INTEGRATIVE MEDICINE

 

What is it?

  • Integrative Medicine
    • “comprehensive primary care system that emphasizes wellness and healing of the whole person… as major goals, above and beyond suppression of specific somatic disease” (Arch Intern Med. 2002. 162. 144-140).
    • views patients as whole people with minds and spirits as well as bodies and includes these dimensions into diagnosis and treatment” (BMJ. 2001. 322. 133-140).
    • “the practice of medicine that reaffirms the importance of the relationship between the practitioner and the patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing” (Consortium of Academic Health Centers for Integrative Medicine Steering Committee, revised in 2006, based on input from the Academic Consortium for Complementary and Alternative Health Care).
  • In part an extension of allopathic medicine, in part a philosophy of treatment, in part integration of diverse providers rather than simply integration of modalities by a M.D. or D.O.
  • Allopathic Medicine - a system of therapeutics based on production of a condition incompatible with or antagonistic to the condition being treated (i.e. antibiotics, antihistamines, antipyretics, anti-inflammatory medications).

 

What are some of the basic tenets of Integrative Medicine?

  • It is a philosophic approach to treatment rather than just more tools in the toolbox.  In contrast, in terms of contemporary terminology, CAM (complementary and alternative medicine) is about specific modalities of treatment.
  • It is patient-centered rather than physician-centered, and emphasizes the centrality of the doctor/patient relationship in the healing process.
  • Acknowledgement that healing is innate - the role of the practitioner is to remove any blocks to healing, and facilitate or stimulate one's own natural healing potential.
  • Recognition that often the patient is the diagnostician and the practitioner is the educator.
  • Recognition of the role of the mind and the spirit in good health.  Health is a cohesive balance of mind, body, and spirit.
  • Recognition of the role of nutrition and exercise in good health.
  • Recognition that health is more than the mere absence of disease.
  • Use of herbs and vitamins and dietary supplements in addition to or instead of prescription medication.
  • Use of complementary modalities of treatment such as chiropractic, massage therapy, acupuncture, homeopathy, and others, when indicated.
  • Commitment to the scientific method and evidence-based practice.

 

Why should physicians learn about it?

  • Consumer demand (i.e. chiropractic was covered by Medicare in 1966 despite the Surgeon General warning against it, based in part on 12 million letters sent by Americans to their Congressmen).
  • Popularity of complementary modalities (functionally defined as interventions neither taught widely in medical schools nor generally available in U.S. hospitals, and by definition includes relaxation techniques, herbal medicines, massage, chiropractic, spiritual healing by others, megavitamins, self-help groups, imagery, commercial diets, folk remedies, lifestyle diets, energy healing, homeopathy, hypnosis, biofeedback, and acupuncture, in order of decreasing popularity of use in the past 12 months in 1997).
    • Popularity in 1990 (Eisenberg DM, et al. Unconventional Medicine in the United States. New Engl J Med. 1993; 328: 246-252).
      • One in three adults in the U.S. used unconventional care in 1990.
      • The use of unconventional care is distributed across all socioeconomic groups.
      • 83% of users of unconventional care also used conventional treatment.
      • The number of visits to providers of unconventional care (425 million visits) was greater than the number of visits to all primary care medical doctors (388 million visits).
      • Out-of-pocket expenditures for unconventional care (10.3 billion dollars) were approximately equal to out-of-pocket expenditures for all hospitalizations.
      • One in four adults seeing a medical doctor for a serious health problem are also using unconventional treatment, but seven in ten do not tell their physician about the use of unconventional care.
    • Popularity reassessed in 1997 using the same definitions (Eisenberg DM, et al. Trends in Alternative Medicine Use in the United States, 1990-1997. JAMA. 1998; 280:1569-1575).
      • Use of alternative therapies increased from 33.8% in 1990 to 42.1% in 1997, with the largest percentage increases in use seen for herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy.
      • The probability of users visiting an alternative medicine provider increased from 36.3% in 1990 to 46.3% in 1997.
      • Alternative therapies in both 1990 and 1997 were used most frequently for chronic conditions, including back problems, anxiety, depression, and headaches.
      • There was no significant change in disclosure rates to physicians regarding the use of alternative therapies (39.8% vs. 38.5%).
      • The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly (64.0% vs. 58.3%).
      • Extrapolations to the U.S. population suggest a 47.3% increase in total visits to alternative medicine practitioners, from 427 million visits in 1990 to 629 million visits in 1997.
      • 18.4% of all prescription users in 1997 took herbal remedies and/or high dose vitamins concurrently.
      • Estimated expenditures for alternative medicine professional services increased 45.2% to 21.2 billion dollars, with an estimated 12.2 billion dollars paid out-of-pocket.
      • Total out-of-pocket expenditures in 1997 for alternative therapies were approximately 27 billion dollars, exceeding out-of-pocket expenditures for all physician services in 1997.
    • Popularity reassessed in 2002 using the same definitions (Tindle HA et al. Trends in use of complementary and alternative medicine by US adults, 1997-2002. Altern Ther Health Med. 2005. 11. 42-49).
    • Since 1990 there have been 10 national surveys looking at popularity of CAM, but each has used a different definition of CAM, and the demographic makeup of the study group has varied from study to study.
    • The most complete and comprehensive findings on Americans' use of CAM are derived from National Health Interview Surveys (NHIS). The questions were developed by NCCAM and the data can be viewed at http://nccam.nih.gov/news/camsurvey.
      • Initially, questions included in the 2002 survey, administered to 31,044 adults.  This survey showed that 74.6% of adults surveyed had ever used CAM, with 62.1% of adults using CAM in the past 12 months.  If prayer for health was excluded the statistics were 49.8% of adults had ever used CAM, with 36.0% of adults using CAM in the past 12 months.  The ten most common CAM therapies utilized were prayer/self 43%, prayer/others 24.4%, natural products 18.9%, deep breathing 11.6%, prayer group 9.6%, meditation 7.6%, chiropractic 7.5%, yoga 5.1%, massage 5.0%, diets 3.5%. Note that only 12% of survey respondents sought care from a licensed CAM provider. This survey also included data on reasons for CAM use.
      • Based on data from the 2007 survey, 38% of adults reported using CAM in the previous 12 months; 83 million US adults (40% of the adult population) spent $33.9 billion out of pocket on visits to CAM practitioners and on purchases of CAM products, classes, and materials (11.2% of total out of pocket expenditures on health care in the US); out of pocket spending for supplements was $14.8 billion (1/3 the total of $47.6 billion in out of pocket expenditures for prescription drugs); out of pocket spending for CAM practitioner visits was $11.9 billion (1/4 of the total of $49.6 billion out of pocket expenditures for physician visits) [Nahin RL et al. National Health Statistics Report; no 18, National Center for Health Statistics. 2009].
    • The contemporary ecology of medical care in the U.S. in 2000 - it is estimated in a typical month that 800 of 1000 persons report symptoms, 217 visit a physician's office, 113 of the 217 visit a primary care physician's office, 65 visit a complementary or alternative medicine care provider, and 8 are hospitalized (N Engl J Med. 2001. 344. 2021-2025).
  • More options to offer your patients.
  • Greater job satisfaction.

 

Why are complementary modalities popular?

  • Downer SM, et al. Pursuit and Practice of Complementary Therapies by Cancer Patients Receiving Conventional Treatment. Br Med J. 1994; 309. 86-89.
    • These authors surveyed all patients in a cancer registry in England - 600 surveys were sent and 415 were returned.
    • The results showed that 16% of the 415 patients used complementary treatments, and 80% of these patients responded that they were satisfied with their complementary treatment (even though other results showed no survival advantage).
    • Patients cited a more hopeful outlook on the part of the practitioner and a more supportive relationship as reasons for satisfaction.
  • Astin JA. Why Patients Use Alternative Medicine: Results of a National Study. JAMA. 1998; 279: 1548-1553.
    • This paper reports the results of a survey of 1035 randomly selected Americans.
    • Response rate was 69%.
    • 40% of respondents used alternative therapies, but only 4.4% relied primarily on alternative therapies.
    • Other than in the 4.4% who relied primarily on alternative therapies, dissatisfaction with conventional medicine did not predict use of alternative therapies.
    • Use was associated with subjective reports of poorer health status.
    • Furthermore, users were more likely to have had a self-reported transformational life experience, and users were more likely to report that health care alternative treatments were more congruent with their individual values (i.e. a more holistic attitude toward health).
  • Note: Other surveys fail to verify the notion of widespread fraud amongst practitioners of complementary modalities, and find that most practitioners are dedicated, caring individuals.
  • Positive motivations for seeking out complementary modalities
    • Perceived effectiveness and safety
    • Fits with the patients philosophy
    • Seeking a particular kind of practitioner/patient relationship
    • Non-invasive
  • Negative motivations for seeking out complementary modalities
    • Conventional medicine ineffective
    • Side effects of conventional medicine
    • Rejection of “the establishment”
    • Desperation
  • Limitations of allopathic medicine:
    • Operational weaknesses:
      • Not very effective at treating viral illnesses, nutritional and metabolic diseases, allergies, autoimmune diseases, cancer, and the mental illnesses.
    • Inherent weaknesses:
      • Focus on a paradigm of war and external forces as a cause of disease instead of a paradigm of balance and internal forces or the terrain as a cause of disease (i.e. focuses on meningococcemia rather than focusing on the individuals colonized with meningococcus who do not get sick, focuses on strep throat rather than focusing on individuals colonized with streptococcus who do not get sick).
        • Weapons can backfire (antibiotic resistance).
        • Model does not work well for chronic disease.
      • Defines health only in the negative sense as the absence of disease.
      • Lack of adjustment for biochemical individuality.
      • Defies a precise definition of the approach to illness in a positive sense.
    • Acquired weaknesses:
      • Focus on dissection of dead bodies (i.e. lack of appreciation of "life force").
      • Focus on abnormal psychology (Maslow and self-actualization is the exception).
      • Based on 19th Century physics.
      • Focus on separation of the mind and the body
      • Failure to take into account important social, spiritual, emotional, and environmental factors (i.e. not holistic).
      • Failure to listen and to spend enough time with each patient (distorted reimbursement).
      • Failure to communicate effectively.
      • Failure to empathize/become emotionally attached.
      • Physician centered care instead of patient centered care.
      • Pessimism.
  • Paradoxes of Complementary Medicine (Davidoff F. Ann Intern Med. 1998; 129: 1069-1070).
    • Responsibility paradox:
      • Patient controls his/her own destiny.
      • Paradox of therapeutic failure blamed on the patient, not on the complementary modality.
    • Truth telling paradox:
      • Optimistic viewpoint gives hope.
      • Paradox of unrealistic optimism that can distort reality.
    • Self-scrutiny paradox:
      • Conventional medicine is constantly subject to self-scrutiny.
      • Paradox of conventional medicine in trouble due to self-scrutiny.

 

What are the myths about complementary medicine users?   [British Journal of Clinical Psychology. 1996. 35. 37-48]

  • Disillusioned with medicine in general - national survey data do not support the view that users of CAM are dissatisfied with conventional medical care.  Furthermore, adults who use both CAM and conventional care are less concerned about their doctor's disapproval than their doctor's inability to understand or incorporate CAM therapy use within the context of their medical management (Eisenberg DM, Kessler RC, et al. Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey. Ann Intern Med. 2001. 135. 344-351).
  • Anti-science.
  • Largely motivated by lower cost.
  • Using it because it was the only choice available.
  • Unusual characteristics or attitudes when compared to non-users.

 

How do I practice Integrative Medicine?

  • Communication skills.
  • Empathy.
  • Humanistic, patient-centered approach.
  • Focus on recognition of patient suffering as well as diagnosis and treatment (three roles of the physician in caring for the sick include skilled diagnosis, effective treatment, and human recognition of suffering).
  • Focus on nutrition, exercise, lifestyle issues, prevention, and wellness.
  • Offer reassurance when indicated.
  • Prescribe vitamins, minerals, herbs, and dietary supplements when indicated.
  • Refer to one of a network of complementary practitioners when indicated.

 

How do I decide when and where to refer?

  • I invoke a complementarity model:
    • Allopathy is the most effective modality for treating trauma, acute medical and surgical emergencies, and acute bacterial, fungal, and protozoa infections.
    • Allopathy is less effective at treating most viral illnesses, nutritional and metabolic diseases, allergies, auto immune diseases, and the mental illnesses.
  • I rely on a classification of complementary treatment modalities:
    • Those which address structural imbalances in the body (osteopathy, chiropractic, physical therapy, massage therapy, shiatsu, rolfing).  NCCAM labels this category as “MANIPULATION & BODY-BASED PRACTICES,” with sub-categories including chiropractic, massage, Pilates, and Feldenkreis.
    • Those which focus on maintaining or restoring biochemical balance (herbal medicine, environmental medicine).  NCCAM labels this category as “BIOLOGICALLY BASED PRACTICES,” with sub-categories including food supplements, herbals, animal products, and special diets.
    • Those that seek to restore mental and emotional balance at a physiological level (biobehavioral methods, including meditation, guided imagery, and biofeedback).  NCCAM labels this category as “MIND-BODY MEDICINE,” with sub-categories including hypnosis, meditation, tai chi, and yoga.
    • Those that address the energetic levels of the body (therapeutic touch, homeopathy, Bach flower essences).  NCCAM labels this category as “ENERGY MEDICINE,” with sub-categories including healing touch, qi gong, and reiki.
    • Complete systems (naturopathy, TCM, Ayurvedic medicine).  NCCAM labels this category as “WHOLE MEDICAL SYSTEMS.”
  • I recognize that belief is central to healing:
    • Healing often will not occur in the absence of belief.
    • Belief alone may be adequate to achieve healing (this is the placebo effect).

 

How does one find a practitioner?

 

Are complementary modalities efficacious?

  • More and more research is appearing, but much is published in peer review scientific journals not read by physicians.
  • Nonetheless, there are still relatively few controlled clinical trials of complementary modalities.
  • Much of the efficacy of complementary modalities may be due to the placebo response.
  • Placebo response rates may be as high as 60 - 70% when the patient believes in the treatment ordered, the practitioner believes in the treatment ordered, and the practitioner-patient relationship is characterized by trust.
    • These are the three elements of the placebo response, as per Dr. Herbert Benson.
    • Consider using the placebo effect as a therapeutic ally, as per Dr. Andrew Weil.
    • Remember that the history of medicine is the history of the placebo response.
  • Issues of a level playing field
    • A Congressional Office of Technology Assessment report in 1978 which indicated that only 10-20% of conventional medical practice was based on controlled studies (Office of Technology Assessment.  Assessing the Efficacy and Safety of Medical Technologies.  Washington, D.C.U.S. Govt. Printing Office; 1978).
    • In 1991, it was estimated that 15% of medical interventions were supported by solid scientific evidence (BMJ. 1991. 303. 798-799).
    • A 2003 study concluded that only about half of medical treatments are supported by evidence (Hardern RD et al. How evidence based are therapeutic decisions taken on a medical admissions unit? Emerg Med J. 2003. 20. 447-448).
    • Another 2003 paper concluded that a range of 11% to 70% of decisions in various medical specialties follow the rules of evidence-based medicine (Pelletier K. Focus Altern Complement Ther. 2003. 8. 3-6).
    • Recognize that even in "evidence-based medicine," most decision-making takes place in areas of scientific uncertainty.
  • Safety versus efficacy
    • From a societal standpoint, especially with regard to limited resources, we should probably require the strictest evidence of efficacy (i.e. large RCTs) for the treatments whether conventional or unconventional which can do the most harm.
    • Issues of a level playing field
      • A meta-analysis of 39 prospective studies in U.S. hospitals found that in 1994, 2,216,000 hospitalized patients had an adverse drug reaction, and 106,000 had fatal adverse drug reactions (JAMA. 1998. 279. 1200-1205).
      • There are 16,000 deaths and 100,000 hospitalizations in the U.S. each year from NSAID's (New Engl J Med. 1999. 340. 1888-1899). It is estimated that only 1 in 5 individuals who GI bleed from a NSAID have any warning symptoms.

 

Differences between acute and chronic disease

Acute

·       Practitioner primarily in charge

·       History is short and focused

·       Focus is on the physical body

·       Diagnosis is about WHAT is happening

·       Intervention tends to be single-focused; primarily pharmaceutical or surgical

Chronic

·       Patient primarily in charge

·       History is long and open-ended

·       Focus is on the body, mind, spirit, lifestyle, and environment

·       Diagnosis is about WHY it is happening

·       Intervention is holistic; patient involvement is vital

 

How does the ‘trajectory’ of CAM differ from that of conventional medicine?

  • Conventional medicine: T>P>E>S. Technical advances (basic research, clinical trials) usually precede political factors (support of the medical establishment), which usually precedes economic factors (determination of economic viability), which usually precedes social factors (public acceptance).
  • CAM: S>E>P>T. Social factors (popular demand) in combination with economic factors (affordability) usually precede political factors (political support) which usually precedes technical factors (clinical trials).

 

Historical Landmarks in the history of integrative medicine

·       1990 – Dr Dean Ornish publication showing a lower rate of revascularization surgery in patients randomized to a comprehensive lifestyle intervention.

·       1993 – Dr David Eisenberg publication on popularity of unconventional medicine.

·       1997 – NIH Consensus conference report on efficacy of acupuncture

·       1998 – JAMA theme issue on CAM

·       2000 – White House Commission on CAM

 

What is the current status of integrative medicine?

  • OAM (Office of Alternative Medicine) at the NIH.
    • Created in 1992 by Congressional mandate (Senator Harkin’s bill, passed by Congress 11/22/91).
    • Budget of 2.2 million dollars in 1992/3, budget of 3.5 million dollars in 1994, 5.4 million dollars in 1995, 7.4 million dollars in 1996, 12 million dollars in 1997, and 20 million dollars for 1998.
    • Initially in 1993 funded 30 pilot proposals – response to request for proposals was largest in the history of NIH, with over 6000 requests for applications, 800 letters of intent, and 452 applications.
    • Expanded research base by funding 10 exploratory centers in 1995.
    • Status changed to a Center within the NIH in 1998, entitled National Center for Complementary and Alternative Medicine, and budget increased to 50 million dollars for 1999. 
    • Budget 68.7 million dollars in 2000, 123 million dollars in 2005, 121.6 million dollars in 2008, 132 million dollars in 2011
    • Collaborative research funded in part by other Centers within the NIH. In 2008, CAM research at more than 260 institutions supported by NCCAM funding.
    • Since 1999, NCCAM continues to add Research Centers, and these are now categorized as either Centers for Excellence for Research on CAM or Developmental Centers for Research on CAM.  The current list of centers (2/09) is:


1.  Bastyr University - HIV/AIDS
2.  Columbia University - Women's health issues
3.  Harvard Medical School - General medical conditions
4.  Kessler Institute for Rehabilitation - Stroke and neurologic conditions
5.  Palmer Center for Chiropractic Research - Chiropractic
6.  Stanford University - Aging
7.  University of Arizona - Pediatric conditions
8.  University of California, Davis - Asthma, allergy, and immunology
9.  University of Maryland - Pain/Arthritis
10. University of Michigan - Cardiovascular disease
11. University of Minnesota - Addiction
12. University of Texas - Cancer
13. University of Virginia - Pain
14. Kaiser in Portland, OR - Craniofacial disorders
15. Oregon Health Sciences University - Neurological disorders
16. Maharishi University in Fairfield, IA - CV disease and aging in African Americans
17. Johns Hopkins University - Cancer
18. University of Pennsylvania - Cancer

19. Univ of Calif, San Francisco - Mindfulness-based stress reduction/HIV

20. Harvard -Alcohol and drug abuse

21. Univ of N Carolina, Chapel Hill - Asthma

22. Univ of Minnesota - Mushroom extracts and immune response

23. Oregon Health and Science Univ - Placebo effects

24. Univ of North Texas - Mechanisms of osteopathic manipulation

25. Purdue Univ - Health effects of polyphenols

26. Univ of Illinois - Botanical supplements and women’s health

27. Pennington - Botanicals and metabolic syndrome

28. Sloan-Kettering - Botanical immunomodulators

29. Wake Forest U - Botanical lipids

30. Univ of Maryland - Arthritis and Traditional Medicine

31. Mt Sinai - Chinese Herbal Therapy

32. Temple U - Mechanism Underlying Millimeter Wave Therapy

33. Univ Maryland - Functional Bowel Disorders in Chinese Medicine

34. Univ Missouri - Indigenous Phytotherapy Studies

35. Univ of Wisconsin - Center for the Neuroscience and Psychophysiology of Meditation

36. Montana State Univ - CAM as Countermeasures against Infectious and Inflammatory Disease

37. Univ of CA, San Fran - Metabolic and Immunologic Effects of Meditation

38. Univ of Chicago - Center for Herbal Research on Colorectal Cancer

o   Office of Dietary Supplements (ODS)

    • This office, which is within the NIH, was established as a result of the 1994 DSHEA legislation on dietary supplements.
    • ODS collaborates with multiple other NIH Institutes and Centers, including NCCAM.
    • The ODS budget has increased from $1 million in 1996 to $25 million in 2004.
    • The ODS IBIDS database currently contains over 690,000 unique scientific citations and abstracts.
    • The ODS exhibits at national meetings such as the Annual Session of the ACP.
  • Education
    • Courses in CAM were a requirement in approximately 90% of US medical schools in 2007-2008, compared with 30% in 2001-2002, according to the AAMC (NCCAM 11/09 newsletter)
    • In a study of 53 medical schools in 2000, 66% taught relaxation and meditation, 37% taught guided imagery, and 34% taught biofeedback (Acad Med. 2002. 77. 876-881).
    • NCCAM in 2000 offers grants of up to 1.5 million dollars per school for innovative programs which integrate complementary and alternative medicine into the medical school curriculum.
    • Quality CME programs for practicing physicians (Center for Mind Body Medicine, Scripps, and University of Arizona).
    • Summit on Integrative Medicine in 2009 led by Dr Ralph Snyderman.
    • Fellowships in Integrative Medicine (Sierpina VS and Dalen JE. The Future of Integrative Medicine. Am J Med. 2013. 126. 661-662).
      • University of Arizona two year residential fellowship started 1997 and transitioned in 2000 to a distance-learning Fellowship, with 1000 hours required. In 2013, more than 1000 MDs, DOs, NPs, and PAs have completed this fellowship.
      • In 2013, 13 medical schools offer fellowships in Integrative Medicine
      • 2013 – Georgetown U Masters Program – 1 year with a focus on research.
    • Integrative medicine in residencies – 200 hour curriculum is in place in 2013 in 30 family practice and 2 internal medicine residencies (Sierpina VS and Dalen JE. The Future of Integrative Medicine. Am J Med. 2013. 126. 661-662).
    • A Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) was formed in 2001, following initial meetings in 1999 and 2000.
      • The initial 8 members were Duke University, Harvard University, Stanford University, University of California at San Francisco, University of Arizona, University of Maryland, University of Massachusetts, and the University of Minnesota
      • The consortium has grown steadily, with 42 member medical schools as of 2009 (38 in US and 4 in Canada), 54 members as of 2012.
      • Initially 3 working groups (clinical care, education, and research), with a fourth working group (policy) added in 2005.
      • The mission is to help transform medicine and healthcare through rigorous scientific studies, new models of clinical care, and innovative educational programs that integrate biomedicine, the complexity of human beings, the intrinsic nature of healing and the rich diversity of therapeutic systems.
      • Consortium is funded primarily by the Bravewell Collaborative, an organization of philanthropists whose goad is transforming medicine. Philanthropists and foundations participating in the Bravewell Collaborative must pay $50,000 annual dues. In 2003, there were 16 foundations/philanthropists participating in Bravewell; this number decreased to 8 foundations/philanthropists at the end of 2007.
      • Consortium’s first research conference was held in 2006, with subsequent research conferences in 2009 and 2012.
      • In 2006, the Consortium decided to require annual dues from member medical schools, $2500/year. www.imconsortium.org.
    • An Academic Consortium for Complementary and Alternative Health Care (ACCHAC) was formed in 2004, following initial meetings dating back to May, 2000 (Integrative Medicine Leadership Summit)
      •  Principally represents leading educators in disciplines such as chiropractic, massage therapy, naturopathy, and Oriental medicine. Founding executive director is Pamela Snider, ND.
      • Consortium got started based on a philanthropic grant; in 2006 decided to require annual dues from member organizations, on a sliding scale ranging from $1000 to $5000.
    • Integrative Family Medicine Residency – in 2004 the Family Medicine RRC approved an experimental 4 year program at six institutions; several of the lead faculty are graduates of the University of Arizona fellowship program.
    • Duke University Medical School opened in January 2007 an Integrative Medicine Center in a free standing building.
    • Integrative Pediatrics (Explore. 2007. 3. 91-92)
      • Between 1997-2007, 17 academic medical centers created pediatric integrative medicine programs.
      • Integrative Pediatrics Council formed in 2004 – consists of individuals in leadership positions in pediatric integrative medicine in the U.S. and Canada, and offers an annual Pediatric Integrative Medicine Conference.
      • American Association of Pediatrics in 2005 established the Provisional Section on Complementary, Holistic, and Integrative Medicine.
    • Integrative Medicine in Residency – in 2008, family medicine residencies at 8 major medical centers have embraced a 250-hour integrative medicine training curriculum developed at the University of Arizona Center for Integrative Medicine, and aimed at developing core competencies in integrative medical practice. The program makes extensive use of online learning tools and web-based course work.
  • Hospitals
    • New York Beth Israel Medical Center in 2006 became the first general services hospital in the nation to add a formal department of integrative medicine. The first chair of the department is Woodson Merrell, MD. The department will coordinate diverse services, including acupuncture, Alexander technique, art therapy, healing touch, massage, meditation, music therapy, and reiki.
    • 40% of hospitals surveyed by the American Hospital Association in a 2007 national poll offered at least one CAM therapy (NCCAM 11/09 newsletter)
  • Peer reviewed journals and newsletters:
    • Alternative Medicine Review - quarterly
    • Alternative Therapies in Health and Medicine – every other month
    • Alternative and Complementary Therapies
    • Explore – every other month
    • HerbalGram – American Botanical Council
    • Integrative Cancer Therapies
    • Integrative Medicine - A Clinician's Journal – every other month
    • Journal of Orthomolecular Medicine – quarterly (since 1970)
    • Journal of the Society for Integrative Oncology
    • Seminars in Integrative Medicine – quarterly review journal
    • Seminars in Preventive and Alternative Medicine – quarterly
    • The Journal of Alternative and Complementary Medicine
    • The International Journal of Integrative Medicine

 

    • Alternative Medicine Alert – every month
  • Centers of excellence:
    • Center for Mind Body Medicine at Georgetown University (James Gordon, MD)
    • Mind Body Clinic at the New England Deaconess Hospital (Herbert Benson, MD)
    • Mindfulness Based Stress Reduction Program at the University of Massachusetts. Established in 1979 (Jon Kabat-Zinn, PhD)
    • Rosenthal Center at Columbia University (Fredi Kronenberg, PhD)
  • Textbooks
    • Essentials of Complementary and Alternative Medicine edited by Wayne Jonas and Jeffrey Levin. 1999. 584 pages.
    • Integrative Medicine edited by David Rakel MD. 2003. 793 pages. Second edition 2006.
    • Integrative Medicine: Principles for Practice edited by Benjamin Kligler MD and Roberta Lee MD. 2004. 184 pages.
    • Integrative Oncology: Principles and Practice by Taylor & Francis. 2006.
    • Nutritional Medicine.  Alan R Gaby. 2011.
    • Textbook of Functional Medicine edited by David Jones MD. 2005. 790 pages.
    • Textbook of Natural Medicine edited by Joseph Pizzorno ND and Michael Murray ND. 1993, 1999. 1620 pages (2nd edition).
    • The American College of Physicians (ACP) Evidence-Based Guide to Complementary and Alternative Medicine. Edited by BP Jacobs and K Gundling. 2009.
  • Other resources
    • Integrative Medicine Consortium (IMC) – a cooperative organization formed in 2006, composed of the American Association of Environmental Medicine (AAEM), American Association of Naturopathic Physicians (AANP), American College for Advancement in Medicine (ACAM), American Holistic Medical Association (AHMA), Institute for Functional Medicine (IFM), and International College for Integrative Medicine (ICIM).
    • Integrative Oncology – the Society for Integrative Oncology (SIO), an international organization of oncology professionals researching and integrating effective complementary therapies in cancer care, held its first international conference in 2004. President in 2005 is David S. Rosenthal, Professor of Medicine at Harvard Medical School and Medical Director of the Center for Integrative Therapies at the Dana-Farber Cancer Institute.
    • Bravewell Collaborative www.bravewell.org – includes a clinical network which is comprised of eight leading integrative medicine centers that are developing successful models of integrative medicine care and delivery.
    • Cochrane Collaboration CAM Field. As of issue 4, 2009, 396 reviews related to CAM categorized at www.cochrane.org/reviews/en/topics/22_reviews.html.
    • See also Appendix below.
  • Insurance - increasing health insurance coverage for complementary modalities of treatment (Oxford, Mutual of Omaha).
  • Public Health - natural medicine program established through the Public Health Service in King County (Seattle, WA and population 1.8 million)
    • Integrative medical clinics in which ND’s and MD’s work side by side, and patients get to choose who they see (if patient is uncertain, scheduler decides whether the initial appointment is with a MD or ND).
    • In 2008 the network consists of 7 integrative medical clinics (six include acupuncture, naturopathic medicine, and nutrition, seventh for now with just nutrition services), 4 dental clinics, and one school based center.
    • This program in the community health centers is administered by HealthPoint, a nonprofit entity.
  • Public Policy:
    • President Clinton in 2000 established a White House Commission on Complementary and Alternative Medicine Policy, which issued a report on legislative and administrative recommendations.
    • In 2003 the Policy Institute for Integrative Medicine was founded by Marc Micozzi, MD, PhD, in affiliation with Thomas Jefferson University, based on a grant from the Ira and Myrna Brind Foundation.  The mission of this Institute is the gathering, analysis, and presentation of best practices that can help policymakers, health professionals, and consumers re-shape the health care system.  Website for the institute is www.piimed.org
    • On 1/12/05 the IOM released a report on a study by an expert committee on many aspects of the use of CAM in the U.S. This study had been requested by NCCAM amongst others, to assist in developing research methods and setting priorities for evaluating CAM therapies.  Complementary and Alternative Medicine in the United States is available free at www.nap.edu/catalog/11182.html or at a charge by contacting 1-888-624-8373.
  • Publicity
    • Dr. Weil on the cover of Time - symbolic of increasing coverage of this topic by the press.
    • PBS 2 hour special 3/29/06 – The New Medicine, focusing on initiatives at leading academic integrative medicine centers.

 

What are the barriers to more widespread use and acceptance of Integrative Medicine?

  • Knowledge barrier - there is currently a "conspiracy of silence" between physicians who do not ask their patients about the use of complementary modalities of treatment and patients who are afraid to tell their physicians.
  • Cost barrier - due to lack of insurance coverage, much is available only to the wealthy.
  • Lack of research - most practitioners are clinicians, and not researchers. Research that does exist is often not in English, and cannot be found by a Medline search.
  • Lack of licensure for some complementary practitioners, such as naturopaths.
  • Health insurance reimbursement schedules for physicians which financially reward shorter visits.
  • Medicolegal system.
  • Biases:
    • Stereotype that practitioners are uneducated or physicians with "weak minds" who are simply out to "make a fortune."
    • Belief of safety in the status quo.
    • Confidence in high technology which exceeds the evidence for effectiveness (COTA study in 1978 which concluded that only 10-20% of conventional medicine practices are based on data derived from controlled clinical trials).

 

Four step approach to the evaluation of complementary modalities:

  • Is it safe?
  • Is there evidence for efficacy?
    • Prospective trials?
    • Retrospective trials?
    • Anecdotal evidence?
  • Is it expensive?
  • Is there a theoretic rationale for its use in a given situation?

       

Pneumonic: I ASK (inexpensive, available, safe, knowledge)

 

Evaluation guidelines as per Dr. Wayne Jonas:

  • Get a three part education:
    • Understand the concepts thoroughly.
    • Evaluate the data critically.
    • Experience the practice openly.
  • Do a two part look:
    • Scientific - strength/likelihood of attribution.
    • Pragmatic - benefit/magnitude of effect.
  • Take a SEC approach:
    • Systematic/explicit/comprehensive (SEC).
    • Use good methods of evaluation.
  • Define the detail, do not just label the system.
  • Distinguish under-evaluated from ineffective.

 

Physician responsibilities as per Dr. Wayne Jonas:

  • Protect:
    • Toxic therapies (i.e. megavitamins).
    • Ineffective therapies, especially if substituted for effective therapies.
  • Permit:
    • Safe, inexpensive therapies (i.e. homeopathy).
    • Chronic disease management.
  • Promote:
    • Safe and effective therapies (i.e. relaxation techniques for pain management).
    • Therapies for which the mechanism is understood (i.e. acupuncture for pain and endogenous opiates).
  • Partner:
    • Communicate with the patient.
    • Co-manage illness - provide input on the evidence.

 

The future:

  • Integrative Medicine as a river, ever changing.
  • The consumer is awash in the ocean amidst many islands of treatment modalities - practitioners must build bridges.
  • Centers for Integrative Medicine.

 

Appendix - web sites:

 


[Last Updated September 21, 2014] [Return to List of Topics]