm not sure what to make of it but there is a fair amount of pressure in our practices to consult integrative/ alternative medicine therapies in the last yr or so

What is the experience of other MD /DO with these modalities?

Thanks

There is a growing number of MD/DO's who are getting certifications in TCM and Acupuncture. This is stemmed from the fact that there is a growing number of research that shows the efficacy of acupuncture and TCM. Harvard, Yale, John Hopkins, Cornell, UCLA, and other major Medical School/University Hospitals have already integrated TCM and Acupuncture into their modalities and many other hospitals are following suit.
In fact, some Universities, such as UCLA, have fellowships where Family Med or Internal Med Physicians can be certified in acupuncture and Traditional Chinese Medicine. UCLA has some clinics that offer Traditional Chinese Medicine treatments. So does Harvard.

The point? Many University Hospitals and other clinics are incorporating Traditional Chinese Medicine into their modalities. However, you rarely ever see Hospitals integrate other forms of Alternative Medicine such as homeopathy, naturopathic remedies, ect. Why? I'm NOT here to take a crap on anyone who supports these forms of medicine AT ALL... BUT.... out of the many forms of Alternative Medicine that exist, Traditional Chinese Medicine has proven time after time again that it has its proven benefits and serves as excellent compliments to pharmaceutical therapies. If TCM is pure BS, then why would major University Hospitals/Medical/Research Institutions such as UCLA, Harvard, John Hopkins, Yale, ect., dare to risk their credibility and reputation to support TCM? They do it because TCM has shown time after time, throughout thousands of years that it has many benefits.

This increase in the support from MD/DOs for the use and practice of TCM will only keep growing from here on out.

 

[Sardonix]

There is a growing number of MD/DO's who are getting certifications in TCM and Acupuncture. This is stemmed from the fact that there is a growing number of research that shows the efficacy of acupuncture and TCM. Harvard, Yale, John Hopkins, Cornell, UCLA, and other major Medical School/University Hospitals have already integrated TCM and Acupuncture into their modalities and many other hospitals are following suit.
In fact, some Universities, such as UCLA, have fellowships where Family Med or Internal Med Physicians can be certified in acupuncture and Traditional Chinese Medicine. UCLA has some clinics that offer Traditional Chinese Medicine treatments. So does Harvard.

The point? Many University Hospitals and other clinics are incorporating Traditional Chinese Medicine into their modalities. However, you rarely ever see Hospitals integrate other forms of Alternative Medicine such as homeopathy, naturopathic remedies, ect. Why? I'm NOT here to take a crap on anyone who supports these forms of medicine AT ALL... BUT.... out of the many forms of Alternative Medicine that exist, Traditional Chinese Medicine has proven time after time again that it has its proven benefits and serves as excellent compliments to pharmaceutical therapies. If TCM is pure BS, then why would major University Hospitals/Medical/Research Institutions such as UCLA, Harvard, John Hopkins, Yale, ect., dare to risk their credibility and reputation to support TCM? They do it because TCM has shown time after time, throughout thousands of years that it has many benefits.

This increase in the support from MD/DOs for the use and practice of TCM will only keep growing from here on out.

Sir/madam, this is a Wendy's.

But for real, you may not be here to crap on any of those fakes, but I certainly will. Homeopathy is 100% BS. Naturopathiy exists on the blatantly flawed logic that something natural is automatically good. May as well mention hydropathy too since in the last 10 years we've seen a resurgence of disproven medical theories from 120 years ago. Heck, germ theory ain't all that cracked up, let's start arguing for miasma origins of disease while we're at it.

I am willing to accept that acupuncture has some evidence behind it. But otherwise I'm gonna need to see some RCTs supporting a single thing you just said. "If it was false why would ___ institution have ___ department for it" is an ineffective argument. Big institutions are businesses and they smell money, not necessarily truth, in "alternative" medicine. If you want widespread support for TCM, get FDA approval and actually have the ingredients to the herbs and spices or whatever else involved listed.

"Proven time after time" is a lazy way of saying "it's accepted but not actually supported by data." If I have to sit through my attendings pimping me on cutting edge papers arguing pros/cons about individual drugs even 50 years after they were originally discovered it's only fair. Give me data or give me something else to sell.

 

[sloh]

If TCM is pure BS, then why would major University Hospitals/Medical/Research Institutions such as UCLA, Harvard, John Hopkins, Yale, ect., dare to risk their credibility and reputation to support
TCM?

The good old appeal to authority. That’s not how we should vet whether treatments are effective or not.

 

[deleted87716]

Sir/madam, this is a Wendy's.

Traditional Chinese Medicine has proven time after time again that it has its proven benefits and serves as excellent compliments to pharmaceutical therapies.

 

[deleted87716]

Sir/madam, this is a Wendy's.

 

[Dolphin-Taco21]

Wow... this is a lovely comment section XD
No wonder why there is a distrust of patients in their Doctors in the US. Patients feel ridiculed and humiliated when Doctors shun them because they want to explore Alternative Medicine. Fun fact: I never said that Homeopathy, Hydrotherapy, or Naturopathy was effective. The only one I have supported was TCM.
Furthermore, I respect your difference of opinion.

 

[sloh]

Wow... this is a lovely comment section XD
No wonder why there is a distrust of patients in their Doctors in the US. Patients feel ridiculed and humiliated when Doctors shun them because they want to explore Alternative Medicine. Fun fact: I never said that Homeopathy, Hydrotherapy, or Naturopathy was effective. The only one I have supported was TCM.
Furthermore, I respect your difference of opinion.

But the evidence doesn't even support TCM.

 

[deleted87716]

"TCM is a pre-scientific superstitious view of biology and illness, similar to the humoral theory of Galen, or the notions of any pre-scientific culture. It is strange and unscientific to treat TCM as anything else. Any individual diagnostic or treatment method within TCM should be evaluated according to standard principles of science and science-based medicine, and not given special treatment."

What Is Traditional Chinese Medicine?

Traditional Chinese Medicine is not actual medicine, and should not be treated as such. It has more in common with Galen's theory of the four humors than anything a doctor would recognize today.

sciencebasedmedicine.org

 

[Sardonix]

Wow... this is a lovely comment section XD
No wonder why there is a distrust of patients in their Doctors in the US. Patients feel ridiculed and humiliated when Doctors shun them because they want to explore Alternative Medicine. Fun fact: I never said that Homeopathy, Hydrotherapy, or Naturopathy was effective. The only one I have supported was TCM.
Furthermore, I respect your difference of opinion.

I also never said you claimed to support any of the things other than TCM. I said I am more than willing to crap on them where you are not.

If you interpret "Show me evidence TCM works" as "being ridiculed and humiliated" I do not trust you. Just like if a med student says "Man that attending really ripped me a new one!" when actually the attending asked a very basic question in a totally reasonable manner, I too will question their judgement.

 

[Sardonix]

I also never said you claimed to support any of the things other than TCM. I said I am more than willing to crap on them where you are not.

If you interpret "Show me evidence TCM works" as "being ridiculed and humiliated" I do not trust you. Just like if a egg says "Man that rabbit really ripped me a new one!" when actually the rabbit asked a very basic question in a totally reasonable manner, I too will question their judgement.

Just need to preserve this message for posterity after today.

 

[hallowmann]

Acupuncture has some evidence. The fact that TCM as a whole is taught at elite schools is meaningless. Harvard also teaches OMT with cranial/Chapman's points. I'm usually first to admit that myofascial techniques in OMT have a place in treatment (especially given the overlap with PT), but cranial? Nope. Nope. Nope.

Appeal to authority no matter how many times its repeated in the same post isn't going to be sufficient.

 

[scharnhorst]

David Gorski - Wikipedia

en.wikipedia.org

“Integrative medicine”: A brand, not a specialty

Back in the mists of time, what used to be considered quackery became "alternative medicine." Thus began the rebranding. The latest iteration is "integrative medicine," which advocates the "integratio

sciencebasedmedicine.org

 

[PikminOC]

In my field, people pay for BrainAvatar training uses small sensors placed on the head, that analyze brainwaves, providing auditory or visual feedback to the client. Over time, the individual increases their ability to use the desired brainwaves through a computerized operant learning protocol.
Low Energy Neurofeedback System (LENS) is a type of brain stimulation therapy that utilizes a microcurrent neurofeedback signal. LENS treatment uses sensors to measure brainwave activity and then delivers a signal that mimics brainwave frequencies.
Etc

 

[PikminOC]

Lots of people paying for lyme disease testing and iv fluids

 

[TableMD]

So its sounds like you all would benefit from a functional medicine assessment. For a low consultation fee I offer a
Vitamin and hormone assessment and testing inventory in order to maximize gut
Health, hormone and vitamin levels.

Morning drowsiness, fatigue in evenings or a full, bloated sensation after a heavy, fatty meal could be signs of low vitamin C, low testosterone or sub optimized gut biome management!!!

 

[deleted87716]

 

[PikminOC]

So its sounds like you all would benefit from a functional medicine assessment. For a low consultation fee I offer a
Vitamin and hormone assessment and testing inventory in order to maximize gut
Health, hormone and vitamin levels.

Morning drowsiness, fatigue in evenings or a full, bloated sensation after a heavy, fatty meal could be signs of low vitamin C, low testosterone or sub optimized gut biome management!!!

Small fee? At least 500$ in cash. That's what people charge, and then 1000 for expensive labwork.

 

[sloh]

So its sounds like you all would benefit from a functional medicine assessment. For a low consultation fee I offer a
Vitamin and hormone assessment and testing inventory in order to maximize gut
Health, hormone and vitamin levels.

Morning drowsiness, fatigue in evenings or a full, bloated sensation after a heavy, fatty meal could be signs of low vitamin C, low testosterone or sub optimized gut biome management!!!

But hey, even if it's all placebo, studies show that if you tell patients it's placebo they still feel better! Def clears the MD/DO bar!

 

[hallowmann]

Small fee? At least 500$ in cash. That's what people charge, and then 1000 for expensive labwork.

Hey, $1500 IS smaller than $2000, amiright?

 

[scharnhorst]

So its sounds like you all would benefit from a functional medicine assessment. For a low consultation fee I offer a
Vitamin and hormone assessment and testing inventory in order to maximize gut
Health, hormone and vitamin levels.

Morning drowsiness, fatigue in evenings or a full, bloated sensation after a heavy, fatty meal could be signs of low vitamin C, low testosterone or sub optimized gut biome management!!!

yes please sign me up
also how can i get the blood tests for Molybdenum Antimony and NADPH?

 

[scharnhorst]

this will change your life esp if the ingredients are cut with slap chop

 

[Sardonix]

this will change your life esp if the ingredients are cut with slap chop

"You're gonna love my nuts... it's so easy, just one finger... kids can do it."

Vince being in prison makes a lot more sense now.

 

[PikminOC]

Basically we have a whole panel of practitioners from tai chi to herbal med to acupuncture and we are encouraged to involve them in the care by referrals in appropriate patients
I just dont know what is an " appropriate " time or patient to refer and i don't believe how legit these " practitioner " are

Yes always follow the money...
And surprised no one has mentioned stem cells yet...

 

[Atlas Shrugged]

If integrative or alternative medicine worked, it would be called medicine. OMT, battlefield acupuncture, and even most of sports medicine procedures fall within this.

 

[sloh]

If integrative or alternative medicine worked, it would be called medicine. OMT, battlefield acupuncture, and even most of sports medicine procedures fall within this.

Bolded and underlined for truth.

 

[FamilymedMD]

Acupuncture has some evidence...

...Appeal to authority no matter how many times its repeated in the same post isn't going to be sufficient.

If there are hundreds of studies, we should expect a few of them to be positive simply by chance. Most of the reviews I've found of acupuncture studies show no significant benefit when compared to placebo (sham acupuncture).

An example: Episode 486: Needle in a Pain-Stack – Acupuncture for Chronic Low Back Pain July 23, 2021 In episode 486, Mike and James go over the evidence we have for acupuncture in chronic low back pain. We find out that some evidence shows acupuncture will improve chronic low back pain in one in 6 patients. However, the magnitude of the effect seen is importantly less when you look at trials that actually use a sham control or those that are of higher quality or longer duration.

 

[AFMD]

If integrative or alternative medicine worked, it would be called medicine. OMT, battlefield acupuncture, and even most of sports medicine procedures fall within this.

A lot of medicine that we do is not particularly evidenced based, and is essentially alternative medicine, as you suggested above.

Joint injections, trigger points, vertebral fusions, ESIs in a lot of cases, opioids for chronic pain, tramadol for anything, docusate, sliding scale insulin, nebs instead of inhalers, etc. etc. A lot of the specific things physical therapists do are not evidence based, and some of it is exactly the same as what chiropractors and osteopathic providers are doing.

Choosing Wisely: Things We Do For No Reason has some good reads. We all have used alternative medicine, and most of us will use alternative medicine on Monday. Many are surprised that some common practices are almost completely tradition and not based on much evidence at all.

Much as I see integrative medicine as just part of what we already learned about already in family medicine residency, It also seems strange to me for us to look down on acupuncture or chiropractic when we are often working on the same evidence level.

For example, if you are prescribing tramadol then you are doing something with comparable evidence to acupuncture, and you are doing alternative medicine. This is important to think about because many of our treatments in mainstream medicine have more risk (like an opioid or an invasive procedure/surgery) than many alternative medicine options (like chiropractic or yoga) and do not have a clearly demonstrated higher benefit.

We should be aware of the perverse incentives that exist in our medical system as well. For example, I think we can all agree that there's no way there would be so many spinal surgeries if they didn't make so much money, and the data vs usual care is about the same at 24 months in many scenarios.

It's something uncomfortable to grapple with, but it is important to be academically honest about the whole situation so we can provide the best care.