JAMA 1998 (Mar 4); 279 (9):708-709
By Wayne Jonas, MD,
Director, Office of Alternative Medicine,
National Institutes of Health
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. 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.
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. 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. In addition, mainstream medical
journals are beginning to call for research papers in complementary,
alternative, unconventional, and integrative medicine.
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.
Protecting patients from the risks of CAMGiven 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. Only fully competent and licensed
practitioners can help patients avoid such inappropriate use. Some CAM products contain powerful
pharmacologic substances that can be toxic either alone or in combination with
other medications. Also, contamination
and poor quality control are more likely with CAM products than with
conventional drugs, especially when shipped from overseas. Physicians can also ensure that patients do
not abandon effective care and alert them to signs of possible fraud or
Permitting use of nonspecific therapiesSome 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
Promoting safe and effective CAM therapiesAccumulating
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. Physicians
can search the published medical literature and evaluate the applicability of
CAM for specific patients' problems.
Partnering with patients about CAMMore than 80% of those who
used unconventional practices in 1990 combined these practices with
conventional medicine. 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.
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
Medical and nursing education should include information about
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.
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
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.
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. 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
||University of Texas Health Science Center|
||Columbia University College of Physicians and Surgeons|
|Kessler Institute for Rehabilitation|
|HIV and AIDS
||University of Virginia School of Nursing, University of
Maryland School of Medicine|
||Minneapolis Medical Research Center|
||Beth Israel Hospital, Harvard Medical School|
|Asthma and allergy
||University of California, Davis|
||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
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
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