A Physician's Guide to Complementary and Alternative Medicine

"Savior or Quack?" That was the caption under the photo of internist John C. Pittman in a 1991 North Carolina newspaper article. Pittman became the focus of the article after beginning to integrate oxidative therapies with conventional medicine as part of his clinical practice to treat HIV patients.

Pittman, currently the medical director of the Carolina Center for Integrative Medicine in Raleigh, N.C., says things have definitely changed in the last two decades when it comes to how patients and his fellow physicians view the use of everything from yoga to herbal remedies in healthcare.

"Back then, the viewpoint was extreme - if you were doing something outside convention, you were either walking on water or the devil incarnate - there was nothing in between," he notes. "Now, there is more moderate thinking and acceptance that people doing this kind of thing are a little bit ahead of their time … There is much more supporting the approaches and you can point to an enormous amount of published data."

Both the reception to and the use of complementary and alternative medicine (CAM) by patients has evolved in the United States.

In a 1998 study in the Journal of the American Medical Association, the use of at least one of 16 alternative therapies - including massage and homeopathy - increased from 34 percent in 1990 to 42 percent in 1997. More recent data shows consistent, ongoing use of CAM by patients.

According to a 2007 National Health Interview Survey, a federal data collector, 38 percent of adults were using some form of CAM to promote wellness or to treat various diseases or conditions. In 2009, a subsequent study found that Americans spent $34 billion out-of-pocket for CAM services.

That level of patient use and personal spending has brought CAM to the forefront of physician attentions, but it still suffers from negative perceptions by much of the medical community. Should it? Or could CAM offer you more options for successfully treating your patients? Could it have a role in your practice? Let's find out.

What is CAM?

According to the National Center for Complementary and Alternative Medicine (NCCAM), a research division of the National Institutes of Health, defining CAM is not as easy as it sounds, given that the field is ever-changing. The NCCAM defines CAM as "a group of diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine," with "conventional" meaning Western or allopathic medicine.

"Complementary" medicine usually refers to using such methods in conjunction with conventional medicine; "alternative" generally means in place of it. And "integrative" or "integrated medicine" refers to a practice combining both conventional and CAM approaches, "for which there is evidence of safety and effectiveness," according to NCCAM.

Many CAM approaches - encompassing everything from use of probiotics, meditation, acupuncture, massage therapy, and energy medicine - have long histories, but their use alongside mainstream medicine is still evolving, especially when it comes to physician acceptance.

"Physicians are appropriately, I believe, thinking hard about which of these practices are useful to people and which are dangerous," says Josephine P. Briggs, NCCAM's director. "Our goal at the NIH is to make sure there is good science being done so that these distinctions can be made and so people can base this on real evidence."

Originally called the Office of Alternative Medicine when established in 1992, NCCAM's creation, Briggs says, was based on "heavy use by the American public" and "a feeling there were some health practices the public wanted to know about."

With those practices have also come rules, in the form of state laws and licensure about who is able to perform CAM treatments. CAM credentialing varies from state to state and by method. For example, all 50 states and the District of Columbia require licensure for chiropractic practitioners, while only 42 states and D.C. have licensure rules for acupuncture, according to NCCAM. Then you have licensure for homeopathic physicians, present in only three states.

Michael H. Cohen, an attorney specializing in legal issues for physicians and CAM practitioners based in California, says that the growing number of state laws and licensure does legitimize the use of CAM. But he also notes practitioners still need to be wary of "broadly drafted medical licensing laws" and the threat of regulatory and legal sanctions for unlicensed medical practice. "Ignorance of the law is not a defense," Cohen says.

From exploration to experts

During his pediatric residency in the late 1980s, Pittman says he became "disillusioned" about healthcare and turned to emergency medicine to reignite his interests. While working at two North Carolina hospitals, he expanded on his prior studies of biochemistry and nutrition during graduate school to investigate nutritional approaches to treat illnesses.

"I always had a feeling there ought to be a way to use diet and nutrients to help heal chronic illnesses or any kind of condition as opposed to just drugs and surgery," he says. So Pittman began to seek out mentors in CAM to help him explore ways to combine conventional medicine with botanicals and other natural therapies.

This eventually led to his creation of the Carolina Center, which addresses chronic degenerative illnesses, and his founding of the North Carolina Integrative Medical Society (NCIMS). The NCIMS attracts and serves CAM practitioners as well as physicians curious about CAM after hearing more from their patients about these types of therapies, Pittman says, and educates both groups on various methods.

Like Pittman, professional and clinical questions drew physician Richard Glickman-Simon to CAM as well.

Glickman-Simon had been practicing family medicine in Massachusetts for nearly a decade and was "not sure I was having the impact that I imagined I would and I wasn't really sure why."

"The thing about primary care, unlike other areas of medicine, is that a lot of patients have self-limited conditions," he says. "They will get better and they are there to have that confirmed and maybe get medicine to accelerate their recovery. Sometimes it helps and sometimes it doesn't. What I was finding was I was unsure that what I was doing was helping a lot of people."

Glickman-Simon met a fellow primary-care physician who also was an acupuncturist and began practicing alongside him and learning to integrate acupuncture into his practice. That eventually led him to academia, where he teaches CAM and family medicine at Tufts University as well as instructing at the New England School of Acupuncture (NESA), where he is currently chairman of its board of trustees.

Twenty years ago, following his family medicine training at the University of Maryland, Brian M. Berman went into private practice and also hit a professional wall.
"I had great training, especially for acute care problems … but when it came to chronic problems and diseases, like chronic pain, I did not have all the answers I was looking for with my patients," he said.

Like Glickman-Simon, Berman sought out experts and began incorporating acupuncture into his practice, then entered a fellowship program in England to hone his use of integrated medicine and merge complementary therapies and mind/body approaches for his patients.

"It's not a panacea for everything and it is not a placebo - that's my experience of 25 years," Berman says. "It doesn't mean you throw out all of your medical training, but you have more tools in your toolbox … and it kind of revives interest in medicine, as you can sometimes feel burnt out."

Putting CAM into practice

So how can you decide if CAM could be a useful part of your practice?

Start the conversation. While studies indicate that patients are using CAM in greater numbers, data also suggests that they are not always open in sharing that information with their physicians. A 2008 survey of breast cancer patients indicated such withholding of information for reasons including the impression of physician disinterest or opposition and anticipation of a negative response.

"Physicians should not adopt an automatic dismissive attitude," says Briggs. "If they do, they won't learn what [their patients] are actually doing."

NCCAM has established the "Time to Talk" program, offering tips for both patients and doctors to open up the lines of communication on CAM to promote health and wellness initiatives.

Seek out reliable information. You and your patients have a lot in common, including your reliance on the Internet for information, but be warned, advises Briggs.{C}

"One thing many Americans believe is that somehow, if something is natural, it is safe," she says. "I remind people that heroin is a natural substance and so are the leaves of the tobacco plant … so there is a misconception there."

One of the things Briggs hopes physicians get from NCCAM is information, from licensing and credentialing details to studies on various CAM methodologies. "Our job here is science," she says. The agency's Web site (www. nccam.nih.gov) provides its own data, as well as references to other research bodies exploring the use of everything from dietary supplements to tai chi.

Glickman-Simon says physicians should do their research and realize that areas such as acupuncture and chiropractic services are methodologies with extensive training and regulations, whereas homeopathy, energy medicine, hypnotherapy, and dietary supplements and herbs are "poorly or minimally regulated," he says.

"CAM is not one thing, it is multiple things … so focus on those that are well-regulated and have a good safety record and once you feel safe, investigate whether you feel it is worthy of your attention, especially if a patient is asking about it," he says.

Get familiar with the practices, practitioners. If you are not already using CAM, chances are someone in your community is, so get to know them and what they do.

Nancy Faass is the volume editor/coeditor of two books for health professionals on the integration of complementary medicine in medical practice. Her perspective on referrals is that one always begins from a professional knowledge base, which means educating oneself about a particular complementary therapy that is relevant to one's own practice and patients.

Faass suggests that physicians go straight to the source - attending workshops, conferences, or training on the discipline of interest, interviewing providers regarding their approach to therapeutics, and even obtaining a treatment to see what is actually involved.

"Look at the research and read up on the topic. Go out to lunch with a well-respected provider, get a complementary treatment, and if you like what he or she is doing, have that provider in for a brown bag lunch at your office to train your staff," Faass advises. "Have them explain what they do and how they do it. Choose an area and educate yourself about it."

Pittman also recommends seeking out local medical groups. In North Carolina, he helped found NCIMS, the state's integrative medical society, which offers CME workshops on a regular basis and has seen physician attendance at such events grow over the years. He recently taught a course on integrative medical approaches to Lyme and other tick-borne diseases.

"Family physicians, internists, pediatricians - they are all responding to requests many of their patients have," he says. "We ought to be more comprehensive in our approaches and that can be as simple as learning to do some more functional testing … and use that information to make recommendations. Simple things like this can be the best way for someone to get their foot in the door."

Know your state laws. Cohen, who authors a blog on complementary medicine (www.camlawblog.com), advises a thorough review of state and local laws regarding CAM and perhaps consulting with an attorney who specializes in CAM law.

He notes several states that have "corporate practice of medicine doctrines," prohibiting nonphysicians from creating partnerships with physicians. In California, he notes, the state medical board also openly opposes arrangements between doctors and "medi-spas," with the threat to sanction physicians involved in such relationships.

"The best tip is not to enter into a business arrangement without legal advice, naively assuming that it will all work out for the best," he says.

'Partner' with your patients. Berman returned to the University of Maryland in 1991 to found the Center for Integrative Medicine, which not only includes a clinic incorporating CAM practices, but as an NIH Center of Excellence, also conducts research and education for medical students, residents, fellows, and CME courses for practicing physicians. In addition to a "credibility gap" that still exists today, Berman says another obstacle to integrating CAM is the lack of familiarity with its approaches and therapies. In addition to seeking out experts, Berman says CAM is really about "partnering with the patient."

"This is what integrative medicine is all about - partnering with the patient and looking at the whole person, a holistic approach to care," he says. "It reminds us that the relationship part of care is important … We know this, but we don't always put it into practice in medicine."

Berman uses the example of a patient with chronic back pain, where a doctor needs to go beyond "the magic bullet" of an injection and get into the lifestyle issues that may be exacerbating the pain. By working together, he says, mind-body approaches such as meditation or yoga can address a contributing factor like being overweight that is hindering well-being.

"It is tailoring to the individual then giving them some ways they can help themselves as well as things we might do to help, like a medication," he says. "This could be acupuncture or osteopathic manipulation. It all depends on the individual and what makes sense for them."

Reliable online information. The NIH's National Center for Complimentary and Alternative Medicine (NCCAM)'s Web site features numerous links to CAM information for practitioners, including:

• NCCAM information for providers: www.nccam.nih.gov/health/providers
• National Cancer Institute CAM info.: www.cancer.gov/cancertopics/cam
• NIH Office of Dietary Supplements: http://ods.od.nih.gov
• The Cochrane Collection treatment reviews: www.cochrane.org

In Summary

Before you decide if complementary and alternative medicine is right for your practice, consider the following:

• Educate yourself on what CAM is and what it isn’t through reliable experts, like the NIH

• Talk to your patients regarding their questions and current use of CAM therapies

• Seek out experts and practitioners in your area with your own questions

• Consult state laws on CAM practices for details on licensure, collaboration, and other issues

Keith L. Martin is associate editor at Physicians Practice. He can be reached at keith.martin@ubm.com.

This article originally appeared in the February 2011 issue of Physicians Practice.