The New American Medicine II:
A Meeting of Mindsets
By Michael Mannion
There are many barriers facing the New American Medicine. Political issues must be solved at the national, state and local levels. Powerful economic forces have conflicting interests and it will not be easy to resolve things to the benefit of all. Within a wide range of health institutions, the egos, reputations and financial interests of many influential individuals will also present themselves as hurdles to be leaped. These barriers are not insurmountable but they are significant.
However, the biggest obstacle in the way of the successful integration of conventional and complementary medicine in the United States involves our present-day mindset, that is, our stereotypical uncritical way of thinking, our basic assumptions. This is as true for the proponents of complementary care as it is for the advocates of conventional medicine.
The Conventional Medical Mindset
At present, across the nation, a dialogue has begun. However, while people in the healing professions may be listening to one another, it is not clear yet that they are hearing and understanding one another. There is now a collegial meeting of closed minds.
The assumptions that people make in every culture are not usually thought about consciously, except by philosophers. In the United States, it is our assumption that the rights of the individual are paramount. We do not question this belief; many consider it "self-evident." In other cultures, it is equally "self-evident" that the rights of the group--the family, the state, the religion--supersede individual needs and rights. So it is with our assumptions about health and healing.
In the United States, the mechanistic, reductionistic mindset prevails in medicine. This scientific approach can point to major successes in the diagnosis and treatment of disease. Its contributions to acute care problems, through surgery and some drugs, have unquestionably improved life for millions. However, chronic health problems, and emotional, mental or psychosocial problems, are another matter. The record of mechanistic medicine falls short of its desires and goals in these areas.
The dominant assumptions in a culture are not considered beliefs. They are felt to be factual truths. Other cultures "believe in" things; we "know" or "understand" things objectively. Or think that we do! Yet, many of the most common attitudes toward medicine held by Americans actually are beliefs. For example, Americans believe in drug therapy. Most people do not know what a drug is; how it is made; or how it works. But they believe that chemicals can cure. This "pill for every ill" mentality is widespread in the United States. Watch primetime television some evening and count the number of commercials for prescription and over-the-counter drugs. These ads exploit and reinforce the prevailing belief in the curative power of chemicals.
Few Americans know that there are over 330,000 drugs on the market today. About 300,000 are over-the-counter products and the rest are prescription products. Yet physicians generally agree that 95 percent of health problems amenable to treatment with pharmaceuticals can be handled by about two dozen drugs. The deep-seated belief in the power of these pills spurs on manufacturers to create products that may not benefit a person's health but that certainly benefit a company's bottom line.
In medicine, the mechanistic, reductionistic mindset focuses on the structure, exploring ever-smaller, ever-finer details. This has led to great advances in surgery in particular. Drug treatment also has produced a few major accomplishments but, overall, has more of a mixed record. The technology associated with these techniques has had the unfortunate effect of distancing physicians and medical technologists from their patients. And patients feel this.
A number of years ago, a friend asked me to accompany her for an ultrasound procedure. A lump had been discovered in her breast. The HMO informed her of the growth and then made her wait over a month for an appointment. Her fear of possible breast cancer increased over that interval. At the clinic, all attention was focused on the ultrasound equipment and the image of the breast on the monitor. For all practical purposes, the patient did not exist. As I held her hand and made reassuring eye contact, the physician, nurse and medical technologist all stood with their backs to her, focused on the machinery.
The good news for my friend was that the growth was a benign cyst filled with fluid. The bad news for all involved is that this example is but a small symbol of what has gone wrong with mechanistic medicine at the very time that it is also accomplishing much.
One of the main reasons patients are turning toward complementary care is that, in general, complementary practitioners see them and treat them as human beings. An emotional connection is made that is rarely possible today in conventional medicine. This lost emotional connection between allopaths and their patients is evident in sentimental Norman Rockwell paintings, and in nostalgic reminiscences about the family doctor who made house-calls in the halcyon days of fee-for-service medicine. But the emotional patient physician bond is almost universally lacking today in conventional medicine.
Ironically, most primary care physicians know-and studies support their experience-that about 60 percent of patients who come to their offices have no organic health problems. They have emotional problems caused by difficulties in the marriage or at work, or by worries about their children. And they need someone they trust to talk to, someone who will listen to them. So they turn to the "regular" doctor-who no longer can afford to spend the necessary time with them
The Complementary Care Mindset
The mindset of the complementary care practitioner is completely different from that of the conventional physician, although their goals are the same. In general, the complementary practitioner does not focus solely on the physical complaints the patient voices or their physical signs and symptoms. The emphasis is on understanding the person in the context of his or her whole life. It is easy to see how attractive this can be in an era of depersonalized medical care.
Herbal medicine offers itself as an instructive example illustrating these two mindsets at work. There has been an astounding 380 percent rise in the use of herbal remedies in the United States since 1990. The overall supplement industry in the U.S. exceeded $13 billion in sales in 1997 and is growing at a rate of 20 percent annually. Botanicals, as herbal products are more correctly called, now have annual retail sales of over $4 billion, up from less than $1 billion in 1991. The AMA has urged its members to become knowledgeable about herbal remedies and other natural products. In fact, there is now a Physician's Desk Reference (PDR) for herbal medicine offered by the publishers of the standard pharmaceutical PDR.
Who uses herbal remedies? Surveys show that 66 percent of the customers for herbal remedies are married women about 40 years old. These women are college-educated and have a household income of over $50,000. In addition, these customers buy products for others in the household as well as for themselves. It is estimated that about 37 percent of Americans use supplements; seven percent are heavy users. Asian and Hispanic immigrants, who follow their traditional medical practices, are also frequent users of herbal remedies.
People using botanicals are motivated to do so by a desire to live healthier lives. Most Americans realize they will live longer lives than their parents and grandparents and they want to live better lives. More and more people are taking responsibility for their own health care and this increases interest in herbal remedies. Baby Boomers and "Gen Xers" are leading this self-care revolution. Americans are not abandoning conventional medicine. They are seeking to integrate the best of both worlds in their health care.
Products whose names most Americans would have been unable to pronounce a few years ago-such as Ginkgo Biloba or Echinacea-now line the shelves of supermarkets and drug stores, as well as health food stores. These products are also sold by marketers such as Amway, through mail-order catalogs and on the Internet. Herbal remedies now fill many household medicine chests. The giants of the pharmaceutical industry are now getting in the act and are introducing herbal products. Numerous clinical trials of herbal remedies are underway nationwide, many at prestigious traditional medical schools such as Columbia, Harvard, Stanford and Emory.
Where Mindsets Overlap: Botanicals and Pharmaceuticals
In the field of herbology, the two mindsets overlap or intersect. The mechanistic, reductionist mind can analyze these botanical products and look for the chemical active ingredients that they believe make the remedy effective. Herbs seem to fit in with the basic assumptions about health and healing of the mechanistic mindset.
A complementary practitioner can look at the same botanical remedies and not focus attention on the chemical constituents at all. Rather, the complementary practitioner may be more interested in the chi or energy in the botanical remedy.
For the patient, there may not seem to be much difference-save for costs and adverse side effects-in taking a "natural" pill like St. John's Wort instead of a prescription antidepressant. For many, an herbal remedy still fits the "pill for every ill" mindset.
In the last few years, herbal remedies have arisen from the status of fringe "health-nut" quackery to near-complete acceptance by the American public and mainstream medicine. Capsules, tablets, tinctures and teas abound. Even "junk food" products such as potato chips and sugary fruit drinks now contain herbal constituents. Various bottled water products containing minimal levels of vitamins, antioxidants or botanicals are now sold as "nutraceuticals."
Those who have long distrusted conventional medicine and the drug industry embraced herbal remedies decades ago. Now the public at large is joining them. But are profit-oriented, market-driven companies actually offering the public useful products? In many cases, the answer is no. They are merely exploiting the increased interest in natural products and remedies.
Because the herbal products are now classified as dietary supplements, they are not subject to governmental regulations concerning safety and efficacy. Neither are there manufacturing standards in effect to insure that products are of high quality. Some studies have shown that up to two-thirds of herbal products do not contain any amount of the herb purported to be in the bottle. Another large segment of products contain the herb listed on the label, but not in an amount that will produce a beneficial health effect.
Varro E. Tyler, PhD, considered by many to be the leading independent authority on herbal medicine in the United States, believes that consumers have no way at present of knowing which products are safe, effective or even contain the active ingredient in question. The industry is now taking steps its first small steps to correct this problem. For example, Next Pharmaceuticals, a company in Southern California, is promoting what they call "Certified Nextracts," that is, the company's seal of approval that a product is safe and effective. Other industry associations and putting forward a number of methods that will help assure consumers that herbal products are reliable. It remains to be seen if this approach will succeed.
The explosion of interest in herbal remedies has been so great that the very existence of the natural plants used to make them—Echinacea and goldenseal, for example—is threatened. These and other plants are becoming scarcer as demand increases. As a result of this scarcity, many products are in danger of becoming adulterated. The New York Times reported that Peggy Brevoort, the president of East Earth Herb, Inc. in Eugene, Oregon, said that the demand for St. John's Wort and kava exceeds their supply. Ms. Brevoort feared that unscrupulous dealers may sell adulterated products.
Most of the contradictions of American medicine are present in the expanding field of herbal medicine. Patients want to turn to medical authorities for reliable health information. But few physicians have taken any courses in herbology or botanical medicine. Most American doctors are wary of botanicals and concerned when patients begin to use them to self-medicate. Complicating the picture is the fact that patients are afraid to talk to their doctors about their use of herbal remedies. Many fear they will be met with ridicule.
Clearly, there is a clash of mindsets between the public and physicians, and between conventional doctors and other health practitioners, here and abroad, who are knowledgeable about the benefits of botanicals when used correctly. A lack of education on the part of both conventional physicians and their patients is at the core of this problem.
Some medical schools and schools of pharmacology are now offering courses of study in botanicals. This field is called phytomedicine. The American Pharmaceutical Association has even added a two-day program on herbal medicine to the schedule of its annual meeting. Two new books — Physicians' Desk Reference for Herbal Medicines and the English-edition of The Complete German Commission E Monographs are now available. These are extremely valuable resources for physicians, pharmacists and consumers.
The information in both books is based mostly on studies conducted in Germany, covering about 600 botanicals now available in the United States. Information about the proper use of botanicals, correct dosages and safety issues is available. These books, and other useful publications, such as Tyler's Herbs of Choice by Dr. Varro E. Tyler and James E. Robbers and Tyler's Honest Herbal by Dr. Varro E. Tyler and Steven Foster, can do much to educate professionals and the public. However, the problem of changing mindsets requires more than information.
Consumers may often be overly naive when it comes to herbal remedies, putting too much faith in unknown manufacturers and in words such as "organic," "natural" or "standardized." Many consumers believe that natural equals good, safe, without side effects. This is not necessarily so. Many physicians seize on this prevalent attitude in their patients, and on the scores of books that make extravagant and undocumented claims for natural remedies, to dismiss their value entirely. Other physicians are concerned about problems that can result from the misuse or overuse of botanicals or the adverse reactions that can result from the interactions of herbs and prescription drugs. These are valid concerns and could be easily managed if there were better communication between doctors and patients.
If patients are frequently too naive and over-enthusiastic in their attitudes toward herbal remedies, physicians are frequently too quick to dismiss their value and unable or unwilling to take the time to learn more about the subject. Although 25 percent of prescription drugs, and hundreds of over-the-counter drugs, are derived from plants, many physicians have a prejudice in favor of synthetic drugs.
Ephedra was formerly available in a number of over-the-counter weight-loss products and as a decongestant. It was in herbal remedies as well. Its misuse is equally dangerous in both forms, especially when taken as a diet aid or stimulant. And both forms of ephedra can be harmful to people with underlying health problems. The clash of mindsets was evident in the late 1990s in the press reports on the misuse of products containing ephedra, which highlighted herbal formulations, not the synthetic over-the-counter products.
Physicians often say they need scientific studies of botanicals to prove to them the value of these remedies and claim that these studies are not available. The Federal government supports research for synthetic drugs but recently, even though a presidential commission recommended that the FDA appoint a committee to evaluate the safety and efficacy of herbal products, the agency declined, claiming it lacked the funds to do so.
There have been only a few studies of popular botanicals by American physicians that are considered well-designed. One study showed that saw palmetto is useful in shrinking an enlarged prostate. Another study showed that ginkgo biloba improved the memory of early Alzheimer's patients. At the National Institutes of Health, the Office of Dietary Supplements is financing part of a three-year, multicenter study of St. John's Wort for depression, as well as a study of the effectiveness of plant-based estrogen for postmenopausal health problems.
Although there are few American studies acceptable to the biomedical mindset, this is not the case at all in Germany and other European nations, where thousands of valid studies of botanicals have been completed and published to wide acceptance. The evidence gathered overseas indicates that well over 200 botanical products have an important role to play in promoting health. Germany's Commission E approved 254 of 380 botanicals it studied, finding them safe and effective.
Pharmaceutical companies recognize the value of these botanicals, even if American doctors remain over-cautious and the American public over-enthusiastic. By the late 1990s, the FDA had received over four dozen applications by drug companies to study botanicals as investigational new drugs. If these studies progress, and if any of the drug companies show that the botanicals are safe and effective, the FDA would approve them as drugs and allow health claims to be made for them-claims that cannot be made for the same products when sold as dietary supplements.
Mindsets in the Media
Safety fears about herbal medicines, although valid in certain instances, also reveal the double-standard of the conventional medical mindset. The New York Times regularly features news reports about adverse reactions to herbal and other natural products. In some ways, the newspaper exaggerates the reports. In contrast, news stories about serious adverse reactions to prescription drugs and deaths from FDA-approved pharmaceuticals are almost always downplayed. The medical value of drug treatment overall is always stressed in the news pieces as a counterbalance against the negative impact of information about the death and disability caused by FDA-approved prescription drugs.
In a large article on herbal medicine, The Times noted that ephedra, "in its herbal form, has been responsible for serious adverse reactions and dozens of deaths, mainly among people who inappropriately used it as a stimulant or diet aid." In articles by its medical and science writers, The New York Times has a negative tone about herbal medicine in particular and complementary health care in general.
This is in glaring contrast to its reporting on pharmaceuticals, which in general is quite positive and supportive. In April 1998, the Journal of the American Medical Association published a paper in which researchers reported that adverse reactions to prescription drugs are killing about 106,000 Americans each year, making prescription drugs the fourth leading killer in the U.S., after heart disease, cancer and stroke. The researchers only included the deaths of hospitalized patients caused by drugs that were properly administered under normal circumstances. Of the people who were killed, 43,000 or 41 percent were in the hospital because of an adverse drug reaction in the first place. Every year since, well over 100,000 people die in American hospitals from prescription drugs properly administered. Imagine the level of media outcry if it were botanical medicines causing such great harm
According to an article in The New England Journal of Medicine in December 1998, "it is simply not possible to identify all the adverse effects of drugs before they are marketed." An article in the Journal of the American Medical Association in 1998 observed that "51 percent of approved drugs have serious side effects not detected prior to approval." Neither the government nor the drug companies systematically collect information on adverse reactions to new drugs.
The 106,000 deaths a year from properly administered drugs to hospitalized patients does not include the prescription drug-induced deaths of people outside of hospitals, or the deaths of people caused by adverse but unsuspected prescription drug-drug interactions. The number of deaths caused by prescription drugs among hospitalized patients each year is the equivalent of five jumbo jets with 400 people aboard crashing every week, 52 weeks a year.
Compare and contrast these figures for FDA-approved drugs used properly with the mortality figures for the 70 million Americans who are using all kinds of unregulated natural products in an uncontrolled manner. Apparently, the highly regulated pharmaceutical products are a far greater danger to public health. Yet, the medical profession and some of the larger media outlets are much more concerned over the hazards of botanicals.
This situation clearly illustrates the impact that a mindset, a collection of unthinking assumptions and unquestioned values, has on the evaluation of the forms of treatment that are widely used in medical practice today. This comparison is not made to put forth a naive "good natural remedy, bad synthetic drug" argument. These facts are presented to show how even such startling information as this does not shake deeply held beliefs.
Once again, in the area of herbal medicine, we see all the contradictions present in American health care. Patients want to turn to their physicians for advice about herbal remedies but fear ridicule. Physicians are wary of patient self-medication with botanicals but are not themselves educated on the subject. Neither are they generally aware of the body of scientific evidence that supports the health-promoting effects of herbal remedies. Government regulations and bureaucracies work at cross-purposes. Business interests pursue profits, not health, sometimes ethically, other times unscrupulously. Complementary practitioners try to maintain their integrity and advance their causes, all the while trying to find a place in the confusion of the health care marketplace.
The integration of the biomedical model and the complementary model of health is increasingly desired. Yet the path to that end is filled with pitfalls. However, many hard-working, honest men and women on both sides of the issue see the need for a New American Medicine and, despite disagreements and varying points of view, are struggling to create a new way of healing.
The great popularity of botanicals has forced the medical establishment to face the issue head on. Once again, the change has been patient-driven. Although the situation is still in flux, it indicates what obstacles lie in the way of the integration of conventional and complementary medicine for the benefit of all.
Complementary or Integrative Practices
What does the situation look like today beyond a focus on herbal medicine? Americans are visiting over 500,000 complementary practitioners who offer a broad range of services in up to 200 different types of therapy. However, about 60 complementary approaches count for the majority of health services. They emphasize preventive medicine and treating the whole person, in contrast to the disease-oriented approach of conventional care.
Some forms of complementary care-such as chiropractic, acupuncture, and massage-are becoming more widely accepted. Other approaches, such as psychic healing, remain on the fringe. Overall, the complementary field is growing to meet the consumer demand. The U.S. Department of Labor has reported that chiropractic is one of the fastest-growing occupations in the country. The American Colon Therapy Association reported a 50 percent jump in membership recently. Five hundred new acupuncturists enter the market each year in the United States.
The most widely practiced complementary therapy in the U.S. is chiropractic. There are over 65,000 licensed chiropractors, according to the American Chiropractic Association. They generate over $8 billion a year in revenue, with an more than $200 million also coming in sales of supplements and herbal remedies in chiropractors' offices.
The second largest discipline is Traditional Chinese Medicine, which is comprised of acupuncture, cupping, moxibustion, Chinese herbology, and physical techniques such as Qi Gong and Tai Chi. It is estimated by the American Association of Acupuncture and Oriental Medicine that there are 10,000 acupuncturists in the U.S.; 1,000 of them are physicians. Between 5-8,000 of the acupuncturists are licensed. Licensure is granted in only 16 states. In 1996, acupuncture needles were classified as "medical devices" in the U.S., paving the way for medical coverage of treatment.
There are about 1 million massage therapists practicing in the U.S.; 150-200,000 are certified in some fashion. Practitioners of various schools of massage, walk-up massage stands in malls or parks, sports massage and other legitimate services generate about $6 billion a year in revenue.
In 1970, there were around 300 homeopaths practicing in the United States. Today, that number has risen to 3,500. About 500 homeopaths are also MDs. For one-third of these practitioners, homeopathy is their primary discipline. Nurses, naturopaths, acupuncturists and lay practitioners also use homeopathy to treat patients. Some estimate the market for homeopathic services at over $200 million yearly.
Naturopathy is licensed in 11 states and there are about 2,500 licensed practitioners in the U.S,, who generate about $200 million in business each year. Aromatherapists, Ayurvedic physicians, herbologists and many other types of practitioners are flourishing as never before.
Nearly 800,000 allopathic physicians and osteopaths practice in the United States today. About 20 percent of these physicians use some form of complementary medicine in their practice. Most of the 160,000 practitioners in this category are in family practice or osteopathy. Some specialists-allergists, gynecologists, dermatologists, and gastrointestinal physicians-are involved in complementary care. Physician membership in complementary medical associations has risen 30 percent in the past few years. There is good evidence suggesting that the number of doctors prescribing botanicals and other natural products is rising rapidly.
A study of physicians' attitudes toward and practice of complementary medicine was published in November 1998 in the journal Alternative Therapies. The researchers interviewed primary care physicians and specialists at a mid-western teaching hospital. The results suggest that an alliance between mainstream medicine and complementary disciplines is possible now. Even the changes in language suggest that this is so: "alternative" has yielded to "complementary" and "integrative," indicating that an adversarial approach is yielding to a collaborative approach. The physicians' responses indicated that:
- about 65% agreed that a number of complementary therapies hold promise
- approximately 60% believed physicians should know about the most prominent complementary systems
- over 52% had referred a patient to a complementary practitioner
- nearly 50% said they would refer a patient to a complementary practitioner in the future
- approximately 30% of physicians initiated discussions about the benefits of complementary medicine with their patients
- nearly 50% believed that complementary therapies offered moderate to extreme benefits for their patients
- just over 77% felt that the integration of complementary therapies into conventional practice would increase patient satisfaction
- over 40% believed complementary medicine would have a positive impact on their careers
- more than 25% had attended lectures on or received training in at least one form of complementary medicine
The Times They Are A'Changing
This change in American medicine suddenly is swift and startling. In 1990, the AMA prohibited physicians from referring patients to what it called "unscientific practitioners." In 1995, the AMA amended its position and recommended that its members become "better informed regarding the practices and techniques of alternative or unconventional medicine." In 1998, the Journal of the American Medical Association devoted an entire issue to the topic of alternative medicine. One of the AMA's other publications, the Archives of Internal Medicine, also focused on complementary care. Today, many hospitals staffed with AMA-style physicians have complementary or integrative health care clinics.
Individual physicians are being forced by their patients to educate themselves about a variety of complementary therapies and many are beginning to incorporate them into their practices. Many of the nation's most prestigious medical facilities are opening complementary care clinics-Harvard, Stanford, New York — Presbyterian Hospital, and California — Pacific Medical Center in San Francisco.
Eisenberg's Studies: A Wake-Up Call to American Medicine
Dr. David M. Eisenberg, of the Center for Alternative Medicine Research and Education, Department of Medicine, Beth Israel Deaconess Medical Center in Boston, published an article in The New England Journal of Medicine in 1993 that sounded a rude and alarming wake-up call to the medical establishment in America. In a way, it was Eisenberg's report that caused the rapid move toward incorporating complementary care into conventional medicine.
His data indicated that one of three Americans was using an unconventional or complementary therapy and that 70 percent of these individuals were not telling their physicians about it. Eisenberg and his colleagues reported that Americans made about 425 million visits to complementary care providers at a cost of $13.7 billion-three-fourths of which was paid out-of-pocket. Dr. Eisenberg has used the term "invisible mainstream" to describe the complementary care culture in America. A later survey in the Archives of Family Medicine found that about 50% of Americans were using complementary therapies, mainly chiropractic, massage therapy, herbal medicine, megavitamins and meditation.
In 1998, in a follow-up study, published in the Journal of the American Medical Association, Dr. Eisenberg found that alternative medicine use increased substantially between 1990 and 1997. The report concluded that this was due to an increase in the number of people seeking complementary care; it was not the result of increased visits per patient. Eisenberg and colleagues reported that the growing U.S. interest in complementary medicine was part of a worldwide trend in most of the industrial nations.
Studies conducted in Denmark, Finland, the United Kingdom, Australia and Canada all showed that alternative medicine was popular in those countries as well. A 1995 study in Canada indicated that 15 percent of Canadians had used alternative medicine within the previous 12 months; 49 percent of Australians had done so. The figures were 10 percent in Denmark and 33 percent in Finland. Differing definitions of what was an alternative therapy were believed to account for the wide range of use reported.
Eisenberg reported that the use of complementary therapies was not confined to a narrow segment of society. Overall use by Americans ranged from 32 percent to 54 percent. Women used alternative treatments more than men, 48.9 percent to 38.7 percent. Use was less common among African-Americans at 33.1 percent. Just over 50 percent of people aged 35-49 used complementary therapies, compared with 39.1 percent of people over 49 and 41.8 percent of people under 35 years of age. People with incomes over $50,000 a year were more likely to use complementary therapies than those with lower incomes and Americans living in the West used complementary therapies more frequently than elsewhere in the U.S.
What Alternatives Do Americans Use?
This important report investigated the use of the following 16 types of therapies: relaxation techniques; herbal medicine; massage; chiropractic; spiritual healing by others; megavitamins; self-help groups; imagery; commercial diet; folk remedies; lifestyle diet; energy healing; homeopathy; hypnosis; biofeedback; and acupuncture. The researchers found a 47.3 percent increase in total visits to the above practitioners between 1990 and 1997. The increase was mostly in visits for relaxation therapy, massage, chiropractic, self-help and energy healing.
An increased number of Americans turned to complementary therapies for help with neck and back problems, allergies, arthritis, and digestive problems between 1990 and 1997. However, there was an increase in the use of alternative treatments across the board, and a significant rise in the number of people who saw a conventional physician and a complementary practitioner. In 1990, 33 percent of Americans used alternative therapies. By 1997, that figure had jumped to 40 percent, according to the Eisenberg study. Other researchers put the figure even higher. For adults aged 35-49, estimates are that at least 50 percent used at least one alternative therapy. The number keeps rising.
Interestingly, when Eisenberg arranged the 16 therapies studied in a spectrum of "more alternative" and "less alternative," as compared with conventional medicine, he found that visits to the "more conventional" complementary providers (e.g., biofeedback, hypnosis, guided imagery, relaxation techniques, lifestyle diet and vitamin therapy) accounted for less than 10 percent of all visits to complementary practitioners. Over 90 percent of visits were to the "more alternative" practitioners.
The data compiled on the use of herbal remedies and vitamins caused the researchers to sound a note of alarm. The 380 percent rise in the use of herbal remedies, and 130 percent increase in the use of vitamins, is putting an estimated 15 million Americans at risk for potential adverse reactions with the prescription drugs they are taking. Since about 70 percent of those using alternative therapies do not discuss this with their physicians, there is serious cause for concern. Nearly three million adults 65 and older are particularly at risk because this group takes more medications and more combinations of medications that younger age groups.
The intensity of interest among Americans for complementary care is demonstrated by their willingness to pay for these therapies out-of-pocket. Eisenberg noted that few insurers cover complementary care and those plans that do come with high deductibles and co-payments.
Significantly, 58 percent of the use of complementary care was found to be for preventing illness or maintaining health and vitality. This focus on health promotion is an essential element of the complementary mindset, as opposed to the conventional medical mindset which focuses on treating disease. The use of complementary care in a preventive manner also highlights a basic principle of complementary medicine-taking responsibility for one's own health.
Based on their finding, Eisenberg and colleagues concluded that federal agencies, private corporations, foundations and academic institutions should become more "proactive" about fostering the integration of complementary medicine with conventional care.
Mainstream Response to the Growing Complementary/Integrative Movement
The entire medical establishment began to respond, even if it didn't know precisely what to do. Once they became aware of the huge sums of money involved, physicians, pharmacists and nurses; medical associations and professional organizations; insurance companies and HMOs-all recognized that they had to act in the face of the patient-driven alternative revolution.
The American Pharmacy Association passed a resolution urging its members to learn about alternative medicine, as the AMA had done earlier. Insurers, HMOs and other managed care businesses jumped on the complementary care bandwagon, more for financial reasons than medical ones. According to New Age Journal, 39 companies now offer health coverage for complementary medicine. In 1997, the American Association of Health Plans held its first presentation on integrating complementary care and conventional medicine. The third-party payer bean counters are interested in seeing if complementary care provides a more cost-effective approach to chronic conditions (e.g., arthritis, back pain) than conventional care. In some instances, complementary therapies are less expensive. For example, the Utah Workers Compensation Board found that conventional care averaged $1665 per person, while chiropractic care cost only $775.
From OAM to NCCAM
The Office of Alternative Medicine (OAM) at the National Institutes of Health (NIH) was the first cautious political step toward the integration of complementary and conventional medicine. Its budget rose from a mere $2 million in its first year, to just over $11 million in 1997. Congress increased the status of the OAM by naming it the National Center for Complementary and Alternative Medicine (NCCAM), and increasing its budget to $50 million in 1999. Its budget has risen ever since. The Center is now able to fund its own research. As an Office, the OAM could only fund projects in collaboration with other institutes at NIH or outside agencies.
Mirroring the progress complementary medicine is making in American society, the NCCAM is embarking on new evidence-producing studies. The organization is funding 13 research centers at universities and other health institutions across the country. At present, 50 research projects are being conducted. The new Center has initiated a number of large clinical trials that will provide much needed opportunities to train researchers in alternative medicine. The Center's work will undoubtedly spur further research in the private sector.
In the beginning, the OAM met with hostility, indifference and an element of derision. The biomedical research community has changed dramatically since 1993. Conventional medical researchers are increasingly interested in alternative medicine today. More and more researchers are coming to understand that complementary therapies offer a rich and promising area of investigation.
The bulk of the Center's resources have gone to its national complementary research centers. It is in these institutions that the pilot studies and developmental work will be done that will, hopefully, lead to improved prevention and treatment for Americans. Each research center has a specific area of clinical focus. They are investigating the safety and effectiveness of complementary medical practices for addictions, aging, AIDS, asthma, cancer, cardiovascular disease, pediatric conditions, stroke and pain. Among the centers involved are:
- Bastyr University AIDS Research Center
- Center for Complementary and Alternative Medicine Research in Women's Health at Columbia University
- Center for Alternative Medicine Research at Harvard University
- Center for Research in Complementary and Alternative Medicine for Stroke and Neurological Disorders at the Kessler Institute for Rehabilitation
- Consortial Center for Chiropractic Research at the Palmer Center for Chiropractic Research
- Complementary and Alternative Medicine Program at Stanford University
- Program in Integrative Medicine at the University of Arizona Health Sciences Center
- Center for Alternative Medicine Research in Asthma and Immunology at the University of California, Davis
- Center for Alternative Medicine Pain Research and Evaluation at the University of Maryland School of Medicine
- University of Michigan Complementary and Alternative Research Center for Cardiovascular Diseases
- Center for Addiction and Alternative Medicine Research at the University of Minnesota Medical School
- University of Texas Center for Alternative Medicine (Cancer)
- University of Virginia Center for the Study of Complementary and Alternative Therapies (Pain)
These institutions were selected because their staffs have the skills needed to evaluate alternative medicine scientifically. A large, multi-center randomized controlled trial has been designed and applications for this trial are now being reviewed. A study of St. John's Wort to treat depression, run by the National Institute of Mental Health, is underway. A trial to test the usefulness of acupuncture to treat depression is planned, as is a study of a popular dietary supplement, glucosamine, for the treatment of arthritis.
Complementary Care and Cancer
The one condition about which the OAM receives the most questions is cancer. About 60 percent of public inquiries concern this disease. Today, nearly 50 percent of Americans with cancer will try some type of alternative therapy for their disease. The NCCAM is attempting to open up a dialogue between conventional cancer specialists and complementary care practitioners. In addition, it is working closely with the National Cancer Institute
Whether ground-breaking advances in research come directly from NCCAM-funded projects or not, the organization will most likely play a powerful role in helping change the dominant medical mindset and building a bridge between two medical communities, each working in its own way for the same goals.
In a similar vein, Dr. James S. Gordon is working to bring these two groups together. In June 1999, his Center for Mind-Body Medicine in Washington, DC held its second annual conference called "Comprehensive Cancer Care: Integrating Complementary and Alternative Therapies." These successful conference continue today and offer attendees—practitioners and patients alike—a look at the changing field of oncology in the U.S. and abroad.
The best people in complementary and conventional medicine are brought together to discuss such topics as guidelines for creating an integrated treatment plan; mind-body approaches to enhance immunity and prolong life; and the varieties of energy healing with potential in treating cancer. Other organizations, such as the Foundation for the Advancement of Innovation in Medicine (FAIM), are also working to create new models of health that include complementary therapies.
Choosing a "Regular" Doctor
The first step in health care for most individuals will be the choice of both a physician and a complementary health care provider. Most Americans, even those who see complementary medical practitioners, will still want a "regular" doctor to handle many medical problems. It is not as easy to choose a physician as it once was. Managed care has altered the situation and limited a patient's choices. However, there are some general recommendations that apply when looking for a primary care physician.
Don't wait until you are ill to look for a physician. The time to establish a relationship with a doctor is when you are well. Get a recommendation from family, friends or another physician . If that is not possible, a hospital referral service may be useful. Schedule an appointment for a consultation with the practitioner. Let him or her know the purpose of your visit. Don't be afraid to ask questions about the physician's education, experience, board certification, hours, fees, waiting time for appointments and waiting time at appointments. Ask about the physician's admitting privileges at local hospitals. Find out whether you will see this physician or others on the staff on subsequent office visits. Talk to the staff and see if they are helpful and courteous. If you feel the need, you can check a physician's board certification by calling 800-776-2378.
Look for a doctor who listens to you. One of the most frequent complaints that patients voice is that physicians do not listen to them and do not spend enough time with the. One of the most frustrating things that doctors face in their practices is a lack of time. Many managed care programs expect the doctors on their payrolls to spend no more than five to seven minutes with a patient. A physician literally may not have the time to listen to patients, even one who desires to do so.
Look for a doctor who is open-minded. This is particularly important for any patient who is interested in complementary medicine. Many older physicians are set in their ways and are not interested in learning about, never mind incorporating, "unconventional" medical approaches into their practices. Surveys show that doctors under the age of 40 are more open to complementary medicine than older physicians.
Look for a doctor who treats the whole person. Whether a practitioner is an "allopath" (a conventional doctor) or a complementary care provider, he or she needs to see you in the context of your whole life. Physicians need to be aware of a person's family life, job situation, emotional state, sexual behavior and living environment in order to treat the person and not merely the person's symptoms.
Look for a doctor whose goal is to keep you healthy. A primary care physician should be as knowledgeable about preventive medicine as he or she is about the treatment of illness.
Look for a doctor who will be your partner. Each person owes it to himself or her self to take charge of his or her life, including taking responsibility for staying healthy. A physician who fosters this way of being is a prerequisite for creating a healthy way of living. In an era when patients frequently are more knowledgeable about complementary therapies than their physicians, it is only to the benefit of both parties to partner up.
Choosing a Complementary Care Provider
The above suggestions for finding a suitable physician apply to complementary providers as well. However, complementary medicine presents some important differences. "The problem with alternative medicine," said Rudolph Ballentine, MD, author of Radical Healing, "is that there are many, many practitioners using many different methods. The fact that someone calls himself holistic or alternative doesn't tell you much about what he does. It tells you more about what he doesn't do."
In general, conventional physicians view health as the absence of disease. Complementary practitioners see health as the presence of wellness. These health providers see themselves as partners with their patients, as guides and teachers. (The word doctor comes from the Latin word "docere," which means "to teach.") They emphasize the responsibility of each patient for his or her own health. Complementary practitioners look at the lifestyle of the patient, the integration of the physical, nutritional, environmental, emotional and spiritual aspects of the life of that unique individual.
How does one find a good alternative practitioner? "You have got to do your homework, whether it's a conventional or unconventional practitioner," advised Dr. James S. Gordon. "The person coming for help has to be alert. Speak to a patient who has seen the practitioner. Go in and ask the practitioner questions about where he or she has studied. With an MD, you'll know the medical school. With an herbalist, there is often not a formal education program you can check up on. With acupuncture, there is licensure in many states. It all varies greatly."
Dr. Ballentine further suggested "You might try to find a person who has been successfully treated for a problem you have. Or you might try to find a modality that has been successful with the problem you have." Basically, the individual is on his or her own. However, the American Holistic Medical Association (AHMA) may be of help.
Founded in 1978, by a group of physicians who wanted to explore and promote holistic care, the organization now has a membership of about 600 and publishes a national referral directory. This listing of member is updated annually and contains the names of members who are accepting new patients. The list gives the name, address, phone number of the practitioner; describes what he or she is licensed to practice; describes the practice; and includes information on the practitioner's education and health philosophy.
The AHMA suggests that patients ask themselves the following 10 questions when choosing a complementary practitioner:
- Does the practitioner have a healthy professional relationship with others?
- How do YOU respond to the practitioner's office and staff?
- Do you feel like a valued person working as a partner with your practitioner?
- Is your personal dignity respected?
- Does the practitioner honor your anxieties and fears?
- What is the state of the practitioner's health?
- Are you allowed time between diagnosis and treatment?
- Are you treated as if this is an important, ongoing relationship?
- Do you feel unconditionally accepted by this practitioner?
- Would you send the person most dear to you to this practitioner?
Health expert Gary Null offers the following suggestions when looking for a complementary practitioner:
- Obtain a conventional diagnosis to guide you and avoid mistreatment
- Get a second opinion form a conventional MD
- Speak to five or six complementary practitioners before you choose one
- Ask for assurance about the non-toxicity and safety of all treatments
- Ask for at least five case histories that prove the effectiveness of the treatment
- Investigate those cases personally-do your homework
- Don't rush into treatment
- Consider a combination of conventional and complementary care
- Evaluate your treatment as it proceeds, and
- Don't rule out changing procedures.
But, as two medical mindsets meet and enter into dialogue, it remains unclear as to what will emerge. It is to be hoped that the precision of modern science can be merged with the wisdom of ancient healing to produce a New American Medicine that surpasses both to the benefit of all.