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Introduction |
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The term complementary/alternative medicine (CAM) embraces myriad healing
systems, many with centuries of accumulated practitioner knowledge and
experience. Several of the world's great healing traditions include a variety of
therapeutic modalities: Ayurveda (the traditional healing system of India),
Traditional Chinese Medicine (TCM), and Native American medicine systems each
employ medicinal herbs, but in each system the choice of herbs, their
formulation, and explanations of mechanisms of action are different. In the
United States, such traditions and modalities have been labeled "alternative"
for several reasons—scientific, cultural, and
political. Varied in cultural underpinnings, worldviews, theoretical models, and
therapies, all alternative medical practices by definition operate outside the
Western biomedical model and have thus been seen to be unscientific by modern
Western standards. Since medical systems are defined as much by cultural or
social influences as by theoretical constructs, systems arising out of
non-Western milieus will be fundamentally different from their Western
counterparts. Finally, non-Western healing practices are considered alternative
because decisions have been made not to teach them in United States medical
schools, make them available to patients in hospitals, or cover them as benefits
of health insurance.
The barriers to an integrative medicine are beginning to fall, or at least
become less insurmountablebecome less formidable. Nonconventional healing
practices are increasingly being investigated and
validated—or in some cases
invalidated—in well-designed research studies; the
intermixing and growing interdependence of diverse cultures in the West are
bringing once distant cultural perspectives into close proximity, and the
institutions of Western medicine are beginning to respond. As of 1998, 75 out of
117 United States medical schools offer at least one course in CAM. In a survey
published in 1994, 60 percent of physicians reported recommending CAM to their
patients; 47 percent of the responding physicians acknowledged using CAM
themselves. More and more health insurance plans are covering CAM, especially
those modalities, such as acupuncture and chiropractic, whose safety and
efficacy in the treatment of certain conditions has been well researched. A
number of health plans now cover the Ornish cardiovascular rehabilitation
program, which has a foundation in yoga and clinical nutrition, and the state of
Washington now requires healthcare coverage of unconventional therapies even
where there is no research supporting safety or efficacy. All indications point
to the careful movement—often with a healthy dose of
skepticism—toward an integrative medicine system that
incorporates the most useful therapies from the world's many healing
traditions. |
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OAM, NCCAM, and the White House
Commission on Alternative
Medicine |
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The movement toward integrative medicine in the United States has been
catalyzed by a growing consumer demand for CAM services. Eisenberg et al, in a
now famous study published in 1993, reported on the widespread use of CAM by
American healthcare consumers. The study found, in part, that more than
one-third of Americans had sought CAM therapies, that in 1990 they had made more
visits to CAM providers than to their primary care physicians, and that the
unreimbursed expense of these visits exceeded 13 billion dollars. In 1991, under
a Congressional mandate, the National Institutes of Health (NIH) established the
Office of Alternative Medicine (OAM) with an annual budget of 2 million dollars
to coordinate NIH research on nontraditional health practices. Specifically, OAM
was to evaluate CAM practices, support CAM research and training, and establish
a CAM information clearinghouse for the general public.
In 1998 Congress established the National Center for Complementary and
Alternative Medicine (NCCAM) to supersede the OAM. With a FY2000 budget of more
than 68 million dollars, NCCAM's mission is to support basic and applied CAM
research, including training in research methodology for CAM, and provide
information to healthcare providers and the public. Among other efforts, NCCAM
focuses on research that evaluates the safety and efficacy of herbal medicines
and nutritional supplements and their potential for interaction with standard
pharmaceuticals. It also evaluates such CAM modalities as acupuncture and
chiropractic. NCCAM funds several research centers outside of the NIH (to learn
more about the centers and their research agendas, visit NCCAM's web site at
http://nccam.nih.gov/nccam/fi/research/centers.html).
In July of 2000, the White House announced the establishment of a White House
Commission on Alternative Medicine, designating the Chair and the first 10
members. The charge to the commission is to develop a set of legislative and
administrative recommendations to maximize the benefits of CAM for the American
public. Going beyond the research goals of NCCAM, the commission will set the
agenda for the education and training of CAM practitioners as well as provide
policy recommendations for the insurance industry coverage of alternative
therapies. |
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Common Threads Through CAM
Therapies |
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While the histories, theoretical underpinnings, and practices of
nonconventional healing traditions vary widely, several themes can be traced
through them all:
a)The whole person—physical, emotional, social, and
spiritual—is the healer's focus. Indeed, illness is
often considered a manifestation of the loss of balance or right relationship
among these personal aspects, and therapy is directed at restoring balance and
integration.
b)Prevention of illness is a primary concern. But in contrast to the Western
approach of pharmacotherapeutic or surgical intervention, CAM practitioners tend
to call upon the participation of the individual, supporting that person's use
of inner resources to maintain health. In this model, according to CAM
anthropologist Marc Micozzi, MD, PhD, wellness results from the
"balance of internal resources with the external natural and social environment."
c)Treatment regimes are highly individualized, devised in response to the
unique totality of the individual rather than to a disease entity.
d)Treatment is directed at the causes of illness rather than at symptoms.
e)Treatment is designed to support what are seen as the natural healing
processes inherent in all human beings. |
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The Problem of Evidence and
Experimental
Design |
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Another common theme running through healing systems not grounded in the
biomedical model is an absence of scientific research supporting (or disproving)
safety and efficacy. While the knowledge base for practitioners of CAM is
provided by hundreds—in some cases
thousands—of years of weeding out the unsuccessful from
the successful therapies, those practicing in the Western conventional tradition
look to scientific evidence for validation of therapeutic efficacy. This has
been a major contributor to the slow pace of acceptance of CAM by the
conventional medical community. (Ironically, while the numbers vary according to
the source, the Office of Technology Assessment has estimated that
"only 10 to 20 percent of all [standard] procedures currently used in medical practice have been shown to be efficacious by controlled trial.")
Even though there exists a substantial body of well-designed research studies on
CAM and the number of new studies being launched is growing, there are many CAM
modalities that do not lend themselves to investigation with standard clinical
research techniques (i.e., the randomized, placebo-controlled, blinded trial).
Sham acupuncture or massage as placebo, for instance, has proven very difficult
to devise or use successfully. Perhaps the most fundamental barrier to research
investigations, however, has been CAM's typical practice of treating the person
rather than the condition, thus eliminating the availability of standardized
treatment protocols that can be applied to all subjects with the same diagnosis.
While CAM researchers are becoming more clever and sophisticated in their study
designs, it is unlikely that some popular and effective CAM therapies will ever
find validation through the sort of clinical research that is currently being
demanded by many in the medical community. Indeed, the challenge may be to
sharpen the collection and use of data from case studies and other empirical
sources. |
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CAM: A Confusion of
Tongues |
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CAM relies on culturally based and therefore unique sciences and scientific
vocabularies, making communication with Western practitioners difficult if not
sometimes impossible. For example, a TCM practitioner will examine a patient to
identify overall disharmony rather than simply an agent of disease; a resulting
diagnosis of "dampness of the spleen" or "liver wind" is not likely to edify a
Western clinician. However, with more cross training for physicians in
alternative therapies, greater participation on the part of both conventional
and alternative providers in integrative conferences and consultations, more CAM
textbooks written for a Western audience, and more CAM courses being offered in
United States medical schools, the barriers are lowering. Certainly, in learning
to be comfortable with any new culture, immersion, not avoidance, is the
answer.
Conventional medicine and CAM can no longer be an either/or proposition. The
integration of the most useful therapies from all healing traditions has begun,
driven largely by consumer demand. Increasingly, working with patients will mean
taking a nonparadigmatic perspective on therapeutics, seeking out trusted
colleagues with CAM experience for advice and support, and becoming informed
about the most authoritative sources of clinical information on CAM
modalities. |
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Working With Patients |
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As indicated above, Americans are turning to CAM in large and growing
numbers. In many cases they do so without telling their physician for fear of
being scolded. At the same time, they are increasingly bringing questions about
CAM to their providers. To be able to respond to patients and to oversee a
patient's total care, physicians need, at minimum, to learn about CAM and to
keep the lines of communication open with their patients regarding their use of
alternative therapies. The following guidelines may be helpful in responding to
patients' interest in and use of CAM therapies.
a)Solicit from patients the details of their CAM
use—therapies they may be using or are interested in,
CAM practitioners they are seeing, their experiences with CAM therapy, and their
perception of outcomes. Perhaps the number one concern for most physicians
regarding their patients' use of CAM is that a patient will postpone needed
treatment while he or she seeks alternative approaches, and in such cases a
physician should try to dissuade such behavior. If unsuccessful, the physician
should document the disagreement in the patient's record.
b)Inform patients about how to find the most qualified alternative providers.
They can be coached to ask about a provider's certification and licensure and
ask to see the appropriate certificates. Patients should then question the
provider about any proposed treatment, its cost, duration, the changes they can
expect in their condition and when, signs that the treatment is or isn't
working, possible risks/side effects, and whether the practitioner is prepared
to communicate with the patient's primary care physician regularly about his or
her care.
c)If referring a patient to a CAM provider, make certain the provider is
certified or licensed and carries malpractice insurance.
d)Having worked with the patient to establish expectations for improvement,
monitor a patient's CAM treatment. If there is no improvement or there is
deterioration in the patient's condition after an agreed upon course of
treatment (say, six visits to an acupuncturist), the physician, together with
the patient, can then reassess the treatment.
e)Many CAM therapies are essentially harmless, such as most homeopathic
treatments, but others carry serious risks. This is especially true with the use
of herbal medicines, available over-the-counter in pharmacies, health food
stores, and increasingly over the Internet. Many people who use such products do
not understand that these substances are drugs, in many cases quite powerful
ones, and that severe health risks can attend their use. It is therefore
especially important to ascertain which herbs (or nutritional supplements) a
patient is using and in what dosage. Since the per dose percentage of active
ingredients in a particular herbal product can vary considerably among product
lines, it may be necessary to ask the patient to bring in the herbal medicine in
order to determine whether it is being used safely. The potential for drug-herb
interactions with any conventional pharmaceuticals the patient may be taking
should also be considered. Herbal medicines—also called
phytomedicinals—are more widely used in Europe; in
Germany, where up to 80 percent of physicians routinely prescribe herbal
medicines and board examinations of medical students include a section on
phytomedicine, the manufacture and sale of herbal medicines are regulated by the
government. Indeed, the German government's Commission E has investigated the
safety and efficacy of more than 400 medicinal herbs. The complete Commission E
monographs on these herbs are available in English.
Perhaps the single most important point in dealing with a patient's use of
CAM is to maintain open communication about the subject. If patients are made to
feel that their interest in CAM is not condoned out-of-hand, they are likely to
hide their CAM use from their physicians and deprive themselves of the counsel
that could help them avoid untoward consequences. |
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The Future |
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There are many encouraging signs that CAM is finding an increasingly
receptive audience in the conventional medicine community, perhaps none better
than the recent attention CAM research is receiving in prestigious Western
peer-reviewed journals. Still, there are real obstacles to the achievement of
truly integrated medicine. In addition to cultural conflicts and the problems of
evidence, there are difficult administrative issues, such as billing and coding
procedures (in some venues, CPT and ICD-9 codes are presently being massaged
adjusted to cover CAM), scope of practice regulations, the integration of
medical records, and the like. However, given the consensus goals of efficacy,
safety, accessibility, and cost-effectiveness of medical treatment, certainly
these are not insurmountable obstacles to the integration of the best of CAM
into conventional Western medicine. |
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Resources |
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The following web sites are all available free of charge, without
subscription.
Government sites:
FDA Center for Food Safety and Applied Nutrition: Dietary Supplements
http://vm.cfsan.fda.gov/~dms/supplmnt.html
National Cancer Institute: Office of Cancer Complementary and Alternative
Medicine (OCCAM)
http://occam.nci.nih.gov/
National Center for Complementary and Alternative Medicine (NCCAM)
http://nccam.nih.gov/
NIH Office of Dietary Supplements (ODS)
http://odp.od.nih.gov/ods/
Directories:
University of Wisconsin HealthWeb—Alternative /
Complementary Medicine
www.medsch.wisc.edu/chslib/hw/altmed/
NOAH (New York Online Access to Health): Alternative Medicine Resources
www.noah.cuny.edu/alternative/alternative.html
Rosenthal Center: Information Resources
http://cpmcnet.columbia.edu/dept/rosenthal/CAM.html
University of Pittsburgh: Alternative Medicine Homepage
www.pitt.edu/%7Ecbw/altm.html |
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References |
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Blumenthal M. Introduction. In: Blumenthal M, Busse WR, Goldberg A, eds.
The Complete German Commission E Monographs: Therapeutic Guide to Herbal
Medicines. Boston, Mass: Integrative Medicine Communications; 1998:5-70.
Davant C III. What you should tell patients about alternative medicine. In:
Micozzi MS, Bacchus AN, eds. The Physician's Guide to Alternative
Medicine. Atlanta, Ga: American Health Consultants; 1999:363-366.
Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the
United States. N Engl J Med. 1993;328(4):246-252.
Jonas WB. One kind of medicine or many? The view from the NIH. In: Micozzi
MS, Bacchus AN, eds. The Physician's Guide to Alternative Medicine.
Atlanta, Ga: American Health Consultants; 1999:367-369.
Micozzi MS. Characteristics of Complementary and Alternative Medicine. In:
Micozzi MS, ed. Fundamentals of Complementary and Alternative Medicine.
New York, NY: Churchill Livingstone; 1996:3-8.
National Center for Complementary and Alternative Medicine. About
NCCAM: General Information. Accessed on August 8, 2000 at
http://nccam.nih.gov/nccam/an/general/index.html.
Novey DW. Basic principles of complementary/alternative therapies; The
dilemma of evidence; Leaving the medical model; and Integration. In:
Clinician's Complete Reference to Complementary/Alternative Medicine. St.
Louis, Mo: Mosby; 2000:5-7, 7-9, 10-12, 13-16.
The White House: Office of the Press
Secretary—Statement by the President [press release].
M2 Presswire; July 14,
2000. |
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Communications This publication contains
information relating to general principles
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