Special Report: The Mainstreaming of Complementary Medicine
By Jackson & Coker Research Associates
The practice of healing has always been broad and multi-faceted. A specific ailment – a headache, for example -- is treated in different ways by different people, according to their beliefs and training. Where one person swears that the headache will disappear if pressure is applied to the correct points in the face, another insists that only aspirin can shoo the pain away, and a third might suggest a total dietary overhaul– after all, hypertension is a cause of headaches, and certain foods and activities might lower blood pressure.
Western (or conventional) medicine has long subscribed to the “aspirin” school of thought. The body is a machine full of parts; when the machine breaks, you try to fix the parts. Recently, though, alternative, holistic approaches to health have been finding their way into conventional environments, to the point that many top hospitals are incorporating alternative care into their treatment of patients. Opinions about this trend differ greatly – about as much as purported cures for headaches do – but whether or not it is a positive development, understanding its implications is crucial to providing the best care possible to patients whose understanding of medicine is changing.
Complementary and Alternative Medicine (CAM) is a broad term that encompasses a diverse field of “medical and health care systems, practices, and products that are not generally considered part of conventional medicine” . This area of medicine goes by many names, also often referred to as Integrative or Integrated Medicine. The “complementary” aspect of this field refers to the use of unconventional methods as a supplement to traditional medical treatment, while the “alternative” aspect refers to use of these methods instead of conventional treatment. Meanwhile, the “integrative” aspect encompasses “both conventional and CAM treatments for which there is evidence of safety and effectiveness.”
In order to foster greater acceptance of these unconventional treatments in the health care industry, champions of CAM prefer to emphasize the term “complementary” because of its inherent reliance on mainstream medicine as the basis for treatment .
The last two decades have seen a rapid rise in the demand for integrative medicine, largely driven by its promise of “more time, more attention, and a broader approach to healing…that is not based solely on the Western biomedical model” . As described by Esther Sternberg, MD, a senior scientist at NIH who has conducted much research regarding the connections between the brain and the immune system, more patients now want “to be considered whole human beings in the context of their world.”
Figures released as part of the most recent National Health Interview Survey (2007) show that about 38% of adults 18 and older had used CAM during the last year, though women (43%) were more likely to have used CAM than men (34%). In addition, women used CAM more often for neck pain, arthritis, and anxiety, while men used alternative medicine more often to treat high cholesterol .
According to a breakdown of the survey data published by NIH’s National Center for Complementary and Alternative Medicine, use of CAM is highest among individuals aged 50-59 . While natural product use is the most common type of CAM treatment for adult patients, between 2002 and 2007 there was an increase in the use of deep breathing, meditation, massage, and yoga. CAM is used to treat a broad array of health problems, but the most common targets of CAM therapies are back pain, neck pain, joint pain, and arthritis .
In Medical Education
The increased interest in and demand for alternative medical treatment has generally been embraced by top medical schools over the last decade. In 2000, several of these institutions formed the Consortium of Academic Health Centers for Integrative Medicine, an organization that seeks to increase CAM’s presence in medical education. Its members now include 46 medical schools in the U.S. and Canada . While these members are by no means educating their students to use CAM in the place of conventional medicine, interest in alternative methods “has exploded, especially this last year,” according to the executive director of the Institute for Functional Medicine, Laurie Hofmann .
This embrace of CAM has manifested itself largely in the development of elective curricula. Such is the case at the University of California San Francisco and Loma Linda University, which have both introduced integrative medicine electives and have plans to expand these offerings. Other institutions, such as the University of Arizona, have aggressively overhauled curriculum to include integrative approaches. As described by Victoria Maizes, executive director of the University’s Center for Integrative Medicine, "it made sense to integrate these ideas into a variety of courses" because of research supporting the benefits of certain treatments, particularly low-risk holistic remedies .
In Medical Care
As of 2006, about one in five hospitals offered complementary and alternative medicine to patients, a rapid increase from the 7.9% of hospitals that offered CAM services in 1998 . More recently, Health Forum’s Complementary and Alternative Medicine Survey of Hospitals found that urban hospitals were more likely to offer integrative services and that the typical CAM-providing hospital was “in the Eastern or Midwestern United States and maintains between 100 and 300 beds” .
The survey also found that most CAM services are being offered at hospitals on an outpatient basis, with popular services including massage therapy, acupuncture and relaxation training . Meanwhile, the most common inpatient CAM services were pet therapy, massage therapy, and music/art therapy. The vast majority of CAM-providing hospitals indicated that patient demand was the reason for offering these treatments, but about one-third indicated that these services were offered because of their clinical effectiveness. Perhaps not surprisingly then, the majority of hospitals were found to rely more on patient satisfaction and treatment volume in evaluating CAM services than upon the outcomes of treatment .
While establishing CAM services was not found to be exceedingly expensive, they also were not found to be particularly lucrative . About 42% of hospitals reported “breaking even” and 64% indicated that they “never expected to break even” by offering these services. Once established, the main obstacles reported to maintaining CAM programs were budgetary constraints and physician resistance.
While the adoption of CAM services has met considerable resistance, it is telling that many of the top hospitals across the nation have embraced alternative medicine in recent years—in fact, all of the top 18 hospitals on the U.S. News “America’s Best Hospitals” list offer some form of CAM .
The Duke Center for Integrative Medicine is reportedly a “classic model of integrative care” . The Center blends traditional Western treatments with alternative or complementary approaches, offering CAM in the form of “herbal medicine, acupuncture, massage, biofeedback, yoga, and stress reduction techniques.” The Center’s director, Tracy Gaudet, indicates that she has been successful in easing doubts about CAM once her colleagues realize that it is not “blindly advocating for alternative approaches and rejecting conventional ones." While acknowledging the great amount of “quackery” and “dangerous therapies” associated with some CAM, the Duke Center guides patients against those treatments with a focus on implementing therapies that will lead to “the best care for patients.”
At the Children’s Memorial Hospital in Chicago, the integrative medicine program is led by pediatric intensivist and medical director David Steinhorn, who oversees many trials that are underway for various CAM treatments . “I’m a very serious, hard-core ICU doctor,” Steinhorn says, “but I have seen these therapies benefit my patients, even if I don’t know how.”
Meanwhile, at New York-Presbyterian Hospital/Columbia University Medical Center, the Rosenthal Center for Complementary & Alternative Medicine has been established to pursue “rigorous scientific investigation to evaluate the effectiveness, safety, and mechanisms of action of alternative and complementary practices” . The Rosenthal Center also provides a special program exclusively addressing women’s health and aging, which focuses in part on exploring “herbal medicine and dietary approaches for postmenopausal women,” and has a multispecialty medical practice through which it works to integrate complementary treatments in the fields of oncology, gastroenterology, cardiology, and internal medicine.
The Mayo Clinic is also among the elite medical centers now offering CAM treatments like acupuncture and massage, but like most health centers, the Clinic is careful about recommending these treatments . The Clinic's complementary and integrative medicine program director, Brent Bauer, says that medical professionals “should always insist on a high standard” when considering the outcomes of treatment.
Philadelphia’s Thomas Jefferson University Hospital and the University of Maryland Center for Integrative Medicine both offer homeopathic services, while the Oregon Health and Science University Hospital and the University of Pittsburgh Medical Center offer naturopath consultations through which “nonmedical aids such as proper nutrition, colonic irrigation…and special water baths” are advocated .
Still, hospitals are generally conservative in their CAM offerings. The medical director of the University of Colorado Hospital’s Center for Integrative Medicine is reflecting on both the popularity of alternative treatments and the hodge-podge nature of the independent provider market when she comments on the Center’s goal for patients to “have access to these therapies in a responsible fashion” .
Nonetheless, recent years have seen a decided increase in the number of believers in more controversial therapies as research studies increasingly bring these treatments into the scientific arena.
CAM treatments continue to be an out-of-pocket expense for most patients . In 2007, the National Health Interview Survey revealed that adults in the U.S. had spent roughly $33.9B on CAM treatments out-of-pocket over the last year. Most of this spending was devoted to “self-care” costs like CAM products and classes (65%), while the remaining 35% was devoted to CAM practitioner visits .
According to the National Center for Complementary and Alternative Medicine (NCCAM), private health insurers are more likely to cover traditional CAM therapies like acupuncture, massage, and chiropractic treatment, but this coverage is “relatively limited.”
As described by Alan Smith, author of a guide to CAM therapies, these treatments are often “classified as experimental or unproven” by insurance companies . However, there are signs of insurance companies beginning to cover CAM, most often for “acupuncture, massage, chiropractic, biofeedback, and naturopathy therapies.” A small number of insurers, according to Smith, offer a “special policy rider for CAM coverage,” while others have “negotiated discounts with CAM therapy providers for a lower cost.”
For now, CAM treatments covered by an insurer may be associated with higher deductibles and copays, referral requirements from primary care physicians, restriction of coverage to a small network of providers, and annual limits for visits.
As more research surfaces in the coming years, however, insurers are likely to expand their coverage to include therapies with proven results.
While most of the long-term impacts of the Patient Protection and Affordable Care Act (PPACA) remain to be seen, the legislation passed in March 2010 does contain language pertaining to complementary and alternative medicine . The Act prohibits discrimination by insurance providers against any practitioners who are acting within the bounds of their licenses or certificates under State law, which may lead to the greater inclusion of many integrative health practitioners in insurance plans.
Other sections of the PPACA directly mention CAM practitioners. For example, the Secretary of Health and Human Services will establish a program that provides grants to interdisciplinary Community Health Teams which may include “licensed complementary and alternative medicine practitioners.” The term “integrative health” is also liberally sprinkled throughout parts of the Act that mandate, among other things, the duties of the Public Health Council and the compositions of the Board of Governors and Expert Advisory Panels that will develop the agenda for comparative clinical effectiveness research .
Hospitals, insurance companies, and the national government are beginning to acknowledge the growing presence of CAM in both clinical spaces and the minds of the patients they serve. However, not everybody feels favorably towards this presence.
Certainly, doubt remains regarding the effectiveness of many CAM treatments, and critics are wary of its increased acceptance in medical education and the medical profession. Several detractors suggest that “market forces” have driven this trend, and see integrative medicine as nothing more than a response to increased demand from health care consumers. Harvard Medical School professor Tom Delbanco, MD is among these critics, calling increased CAM demand another indication that the U.S. is a “faddish country” . However, lack of substantial research to support CAM treatments is clearly the greatest objection. Delbanco elaborates on this concern:
I worry that people are making claims in the context of scientific medicine that they cannot really justify. I think there have been few rigorously controlled, scientifically sound studies in the area, and when they have been done, the vast majority have shown these medicines to be no different from placebo. I have no trouble with offering hope. I think people need hope and optimism. Where I have trouble is when we promise things to people that aren’t real .
Elsewhere, University of Maryland professor Steven Salzberg also recently voiced his concerns about integrative medicine, calling it a “collection of superstitions, myths, and pseudoscience” . Like Delbanco, Salzberg was particularly concerned with its acceptance by respectable medical schools, including at his own institution, basing his objections of the current lack of scientific evidence to support the outcomes of certain CAM treatments. Beyond discomfort with the absence of evidence, many doctors are untrained in alternative therapies and therefore uncomfortable recommending them to patients . Several critics have asserted that many potentially dangerous CAM therapies have “illusory” benefits .
Despite continued apprehension among healthcare professionals, CAM proponents are hopeful that ongoing research will lead to a greater understanding of integrative medicine in the coming years. "There's a clamoring for understanding the biology of this," says the NIH’s Sternberg .
This “clamoring” in the scientific arena mirrors the changing societal values that have spurred the adoption of CAM in conventionally Western contexts. The American public is increasingly open to medical techniques that are encompassing rather than reductive, and practitioners, insurance providers, and government officials are increasingly willing to incorporate these techniques into their systems.
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