Alternative Medicine and
the Conventional Practitioner

JAMA 1998 (Mar 4); 279 (9):708-709

By Wayne Jonas, MD,

Director, Office of Alternative Medicine,
National Institutes of Health

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Complementary and alternative medicine (CAM) represents that subset of practices that are not an integral part of the dominant health care system in the United States but are still used by patients to supplement their health care.[1] Surveys have operationally defined CAM as those practices used for the prevention and treatment of disease that are not taught widely in medical schools nor generally available in hospitals.[2]

Public and Professional Interest in CAM

One out of every 3 Americans consulted an alternative health care practitioner in 1990, constituting over 400 million visits. Over $13 billion was paid for these services, of which $10 billion was not reimbursed.[2] In Europe and Australia, regular use of CAM practices ranges from 20% to 70%.[3,4]

Substantial professional interest exists in CAM practices as well. Over 50% of conventional physicians in the United States use or refer patients for some CAM treatments, and most perceive them as having some efficacy.[5-7] Hospital systems, health maintenance organizations, and insurance companies are increasingly providing CAM services.[8] In addition, mainstream medical journals are beginning to call for research papers in complementary, alternative, unconventional, and integrative medicine.[9]

The Role of the Conventional Practitioner in CAM

Often patients will accept anecdotes or sophisticated marketing as sufficient grounds to try new therapies. The conventional practitioner can help patients incorporate more scientific evidence in their health care decisions. The following are directives physicians can adopt when discussing the use of CAM practices with their patients.[10]

Protecting patients from the risks of CAM—Given the extensive use of CAM services and the relative paucity of data concerning safety, patients may be putting themselves at risk by their use of these treatments.[11] Only fully competent and licensed practitioners can help patients avoid such inappropriate use.[12] Some CAM products contain powerful pharmacologic substances that can be toxic either alone or in combination with other medications.[13] Also, contamination and poor quality control are more likely with CAM products than with conventional drugs, especially when shipped from overseas.[14] Physicians can also ensure that patients do not abandon effective care and alert them to signs of possible fraud or danger.[15]

Permitting use of nonspecific therapies—Some therapeutic benefits of CAM may be attributed to nonspecific factors.[16,17] Basic science and clinical trials can separate general factors from those components that are specific, and unique to the therapy. Practitioners can combine both specific and nonspecific factors to achieve maximum benefit to the health of their patients.[18]

Promoting safe and effective CAM therapies—Accumulating evidence suggests that CAM practices are valuable for the treatment of disease.[19-21] Importantly, alternative products are often less expensive than conventional medications. For example, studies report that Hypericum (St John's wort) is not only as effective as conventional antidepressants in treating depression but can be obtained at one third the cost.[22] Physicians can search the published medical literature and evaluate the applicability of CAM for specific patients' problems.

Partnering with patients about CAM—More than 80% of those who used unconventional practices in 1990 combined these practices with conventional medicine.[23] Patients who use CAM do not harbor antiscientific or anticonventional medicine sentiments, nor do they represent a disproportionate number of the uneducated, poor, seriously ill, or neurotic.[24,25] Yet 70% of patients who use CAM practices do not tell their conventional practitioner about this use. The physician can fill this communication gap by asking patients about their CAM use and work with them to ensure that these therapies are used responsibly.[12]

Medical Students and Medical Education in CAM

Recognizing the increasing importance of CAM in modern health care, more than 80% of medical students would like further training in these areas.[26,27] Currently, over 40 medical schools in the United States offer introductory, elective courses in CAM and almost one third of family practice residencies provide some type of instruction about CAM practices.[28,29]

In June 1996, a panel of experts in medical and nursing education assessed the status of CAM education. The panel included deans and associate deans for curriculum and education from medical and nursing schools and representatives from the American Medical Association (AMA), American Academy of Family Practice (AAFP), Association of American Medical Colleges (AAMC), Federation of State Medical Boards, Pew Health Professions Commission, American Medical Student Association (AMSA), and other organizations. They made the following 3 recommendations regarding the future role of CAM in health sciences education.[30]

1. Medical and nursing education should include information about complementary practices.
   

2. Medical and nursing education about each complementary and alternative practice should include information about the discipline's philosophical paradigm, scientific foundation, educational preparation, practice, and evidence of safety and efficacy.
   

3. National centers of excellence should continue to be developed to foster collaboration among complementary practitioners, nurses, and physicians and to promote synergy among education, research, and clinical practice.

By "philosophical paradigm" the panel meant that students should learn about the different values and worldviews on health and disease that are to be found in a pluralistic society. Currently, organizations such as the AMA, AAFP, AAMC, and AMSA are discussing strategies for addressing medical education needs in CAM.

CAM Research at the National Institutes of Health (NIH)

The NIH currently invests about $40 million per year in CAM-related research. To address the need for research in complementary, alternative, and unconventional medical practices, Congress created the Office of Alternative Medicine (OAM) at the NIH in 1992. The OAM works with NIH institutes and centers to identify and support CAM research applications and develops new programs in selected CAM-related areas. It supports 11 centers conducting over 50 projects on CAM research at universities around the country. The OAM also maintains an organized bibliographic database of over 90 000 citations. Selections from this database on safety and clinical conditions will soon be available on the OAM web site. An OAM supported public information clearinghouse responds to 2000 inquiries each month.

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Conclusions

As the importance of CAM continues to grow, physicians will be increasingly expected to address issues related to these practices. Physicians cannot become knowledgeable about all CAM practices, but they can apply the principles of evidence-based medicine, as in any area of health care.[31] The OAM can serve as a resource to physicians in their effort to provide safe, effective, and appropriate health care for the American public.

The OAM Supports the Following 11 Centers for Research in CAM Focus Location Cancer University of Texas Health Science Center Women's health Columbia University College of Physicians and Surgeons Stroke and neurorehabilitation Kessler Institute for Rehabilitation HIV and AIDS Bastyr University Pain University of Virginia School of Nursing, University of Maryland School of Medicine Aging Stanford University Addictions Minneapolis Medical Research Center Internal medicine Beth Israel Hospital, Harvard Medical School Asthma and allergy University of California, Davis Chiropractic Palmer College of Chiropractic

For information about CAM research at the NIH, contact the public information clearinghouse at (888) 644-6226 or the OAM Web site at www.altmed.od.nih.gov. For grant information call the OAM at (301) 435-5024; grant applications can be obtained from the Grants Information Office at (301) 435-0714 or by e-mail at asknih@odrockml.od.nih.gov.

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14.   Bensoussan A, Myers SP. Towards a Safer Choice. Victoria, Australia: University of Western Sydney Macarthur; 1996.

15.   Barrett S. The public needs protection from so-called "alternatives." Internist. 1994;9:10-11.

16.   Roberts AH, Kewman DG, Mercier L, Hovell M. The power of nonspecific effects in healing: implications for psychological and biological treatments. Clin Psychol Rev. 1993;13:375-391.

17.   Thomas KB. The placebo in general practice. Lancet. 1994;344:1066-1067.

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31.   Rosenberg W, Donald A. Evidence based medicine: an approach to clinical problem-solving. BMJ. 1995;310:1122-1126

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