Respectful Insolence

One of the most frustrating aspects of so-called “complementary and alternative medicine” is how much it’s managed to bypass the scientific orientation of academic medical institutions and insinuate itself deeply into medical academia. Indeed, Dr. R. W. Donnell once quite aptly referred to this phenomenon, where wildly implausible claims with no science behind them somehow find truck in some of the oldest and most prestigious academic medical centers, as “quackademic medicine.” Therapeutic touch, reiki, acupuncture, it doesn’t matter. Somehow, much of medical academia seems to have forgotten the scientific principles that should underpin modern medicine, at least when it comes to ancient claims from prescientific times.

Unfortunately, it’s not just medical academia.

Primary care physicians are on the front lines of medical care in this country. They take care of patients, big and small, healthy and chronically ill, old and young. They are the ones patients visit when they have back pain, headache, fever, coughs, chills, and the entire panoply of symptoms that plague humankind. These symptoms can mean anything from nothing, being entirely self-limited, to impending death from cancer, and it’s up to primary care doctors figure out which is which, or at least to know when he can’t and to which specialist he needs to refer a patient. Through it all, primary care doctors manage a wide variety of diseases and conditions, from diabetes to hypertension to heart disease to any number of other problems that plague so many of us. Taking care of so many different conditions requires a wide knowledge, keen diagnostic skills, and a good bedside manner. It does not require primary care doctors to embrace woo.

Sadly, the American Academy of Family Physicians (AAFP) doesn’t see it that way.

Why do I say that? It comes from my having seen a most disturbing article posted to the AAFP website entitled New Report Details Billions Americans Spend on Complementary, Alternative Medicine: Physicians Can Benefit from Adding CAM to Their Practices, Says FP.

Noooo! Not you, too, AAFP!

Sadly, the AAFP is promoting woo:

A recently released government report (15-page PDF; About PDFs) found that U.S. adults are spending almost $34 billion a year on complementary and alternative medicine, or CAM, products and therapies, as well as on visits to CAM practitioners. And that popularity can translate into extra dollars for family physicians, says one FP.

No doubt it can. There’s no doubt that selling woo can be very, very lucrative, $34 billion a year worth of lucrative. No doubt, if a physician has no concern about scientific medicine, he could rake it in hand over fist. No doubt, if a physician has–shall we say?–situational ethics, he could dive right into that filthy lucre, if he wanted to. That doesn’t mean he should. Not so, according to this article:

There’s no reason CAM techniques and remedies can’t be incorporated into family medicine practices, says Reid Blackwelder, M.D., of Kingsport, Tenn. — especially when doing so can help many diverse patients and earn FPs added compensation.

According to Blackwelder, who practices integrative medicine, “CAM providers may not do much more than we do or can do. We can recommend or use self-help tools just as well as they can, with the extra ‘oomph’ of our medical knowledge.”

Ah, yes. “Integrative” medicine, or what I like to call “integrating” pseudoscience into science-based medicine. What frightens me, however, is how Blackwelder apparently assumes that adding the extra “oomph” of medical knowledge can somehow make a worthless “treatment” suddenly have value. Actually, Blackwelder’s medical knowledge should have told him that the vast majority of CAM therapies have no basis in science and are incredibly implausible from a scientific standpoint. But, hey, who cares? It makes money!

After listing just how much money is spent by Americans on woo, including herbs and botanicals, homeopathic products, yoga, and manipulative and body-based therapies such as chiropractic, Blackwelder starts out reasonable:

“Family doctors should recognize many patients use such approaches, and explore for them in an open and nonjudgmental way,” said Blackwelder, who is a professor and program director of the East Tennessee State University Family Physicians of Kingsport family medicine residency. He’s also a former chair of the AAFP Commission on Continuing Professional Development.

“First and foremost, family physicians can use their best tool — bedside manner,” Blackwelder said. “That is a key aspect of many alternative processes and providers,” and FPs would do well to use that empathy to connect with patients.

And, of course, there’s nothing wrong with that. We physicians should explore in open and nonjudgmental ways everything about their health history, including any CAM therapies they may be using. We should also be open and willing to offer our opinions in the aforementioned nonjudgmental manner. Moreover, physicians should work on their bedside manner. Not only is the bedside manner what so many CAM practitioners have that too many physicians do not, but that empathy and caring is what maximizes the placebo effect that so many CAM practitioners rely on. What physicians should not do is this:

In many ways, the physician-patient encounter creates a suggestible moment similar to what is done in a hypnosis session,” said Blackwelder. “Use that power!”

Family physicians can build in discussions of CAM during face-to-face office visits for specific complaints, he said, by suggesting, for example, nasal irrigation for allergies and respiratory problems; yoga relaxation breathing for insomnia and anxiety; yin yoga for back, hip and flexibility problems; journaling for grief, depression, rheumatoid arthritis and asthma; and meditation and prayer for hypertension, stress and depression.

“A suggestible moment similar to what is done in a hypnosis session”? Even if that were true, it would be profoundly unethical to take advantage of a suggestible state in that way. Think of it. In the first part of the article, it is being argued that CAM modalities can make money for family physicians. Now, Blackwelder is arguing that the physician-patient encounter provides a “suggestible” state that would allow physicians to sell their patients on CAM. Is it just me, or, putting it all together, did Blackwelder just say to take advantage of the power and trust physicians have in the physician-patient relationship in order to enrich themselves by selling CAM? No, I don’ think that’s a straw man argument at all. In context, that certainly seems to be the implication of Blackwelder’s overall argument. I don’t think it’s a strawman at all. Whether Blackwelder meant it that way when he said it, he sure as heck came off as arguing to take advantage of the trust and power physicians have in order to prescribe woo and make more money.

Worse than that, much of what he suggests has already been tested scientifically and been found not to work. For example, prayer doesn’t work for hypertension. In fact, it may even be correlated with hypertension. There’s little or no evidence for the rest of these, with the possible exception of nasal irrigation. However, as a reader has informed me, the evidence in favor of nasal irrigation is weak. Even so, note how Blackwelder coopts a science-based treatment (nasal irrigation) as being some how “alternative” or CAM. Oh, well, I suppose I should be grateful that Blackwelder refrained from suggesting homeopathy (a.k.a. The One Quackery To Rule Them All), therapeutic touch, reiki, or acupuncture.

Oh, wait. Blackwelder did advocate acupuncture. Indeed, he suggested that family docs “take a course” to learn acupuncture. Personally, I wouldn’t recommend it. I can do acupuncture. No, I haven’t taken a course, either. The reason I say that I can do acupuncture is that numerous studies have shown that it really doesn’t matter where you place the needles. So I could place the needles anywhere I wanted to, spin some imaginative name for the “meridian” I’m putting the needles in, and–voilà!–I’m an instant acupuncturist! Heck, I’ll even teach you. It’s all placebo effect. In fact, it doesn’t matter if the needles are even inserted if the patient thinks they’ve been inserted. Toothpicks will do just as well!

The article then lists several conditions for which, it is claimed, there is evidence that CAM is effective. The problem is that they’re not. Perhaps the most egregious examples are the claims that gingko biloba is effective for claudication (it’s not) and saw palmetto for prostatic hypertrophy (it doesn’t work). But this is the most disturbing thing in the article:

As for payment, Blackwelder said techniques such as OMT are supported with specific CPT codes and can be billed along with an appropriate evaluation and management service. Moreover, he added, if a physician spends more than half of a face-to-face visit of 25 minutes’ duration counseling a patient about various health issues and treatment options, including CAM techniques, he or she can code that visit as a 99214 — even in the absence of history, physical exam or medical decision-making elements.

The physicians reading this will know why this paragraph is so disturbing. According to my handy dandy CPT manual (2008 edition), CPT code 99214 involves:

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

  • A detailed history
  • A detailed examination
  • Medical decision making of moderate complexity

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

In other words, Blackwelder looks to be wrong, and all I had to do figure that out was to pick up my CPT manual off the shelf of my office and find the code. I worry that any physician who follows his advice about CAM and uses CPT code 99214 in the way Balckwelder advocates could easily find himself in a world of hurt, thanks to third party payers and in particular the federal government, the latter of which considers Medicare or Medicaid fraud to be a very serious offense. It also doesn’t always take ignorance of requirements for the various codes as an excuse. In fact, a physician I wonder whether a physician who makes the mistake of following Blackwelder’s advice with regards to billing Medicare could find himself in jail if he does it enough times. At the very least, it’s possible he could find himself in a whole heap o’ trouble with Medicare in terms of returning money and paying fines.

I’ve often discussed the corrosive effect that CAM has on medical academia, how it corrupts the very scientific basis of medicine. Unfortunately, it does more than that. As advocated by the AAFP, it can corrupt professional societies like the AAFP to the point where, not only does the AAFP advocate CAM quackery in the pages of its journal, but it publishes advice on its own website that could cause serious trouble for any of its members who follow it.

Comments

  1. #1 Robert W. Donnell
    September 29, 2009

    Orac,
    As I understand it, there is a separate provision that when counseling and/or care coordination dominate an encounter (take over 50% of the time of the encounter)the time spent trumps the key components, so that the physician can support the code based on time alone. (I may be wrong about 99214, as I haven’t used outpatient codes in over 10 years). I tried to make this point about Harriet’s post but I’m having trouble with the comments at SBM.

    Of course, no one need invoke CPT coding regs to make the point. You and your readers know as well as I do that to use ones good name and credentials to push woo is fraud, and it’s all the more egregious to use the power of suggestion to do so.

  2. #2 Orac
    September 29, 2009

    I went back and looked at the CPT manual (2008 edition). I couldn’t find any provision that says that. If it’s there, it’s either new (since 2008) or it’s not in the AMA’s CPT manual, which is what I use when I need to look up a code because, well, that’s what the Department of Surgery gave me.

    I don’t use these visit codes very often either, given that most of my visits are either new patient visits, with a complete H&P, or are postoperative visits, which are included in the global surgery fee.

  3. #3 Robert W. Donnell
    September 29, 2009

    Here’s a link to what I was talking about with a paste of the relevant statement:

    http://emuniversity.com/CodingBasedonTime.html

    *E/M Coding Tip: If you code based on time, there are NO SPECIFIC DOCUMENTATION REQUIRMENTS FOR HISTORY, PHYSICIAL EXAM AND MEDICAL DECISION MAKING.*

  4. #4 micheleinmichigan
    September 29, 2009

    As a patient, I can completely agree with many of your points. I certainly do not want my doctor to suggest unproven therapies just because they are popular in the alternative medicine set. I’d just go to Whole Foods if I wanted that. Why deal with insurance, copays and a doctor’s office (which doesn’t have samples of yummy gluten free brownies)?

    But just to be nitpicky.

    “for example, nasal irrigation for allergies and respiratory problems;”

    This is CAM? Nasal irrigation with saline is what every pediatrician recommends for a congested nose in children since they can’t take cold medication.

    “yoga relaxation breathing for insomnia and anxiety;”

    One of the first things a social worker/therapist using CBT (cognitive behavior therapy)will suggest to a patient with anxiety and insomnia is breathing exercises (That are almost exactly the same as yoga breathing without the fuzzy explanation)

    “yin yoga for back, hip and flexibility problems;”

    Exercise helps people with fatigue/tension type pain, stretching helps people with tight muscles. This is not rocket science. Why is yoga or tai chi worse than a walking program, the local aerobics or saying “you need to get more exercise” Of course if the person needs specific exercises you should send them to PT, not a yoga instructor.

    “journaling for grief, depression, rheumatoid arthritis and asthma;” journaling has been shown to be helpful for depression and can provide a foundation for CBT. Journaling can also help people with some auto-immune disorder establish flare-up patterns or discover asthma tiggers.

    “meditation or prayer for hypertension, stress and depression.” Some aspects of meditation or “mindfulness” are also used in CBT, which has been shown to be as effective as anti-depressants when used alone (combining anti-depressants and CBT gets better results than either alone).

    I guess all I’m saying is No, doctors should not advise patients to use unproven therapies. But they should also not be unreasonably bias against a technique just because it has some association with CAM.

    As an aside, I do have to wonder why the family doctor is giving advice on things like anxiety, depression or rheumatoid arthritis at all?

    If their answer to someone with depression is to give them a script for Paxil, tell them to do some yoga, keep a journal and check back in six months, they certainly are not working in the best interest of the patient. Of course if they leave out the yoga and journal, their treatment has not improved.

    From a patient/layperson perspective.

  5. #5 Jojo
    September 29, 2009

    In many ways, the physician-patient encounter creates a suggestible moment similar to what is done in a hypnosis session,” said Blackwelder. “Use that power!”

    As a patient, I rely on my doctors to provide me with the best possible care that they can based on current medical evidence. I have literally placed my life and that of my child into their care at times. To read that a doctor is suggesting that other doctors use the power of the suggestible moment that their position creates so that they can increase their bottom line makes me cringe. Legal or not, it is a huge breach of trust and an abuse of power.

  6. #6 Dawn
    September 29, 2009

    Hi, Orac. Something I DO know about, being a CPC (certified professional coder). Mr (Dr? I don’t want to insult him) Donnell is correct there are counseling codes, 99401-99404. However, they reflect a different activity than the E&M codes 99201-99215.

    CMS and my employer severely frown on coding based on time alone for the E&M codes. We (and we use CMS guidelines when we do provider audits) require the appropriate documentation for them. As you said, the E&M codes require the appropriate documentation.

    I could tell you what happened to the doctor who billed 99215 fairly constantly and whose documentation consisted of patient date, time seen and “OV” for office visit. Needless to say, after CMS got involved (our fraud people have a very friendly relationship with CMS fraud), the doctor wasn’t in practice…unless doc could practice in prison with no license. AND pay back a huge chunk of money with interest (CMS makes your neighborhood loan shark look friendly).

  7. #7 Anthro
    September 29, 2009

    Why was this article even published? It seems blatantly unethical at best. If I were a medical professional, I don’t think I would have much confidence in this journal in future.

  8. #8 Squillo
    September 29, 2009

    Ugh. I agree with Anthro: smacks of shady ethics. It reads to me as one giant appologetic, designed to make so-inclined FPs feel better about incorporating woo to increase income.

    Perhaps a better title would have been: “How to Bill for Placebo”

  9. #9 Tsu Dho Nimh
    September 29, 2009

    I just gave them some feedback on their “contact us” page.

  10. #10 Mark C. Chu-Carroll
    September 29, 2009

    With regards to the saline irrigation thing;

    It’s not CAM. And the evidence is pretty strongly in its favor. The catch (and there’s always a catch, isn’t there?) is that a lot of CAM types have latched onto it, and promoted “enhanced” methods, as well as promoting it as a cure-all.

    For example, I use a machine called a grossan irrigator. It was recommended by my allergist, with the warning that I should ignore all of the advertising hype that goes with it. You don’t need an electric machine; a spray bottle of saline, or an old-fashioned sil pot do just as well. What the machine does is make the process less unpleasant and messy.

    But what the CAM folks claim is that an electric irrigator does is “reactivate the sinuses natural drainage”, and that by doing that, it can cure sinus infections, allergies, migraine headaches, post-nasal drip, bronchitis, strep throat, etc.

    What it really does is rinse the mucus out of your nose in a quick, painless way. What the literature that my allergist gave me shows is that using it daily is about as effective as a daily dose of pseudophedrine, and quite a bit more effective than phenylephrine, which has largely replaced pseudophedrine in over-the-counter medications. (phenylephrine, on the other hand, has *very* poor evidence for having any effect at all in over-the-counter doses.)

  11. #11 Kausik Datta
    September 29, 2009

    Michelle (in Michigan) @4: you seem to have missed this part of Orac’s post:

    …There’s little or no evidence for the rest of these, with the possible exception of nasal irrigation. However, as a reader has informed me, the evidence in favor of nasal irrigation is weak. Even so, note how Blackwelder coopts a science-based treatment (nasal irrigation) as being some how “alternative” or CAM.

    This is not an exception, rather a norm. The CAM practitioners, in order to gain legitimacy and acceptance, often coopt scientific terminology or concept in furtherance of their bilge.

    You correctly said that doctors “…should also not be unreasonably bias(ed) against a technique just because it has some association with CAM.” Absolutely. However, all the examples that you have picked on above (nasal irrigation, deep breathing, yoga exercises etc.) are techniques with adjunctive benefits at best. For example, yoga, like any good exercise regimen, will work in a particular way for most people. That is hardly in dispute, I think.

    What is atrocious, however, is the way in which these adjunctive regimens are touted by CAM practitioners to be practiced in absence of a regulated medicinal course – for many diseases that require that medical intervention; this, as you can understand, is essentially bad advice that can lead to disease aggravation, complications, and worse.

    A personal anecdote just to illustrate a point. My aged mother suffers from a condition called frozen shoulder (adhesive capsulitis) in which the shoulder capsule and the connective tissue surrounding the shoulder joint becomes inflamed and stiff, and grows abnormal tissue adhesions, greatly restricting motion and causing chronic pain. For first time sufferers, the therapy often begins with physical therapy and massage, and later, medication and even surgery. Physical therapists in India are more often than not practitioners of some form of CAM. We engaged one such, for my mother’s physical therapy – and it did work in lessening the pain and increasing the range of motion in the long term. However, the man was not content to do that job. During the sessions, he would often offer gratuitous advice as to how my mother did not really need insulin for her diabetes, or her pressure medications, but should take part in accupressure therapy or reiki, in order to alleviate these conditions! Thankfully, my mother knows better. I went through the roof when I heard this, but my mother merely humors him by lending an ear.

  12. #12 Kausik Datta
    September 29, 2009

    Why that weird formatting after the blockquote I don’t know. What am I doing wrong?

  13. #13 James Sweet
    September 29, 2009

    In general I agree with micheleinmichigan’s characterization of the various techniques/treatments she mentioned. With the exception of nasal irrigation, though, note that all of those are essentially just breathing/relaxation/self-reflection techniques, which of course are useful in treating anxiety and depression. (In that case, the fact that it anecdotally makes one individual “feel good” is evidence enough, at least for that person, because that’s the whole intention — to make that particular individual feel good!)

    I think Orac is more focused on the idea of, for example, meditation treating hypertension, which is well worth debunking. I’d be interested if he has any comments about michelle’s list.

    Mark CC, thanks for the thoughts about nasal irrigation. I personally can’t handle it — I find it extraordinarily uncomfortable, despite trying a few different ways — but I know a couple of people who swear by it and I’ve always wondered how effective it really is. Although I suppose it doesn’t exactly take a double-blind study to show that physically removing the mucus from your nose will physically remove the mucus from your nose… (research would still be necessary to show safety and long-term efficacy, of course)

    I am not at all surprised there is poor evidence for phenylephrine. Anecdotally, I found it does nothing at all for me. In desperation during a bad cold where that was all I had, I tried taking a double dose. After that I felt jittery, but was still congested. Just great… In NYS, you can still get pseudoephedrine if you show your driver’s license, so I stick to that. Works wonders for me when I get a cold.

  14. #14 Mark C. Chu-Carroll
    September 29, 2009

    @13:

    Yeah, the irrigation is really unpleasant. Last year, when I caught the sinus infection from hell, the ENT started to recommend nasal irrigation, and said something along the lines of “This is the most effective treatment that I know, and it’s also the cheapest, but it’s the hardest to get patients to comply with”. My allergist keeps trying to get me to do it regularly, but I just can’t stand it. I end up only using it when I’m feeling really crappy – it takes serious motivation to get me to do it.

  15. #15 Kausik Datta
    September 29, 2009

    I am afraid of this entire nasal irrigation (‘neti’) business (possibly because I am absolutely ignorant about this). I am told that you have to snort water through one nose and push it out through the other. Is that not risky? Wouldn’t the water get to the lungs? Also, since anything introduced into the nose can potentially get to the brain via the ethmoid sinus (popular route for paranasal sinus mycoses), what about the possibility of bugs in the water?

    A friend of mine who had surgery to remove sinus mucus was advised the neti pot for post-surgery maintenance, and she swears by it. But I haven’t had the urge to explore.

  16. #16 trrll
    September 29, 2009

    For nasal irrigation, you don’t have to “snort” water; you can pour water in one nostril and let it run passively out of the other. You can breathe through your mouth while doing this. It’s a bit awkward because you have to turn your head sideways, but not difficult. It’s certainly no more unpleasant than the phenylephrine nose drops that a lot of us got as kids (I notice that only sprays seem to be on the pharmacy shelves these days). I tried it the last time that I had a bad cold, and it seemed to work about as well as vasoconstrictor decongestants like pseudoephedrine. They typical salt solution is a bit hypertonic, which may help with the swelling, in addition to rinsing out mucus.

  17. #17 Jay K.
    September 29, 2009

    I’ve done a few searches around this blog trying to find anything that describes why basic yoga might be called woo, and I’m coming up short. Pubmed and google scholar both come up with a lot of studies that conclude that yoga is a good exercise that reduces stress (in the short term) and then there is just the common sense portion of “physical fitness”.

    I do understand that woo-meisters don’t leave it at basic yoga, and instead attempt to play with “toxin release” and more, but I just don’t see how the generic term “yoga” needs to be any scarier than “stretching while breathing deep”? Can anyone elucidate for me?

  18. #18 David D.G.
    September 29, 2009

    Orac, could you submit this post (or a modified version of it) to the AAFP as a “counterpoint” response piece? I should think that any marginally responsible professional organization would be willing to consider publishing/displaying it, particularly since you bring up the potential for violating not just the principles of the Hippocratic Oath, but also the law as well. If the organization truly cares about its members, it will want to neutralize any apparent endorsement of advice that might get those who follow it in serious trouble (and in prison).

    ~David D.G.

  19. #19 Pablo
    September 29, 2009

    This piece looks more to me like a Medical Office Business Practice article as opposed to medicine.

    My wife is a vet, and you see that all the time in that area, articles that are effectively, “Here are things you can easily do to increase your per-patient revenue,” with a list of additional tests and procedures that everyone should be recommending, based on the fact that they are easy to do and can be billed.

    My wife got canned from her job because she was unwilling to do procedures and tests that were not medically necessary and that the clients couldn’t afford (the practice owner would just do the procedure and then stick the owners with the bill – kind of like the shady automechanic).

  20. #20 MikeMa
    September 29, 2009

    To second, third or fourth the nasal irrigation results, we used it for the kids when they were little (6-12) and regularly stuffed. It was very effective in clearing them up and one of my kids got so as he could do it himself and didn’t need mom to help other than to mix the saline.

    Cheap, effective, non-addictive, and easy enough for a ten year old to do on his own.

  21. #21 micheleinmichigan
    September 29, 2009

    From a long time sufferer of sinus pain (not sinus infection), nasal irrigation, yuck and useless.

    pseudoephedrine and phenylephrine, craziness and useless.

    1 zyrtec + 2 aleve = success

    Kausik Datta, I think the point of offering some things like yoga or meditation breathing exercises through the medical services is to keep the patient engaged with the SBM pratictioner. not send them off to a CAM person who will try them sell them quackery or undermine their medical program.

    Many hospitals have fitness, yoga and stress management classes, etc that are designed to be supportive of medical care. The children’s hospital where my son goes has a massage therapist that does free upper body massage in the family room (for families of admitted children and children in therapy). These are the sort of things that strengthen the practitioner/patient relationship.

    I am completely sympathetic to your concerns regarding your Mom. My grandma’s chiropractor misdiagnosed my Grandma’s breast cancer and gave her cream (yes, WTF!?). My grandma took a year to show it to her GP when it didn’t respond to the cream. Luckily, it was a very slow growing cancer, surgery and radiation brought remission.

    I did not want to unduly disagree with Orac’s post. I particularly agreed about bed side manner being a great tool in defending against CAM and CAM co-opting SBM. The “suggestible moment” thing WAS creepy. I admit I missed the insurance code bit, outside my experience.

  22. #22 James Sweet
    September 29, 2009

    Is that not risky? Wouldn’t the water get to the lungs? Also, since anything introduced into the nose can potentially get to the brain via the ethmoid sinus (popular route for paranasal sinus mycoses), what about the possibility of bugs in the water?

    The water definitely does not get to the lungs, even if you foul it up pretty badly (as I did).

    I, too, have wondered about the risk of infection, though. I’m not aware of any data backing it up, so for the time-being I’m assuming it’s safe… (I don’t do it because I find it extremely unpleasant, but my wife loves it and I have a friend who does it also)

  23. #23 bob
    September 29, 2009

    My doctor told me about nasal irrigation, and I resisted for awhile because he framed it in woo-y terms. But, I was miserable and desperate, so I eventually gave in. (Not my most skeptical moment.) I gotta say, it works great. I have one that’s like a squirt bottle and included a bunch of packets of salt. You’re supposed to add the salt and boil it before use, to kill anything in there and inhibit further infection in your sinuses. (Obviously you need to run cold water over the outside of the bottle to cool it off before use.) It took some getting used to, but I don’t even want to tell you how much crap you can coax out of your head once you’re good at it.

    I’ve run it by a few other doctors, and they all recommended that I keep using it. Admittedly, though, I have gone looking for any peer-reviewed research on it. I guess I figure it can’t hurt, since it ought to be sterile.

  24. #24 Robert W. Donnell
    September 29, 2009

    Dawn,
    The types of codes you cited were special time based codes. However, if the time spent in counseling or care coordination is more than half the total time of an encounter, then time alone can also be used to determine the ordinary codes (99214, etc for ambulatory, 99231-99233 for hospital) without regard to the three key components, right? Here’s another link from another source which perhaps makes that point better than the other link I provided:

    http://www.todayshospitalist.com/index.php?b=articles_read&cnt=339

    From the article:
    *In a hospitalist practice, it is typical for physicians to devote a huge amount of time to the counseling and/or coordination of care. Try to get adequately paid for that time, however, and you’re likely to find that the elements within the history, exam and medical decision-making (MDM) value do not allow you to bill for anything but the lowest level of service.

    The good news is that when you find yourself in this type of situation, you can make sure you’re paid what you deserve by selecting the level of service based on time. The catch? The service must meet the counseling and coordination-of-care guidelines outlined by the AMA.*

    Please see the figure for the types of codes applicable. This was a resource for hospitalists but the principle also applies to ambulatory codes as implied in this paragraph:

    Put simply, those guidelines say that when counseling and/or coordination of care account for more than half of your encounter with a patient and/or family members, you can consider time the key factor in billing for a particular level of E/M service. (The guidelines refer to face-to-face time for office and outpatient visits, and floor/unit time in the hospital or nursing facility for inpatient care.)

  25. #25 tariqata
    September 29, 2009

    I, too, wouldn’t be especially concerned if a medical doctor suggested something like yoga – under certain conditions. If, after a check-up, my doctor says “Tariqata, you could really use more exercise; yoga might be a good choice because it can also help you to limber up” I’d really have no problem. However, if I show up for the same office visit complaining about the low-grade but chronic pain I’ve always had in my knees and hips, and the doctor says “You could really use more exercise; yoga might be a good choice because it will help you to limber up” without an actual examination to try to determine an underlying cause for the pain, I’d be pretty upset.

  26. #26 Orac
    September 29, 2009

    The good news is that when you find yourself in this type of situation, you can make sure you’re paid what you deserve by selecting the level of service based on time. The catch? The service must meet the counseling and coordination-of-care guidelines outlined by the AMA.*

    Interesting. Somehow I doubt what Dr. Blackwelder has in mind meets the coordination of care guidelines outlined by the AMA. Even if it did, it’s cynical in the extreme to use such billing sleight of hand to justify recommending CAM and to get reimbursed for it.

  27. #27 Robert W. Donnell
    September 29, 2009

    It’s one thing to say that your coding is technically in accordance with CPT regs, but when the content of the counseling itself (my woo is good for you) is fraudulent on a whole new level, well…

  28. #28 Orac
    September 29, 2009

    Agreed.

  29. #29 James Sweet
    September 29, 2009

    If, after a check-up, my doctor says “Tariqata, you could really use more exercise; yoga might be a good choice because it can also help you to limber up” I’d really have no problem. However, if I show up for the same office visit complaining about the low-grade but chronic pain I’ve always had in my knees and hips, and the doctor says “You could really use more exercise; yoga might be a good choice because it will help you to limber up” without an actual examination to try to determine an underlying cause for the pain, I’d be pretty upset.

    Well put.

    Some of these things like yoga, meditation, even chiropracty, that straddle the border between CAM and SBM, the test is what it is being recommended for.

    Meditation for stress relief? Great. Meditation to relieve a physical medical condition? Uh…..

  30. #30 Jennifer B. Phillips
    September 29, 2009

    Regarding the nasal irrigation, my ENT recommended it years ago after my sinus surgery and supplied me with a cone-shaped attachment to be used with a standard Water Pik. Boiled, salty water in the reservoir; cone up the nostril (switch sides at the half-way mark); pulsating irrigation; ‘yield’ washed down the sink. It works very well.

    Re the AAFP–very sad, but not surprising, considering how unapologetic the editors were after Harriet Hall’s latest complaints. We really can’t let our guard down for a minute, can we?

  31. #31 Marcus Ranum
    September 29, 2009

    doing so can help many diverse patients and earn FPs added compensation.

    ’nuff said, right there.

  32. #32 gaiainc
    September 29, 2009

    OK… I’m completely embarrassed. I’m an FP, I’m a member of the AAFP, and I’m going to their scientific assembly in about 2 weeks. That said, I’m appalled at what this so-called physician is advocating. Shady ethics indeed. I think I’m going to have to comment.

    Yes, you can bill a E&M code out based on counseling as long as you document the counseling, the time, etc. 99214 is at least 25 minutes, but 99204 is at least 30 or 45 mintues. I do it every once in a while because sometimes that’s all my patient is there for, for counseling about his/her medical issues and what we’re going to do about it. I wouldn’t make it the focus of my coding practice, but it definitely makes up a fair minority.

    As for nasal saline irrigation, I’m embarrassed again because I did a journal club with some of my residents where we reviewed an article about nasal saline irrigation and chronic sinusitis. The evidence is decent, but I can’t cite a source. I do remember that the authors previously did a study looking at nasal saline irrigation in asymptomatic patients that ended up being stopped early because the asymptomatic patients ended up with more middle ear infections. However, it did seem to help in chronic sinusitis. Given its low cost and low side effect profile, I offer it as an option to patients.

  33. #33 jj
    September 29, 2009

    RE: Nasal Irrigation and Infection

    That’s *hopefully* one of the things that is mentioned when you are recommended to do this – You need to sterilize the solution piror to use.

    In my own personal anecdotal experience, nasal irrigation has been about as effective as a good old nose blowing (I don’t really get sinus infections or have allergies *knock on wood*). It does exactly what you think it would, wash out the nasal passage. nothing alternative about that (in fact that’s why it seems many on this forum have been recommended to do so by a non CAM practitioner).

    As usual, good post Orac

  34. #34 weedhopper
    September 29, 2009

    It’s worse than you think. The good doctor is running for a position on AAFP’s board of directors. The election is in a couple of weeks. Yikes…

  35. #35 sailor
    September 29, 2009

    Well, hostile comments on this blog have been telling us for years that the medical profession and pig pharma are out to screw us. I think Orac has just provided the proof.

  36. #36 Pablo
    September 29, 2009

    michelleinmichigan wrote
    Nasal irrigation with saline is what every pediatrician recommends for a congested nose in children since they can’t take cold medication.

    Compared to jj

    In my own personal anecdotal experience, nasal irrigation has been about as effective as a good old nose blowing (I don’t really get sinus infections or have allergies *knock on wood*). It does exactly what you think it would, wash out the nasal passage. nothing alternative about that (in fact that’s why it seems many on this forum have been recommended to do so by a non CAM practitioner).

    Actually, given the description that people have been using for “nasal irrigation” in this thread, it is very clear that this is NOT the same thing that the pediatrician recommends for infants. Little Noses, for example, for infants is used to wash out the boogies, not because they can’t take cold medication, but because you can’t tell a 6 month old to blow into a kleenex. Meanwhile, people above are talking about forcing solution between the passages and stuff? That’s not anything you should be doing with an infant. With them, it is just squirt saline up their nose, let it run out, and wipe it away, hoping that it carried mucous with it. As jj notes, it’s basically in lieux of blowing their nose.

    This is as similar to the “nasal irrigation” described above as using a bidet is to getting an enema.

  37. #37 Rogue Medic
    September 29, 2009

    In many ways, the physician-patient encounter creates a suggestible moment similar to what is done in a hypnosis session,” said Blackwelder. “Use that power!”

    Why stop there? According to Reid Blackwelder, M.D., it is the desire of the physician that needs to be satisfied. Why limit that to monetary desire. The physician could also use the power of the suggestible moment to engage in sexual intercourse with the patient.

    There is a reason that sexual relationships between doctors and patients are not supposed to happen. There is such a power imbalance, that consent becomes questionable. Should we treat financial abuse/misconduct differently from sexual abuse/misconduct?

  38. #38 Rogue Medic
    September 29, 2009

    sailor,

    As with the rest of the magical thinking crowd, logic appears to be beyond your comprehension. Orac has criticized medical misconduct before. Nobody claims that it doesn’t exist. Unlike quacks, real doctors object to medical misconduct.

    While quacks claim to be persecuted, they are unethical abusers of patients. The whole business practice of the frauds practicing alt med is as disgusting as what Reid Blackwelder, M.D.,recommends, except at least Dr. Blackwelder includes some real medicine. The alt med vermin limit themselves to snake oil.

    You, and your kind, will never be respectable or ethical. You are beneath contempt. You abuse patients and defend the charlatans who abuse patients.

  39. #39 DebinOz
    September 30, 2009

    I have a good relationship with my family doctor (I have 3 children, one of whom has multiple medical problems), and we get to have a good chat from time to time as she is examining my children.

    One of her biggest concerns is treating the ‘worried well’ AKA the ones who are into woo. Her concerns are many: how to not blow their concerns off, how to incorporate what they are doing into a regular medical regime, how to inform them without seeming patronising, how to bill them for the time spent going over this stuff without seeming like a hardass, and occasionally trying to help them get our health system (in Australia) to pay for the woo.

  40. #40 webtasarım
    September 30, 2009

    thank you I have a good relationship with my family doctor (I have 3 children, one of whom has multiple medical problems), and we get to have a good chat from time to time as she is examining my children.

  41. #41 James Sweet
    September 30, 2009

    @Rogue Medic: I think sailor was making a joke, i.e. the alt med crowd is always crowing about how the medical establishment is trying to screw us, and now all of a sudden here is an example of someone from the medical establishment who is indeed giving advice on how to screw patients out of money — by using ALT MED. The irony, it burns!

  42. #42 delaneypa
    September 30, 2009

    I preparing to e-mail the editors, I found this disclaimer on the publication’s website: “Opinions expressed in AAFP News Now do not necessarily reflect the policies of the AAFP.”

    Address comments to AAFP News Now, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax them to (913) 906-6089; call (800) 274-2237, Ext. 5225; or contact ann@aafp.org via e-mail.

  43. #43 micheleinmichigan
    September 30, 2009

    Pablo, “Actually, given the description that people have been using for “nasal irrigation” in this thread, it is very clear that this is NOT the same thing that the pediatrician recommends for infants.”

    No, you’re right that was not my original description. My pediatrician recommends saline solution (“little noses” is one) squirted into the nose, then using a nasal syringe to suck out the congestion (before babies, toddlers can blow). Just wiping with a tissue doesn’t work as well, but can be good enough.

    FDA says children under 2 should not be given otc cold or cough medicine. http://www.fda.gov/Drugs/DrugSafety/PublicHealthAdvisories/ucm051137.html

    They are investigating some incidence of serious side effects from same in age 2-11.

    No, I would not use the other poster’s description of nasal irrigation on my child. Definitely for a consenting adult. :)

  44. #44 delaneypa
    September 30, 2009

    Now that I have had time to read the original article, this may be a case of bad reporting…very bad reporting. Dr. Blackwelder may be a CAM proponent, but notice that there are few direct quotes from himin the article. I may be that the reporter just took things a little to far. I would to hear Dr. Blackwelder in his own words.

  45. #45 Pablo
    September 30, 2009

    No, you’re right that was not my original description. My pediatrician recommends saline solution (“little noses” is one) squirted into the nose, then using a nasal syringe to suck out the congestion (before babies, toddlers can blow). Just wiping with a tissue doesn’t work as well, but can be good enough.

    FDA says children under 2 should not be given otc cold or cough medicine.

    It is true that cold medicine is not recommend for young ones, but that is not why they recommend saline to clear the nose. As I mentioned, you do that because little ones (not even toddlers) can blow effectively into a kleenex. It’s really not any more complicated than that.

    If they are able to blow their nose, then you don’t need to use saline any more.

  46. #46 micheleinmichigan
    September 30, 2009

    Pablo “It is true that cold medicine is not recommend for young ones, but that is not why they recommend saline to clear the nose. As I mentioned, you do that because little ones (not even toddlers) can blow effectively into a kleenex. It’s really not any more complicated than that.

    If they are able to blow their nose, then you don’t need to use saline any more.”

    I was going to leave it…and you can call me OCD, but I’m pretty sure you were not in the examining room when I discussed this with our pediatrician. :)

    But in case anybody thought otherwise, I am not a doctor and please do not consider any of my comments as a recommendation for how you should treat your or your child’s nasal congestion.

  47. #47 Pablo
    September 30, 2009

    I guess I don’t understand. Are you saying that your pediatrician told you that you should use saline because you can’t use cold medicine? Because that is what I am talking about.

    That doesn’t even make sense. We don’t use cold medicine to clear mucous from our nose. To do that, we blow it out. Since babies can’t do that, we use a rinse to wash out the snot.

    It’s pretty obvious that a rinse is not used to replace cold medicine because you can use rinses any time your young one has boogies, not just when they have cold or allergies. And even, for the sake of argument, if we did use cold medicines, we would still use a nasal rinse to clear out the snot. They just have nothing to do with each other.

    Did your pediatrician really recommend continuing to use nasal rinses after your child is able to blow their nose?

  48. #48 Rogue Medic
    September 30, 2009

    James Sweet,

    I think you give the magical medicine crowd too much credit. I thing that Dr. Jay Gordon has posted similar stuff at times. They quacks lack the ability to apply objective standards in evaluating treatments. They have a ridiculous faith in anecdote.

    The punctuation and capitalization were better than in many of the comments by unicorn medicine fanatics, but the essence of the comment is a nonsensical gotcha! Maybe sailor was experiencing a Perry Mason moment.

  49. #49 WILLIE
    October 1, 2009

    Orac
    I am surprised at your position on family practitioners when you are so supportive of the pharmaceutical industry, talk about quacks and psuedoscience, these people are typical drug dealers and raving lunatics. you should be writing about these pharmaceutical drug dealer pimps every every hour of everyday. Saline cost a couple of bucks to squirt up your nose and it generally does not kill or cause neurological symptoms. Please respond.

  50. #50 Chris
    October 1, 2009

    WILLIE:

    you should be writing about these pharmaceutical drug dealer pimps every every hour of everyday.

    Hello, Mr. Concern Troll. Perhaps you should spend more time lurking before you make yourself look like an idiot. (hint: that means this blog has taken on “Big Pharma” more than a few times, something you would know if you had, well, actually looked)

  51. #51 WILLIE
    October 1, 2009

    Troll you say? Hey shit for brains I am a real physician and surgeon I know real science if you want to educate me try to begin and bring your friends I got some time but do not condescend that is a privilege your lack of knowledge will not let you enjoy

  52. #52 T. Bruce McNeely
    October 1, 2009

    WILLIE:

    So you’re a “real physician and surgeon” who knows “real science”. Unfortunately, you don’t know how to punctuate. It must be a treat reading your progress notes.

  53. #53 WILLIE
    October 1, 2009

    T Bruce if you have nothing intelligent to add the discussion that is brewing then go back to bed and masturbate. My spell check is fine and my grammar, pros and punctuation is surely sufficient for you name calling dilatants and charlatans

  54. #54 Mark P
    October 1, 2009

    No, Willie, your English is poor enough to pretty much ensure you are not a physician. Even if you were, you are still a troll. Please go back to under your bridge.

  55. #55 Joseph C.
    October 1, 2009

    T Bruce if you have nothing intelligent to add the discussion that is brewing then go back to bed and masturbate. My spell check is fine and my grammar, pros and punctuation is surely sufficient for you name calling dilatants and charlatans

    If your “pros” is fine, then why can’t you write two sentences without making at least seven errors?

  56. #56 T. Bruce McNeely
    October 1, 2009

    WILLIE:

    “…for you name calling dilatants (sic) and
    charlatans”
    “Hey shit for brains…”
    “raving lunatics”
    “drug dealer pimps”

    Did you ever learn about projection in Troll Medical School?

  57. #57 WILLIE
    October 1, 2009

    T Bruce you must have met your friends Joseph and Mark at a bath house somewhere you small minded perverts all think alike. I thought you people had something to say clearly you do not. Projection? So are you am amateur shrink too or just an overall small mind? I would bet it is the latter because you fit right in with Joe and Mark as a couple of disciples to some greater stupidity that has yet to be fully revealed to me but I am sure there will be an apocalypse of it at some point. I wish I had more time to insult you girls but I have a real job. I will come home this evening and see what is going on in this hallowed blog of intelligence

  58. #58 Scott
    October 1, 2009

    Anybody else suspect Willie’s a fifteen-year-old? “I have a real job” as a putdown is pretty much exclusively used by those who in fact do not. The complete inability to make any argument other than insults and profanity is another clear marker.

  59. #59 Willie
    October 1, 2009

    Scott I was speaking to your friends and now you on their level. No intelligent adult refers to anyone as “A concerned Troll” I am versatile however and can “Jive ”(I know you femmes are sucking out of Obama’s ass so I thought I would through that colloquialism in to make you feel more comfortable ) with you and your friends. I am not being facetious when I say that I do not mind blogging with people like you and your friends , some of whom obviously are undergoing psychotherapy to help mitigate their perverted obsessive compulsive sexual desires, on your level. Actually it is quite entertaining and may turn out to be a sort of catharsis for me. Keep shooting girls I have limited time but I will keep checking in.

  60. #60 T. Bruce McNeely
    October 1, 2009

    WILLIE:
    I call Poe!

  61. #61 Chris
    October 1, 2009

    I called you a “concern troll”, not a “concerned“. Look it up. If you don’t like what Orac blogs about, start your own blog.

    You are not “blogging”, you are being a troll. Actually, I think you are twelve years old.

    When you get that time you need, try reading some older posts. Like these:
    http://scienceblogs.com/insolence/medicine/bioethics/

    Pay attention to the ones with titles like Threats to science-based medicine: Pharma ghostwriting, Quoth Elsevier: “Whoops, I did it again.” (Six times, actually, When big pharma pays a publisher to publish a fake journal…, When clinical trials are designed by the marketing department… and on and on.

    If you actually read the stuff, and applied some real thinking you might raise yourself from complete idiot up to half-wit.

  62. #62 Scott
    October 1, 2009

    Thanks so much for proving my case.

  63. #63 James Sweet
    October 1, 2009

    Hey shit for brains I am a real physician and surgeon

    Oh man, ignoring the staggering implausibility of WILLIE’s claims, just imagine for a moment going under this guy’s knife. Egads!

  64. #64 James Sweet
    October 1, 2009

    my grammar, pros and punctuation is surely sufficient

    Hah! Okay, yeah, I agree: Poe. Gotta say though, I love that line. I’m going to use that in the future.

    “My pros is impeccable!” hahahahaha AWESOME.

  65. #65 Jen
    October 1, 2009

    “Jive ”(I know you femmes are sucking out of Obama’s ass so I thought I would through that colloquialism in to make you feel more comfortable ”
    “Keep shooting girls I have limited time but I will keep checking in.”

    And please stop being a sexist (and racist) ass. Thank you.

  66. #66 LindaRosaRN
    October 2, 2009

    I wonder how hospital CAM centers are fairing across the country. One such center at McKee Hospital in Loveland, Colorado, closed a couple years ago for lack of public interest.

  67. #67 Platysma
    October 3, 2009

    I did my residency with Dr. Blackwelder over twenty years ago and remember him as a very bright, capable physician. Nice guy and very thorough…I’m not surprised to see him with the movers and shakers at AAFP. He might have been into a fresh, organic food phase back then, but it was a disappointing to see the praise for native medicine on his website recently. It did seem that he had gone over to the dark side.

    Interestingly, the AAFP policy on complimentary medicine is: http://www.aafp.org/online/en/home/policy/policies/c/complementarypractice.html .
    It seems in posting an article that claims solid evidence for certain alternative treatments, they have broken their policy because the evidence was not presented.

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