Perceptions of CAM

Exploring Issues of Clinical Evidence

The Cochrane Collaboration

Joseph Kleijnen, M.D., director of the NHS Center for Reviews and Dissemination at the University of York, U.K., described The Cochrane Collaboration (CC), with which his center is affiliated. The CC is an international nonprofit organization, and a part of Britain's National Health Service, that "prepares, maintains, and promotes the accessibility of systematic, up-to-date reviews of health care interventions." CC reviews are carried out by of dozens of review groups and by review "fields" that cut across the groups. The CC has many published reviews on CAM topics. Essential elements are:

• A well-formulated question;

• A comprehensive data search;

• An unbiased selection and abstraction process;

• A critical appraisal of the data;

• The synthesis of data; and

• Production of a structured report.

Education on CAM

The final portion of Day 1 of the conference concerned conventional medical education and CAM.

CAM Education in the United States

Brian Berman, M.D., director of the Complementary Medicine Program at the University of Maryland School of Medicine, Baltimore, presented an overview of CAM medical education in the United States, including the following statistics about the 125 U.S. medical schools:

• At least 66% offer some form of CAM education.

• 66% report including CAM information in the core curriculum.

• 50% offer elective courses in CAM.

• 5 schools offer clerkships/rotations in CAM.

• At least 92 family practice residency programs (35%) address CAM issues.

• 12 schools offer continuing postgraduate education in CAM.

Dr. Berman noted that surveys show that doctors and medical students are increasingly interested in CAM therapies, yet barriers exist, including restricted curriculum space, students' limited time, and the explosion of information across the board in medicine. While CAM is being taught in numerous conventional medical schools, there is great variation in approach, content, and depth of the programs. Dr. Berman recommended greater consensus on the ingredients of a core curriculum on CAM and its goals, which could include better knowledge of CAM therapies; an acquaintance with the pertinent legal/regulatory/insurance issues; the ability to advise patients and make decisions about the use of CAM; and the ability to make referrals when appropriate to CAM practitioners. He discussed initiatives to include CAM in medical education in the U.S., including funding at academic institutions and NCCAM funding initiatives to support (1) the development of CAM curriculum and (2) career development and training.

CAM Education in the United Kingdom

David K. Owen, M.B., B.S, M.R.C.S., L.R.C.P., M.F.Hom., of Winchester Homeopathic Practice, England, discussed CAM medical education in the U.K. Almost 40% of general practices in England offer some form of complementary therapy for their patients who are on the NHS. There has been an increase in the past few years in CAM courses for medical students. Overall, however, CAM is provided largely outside the conventional care framework. Funding for complementary medicine research has to compete with funding for all other clinical disciplines.

Dr. Owen identified a need for doctors and their professional organizations to become more familiar with CAM in terms of core curriculum content; training in CAM for established physicians; and integrating CAM techniques into patient care. Like Dr. Berman, he highlighted benefits that CAM approaches can bring to conventional medicine--including an approach of greater holism, intuition, and empathy, to the benefit of clinical care and physician career satisfaction.

Dr. Owen directs a multidisciplinary teaching module for CAM at the University of Southampton, U.K., that has been taken by nurses and student chiropractors and has received very positive feedback. CAM education, he said, very much concerns attitudes, not just knowledge and skills. "There are as many therapies as there are therapists," he said.

CAM Regulation and Certification

Day 2 of the conference opened with a module on regulation and certification, a critical area of interest in both countries.

Regulation in the United Kingdom

Simon Mills, M.D., Director for Complementary Health Studies at the University of Exeter, U.K., and an herbal practitioner, described regulation in the U.K. as radically different from regulation in the rest of Europe and the U.S. In the U.K., citizens have a common-law right to choose their own treatment. It is perfectly legal for a person to put out a shingle as as an acupuncturist, for example, and deliver acupuncture services, as long as he or she does not claim to be a "registered medical practitioner" and refrains from certain protected practices, such as dentistry, midwifery, and veterinary medicine. Despite legal recognition, groups of CAM practitioners are able to organize their own training and professional standards.

"We have found," he said, "that most organizations in CAM are run pretty much as conventional professional bodies; they publish formal codes of ethics and practice codes and member registers, and subscribe to insurance plans. The handling of complaint procedures, however, has been a consistently disappointing area."

As CAM organizations and practitioners have become a larger part, over the last decade, of the health care system and more common as a first career rather than a second," he said, "we will need to have clearer and more overt systems in place, including in professional codes. Most in the field agree with the principle that they need to develop their own standards under their own title, towards potential statutory regulation. Some think this is too burdensome and are lobbying for a unitary regulation, perhaps a kind of council for CAM."

Simon Fielding OBE, chairman of the General Osteopathic Council, U.K., spoke on osteopathy in the U.K. Mr. Fielding described osteopathy in his country as "a complementary form of health care espousing complementary medical principles." A central tenet is that disease originates from problems in musculoskeletal systems. As recently as the 1970s, osteopathy was considered a "fringe profession" in the U.K., and it was a crime to refer someone to an osteopath. Mr. Mills emphasized the importance of having a future research effort in the field: "We desperately need clinically relevant research." With regard to regulation, he identified a schism in osteopathy between those who want to be regulated and those who do not.

Regulation and Certification in the United States

Michael Cohen, Esq., lecturer on medicine at Harvard Medical School, Boston, MA, spoke on regulation and certification in the U.S. from a legal perspective.

In contrast with the U.K., every state in the U.S. has its own licensing scheme, different laws, regulations, and courts and judicial documents that interpret these rules. "Who is authorized to practice which specialty" is determined by state. Further, the system is often "patchwork" from town to town and county to county. Mr. Cohen explained the four levels of the U.S. model: (1) mandatory licensure, the most common; (2) title licensure: needing a license to claim a particular title such as "massage therapist"; (3) registration, with the designated state agency; and (4) exemption from licensure requirements. A hypothetical example of number 4, exemption, would be a religious healer who is allowed to practice only under the tenets of a recognized church and only by using prayer, not prescribing medications.

He discussed boundary issues that arise between the professions; e.g., a healer who crosses the line of his own scope of practice can be prosecuted for unlicensed medical practice. The outcome of these situations depend on each state's own interpretation.

Douglas Wood, D.O., Ph.D., president of the American Association of Colleges of Osteopathic Medicine (of which there are 19 in the U.S.), gave a presentation on osteopathy--its history in the U.S. and an overview of the current state of osteopathic medical education. Important components in osteopathy include: physical, social, and other environments; holism, or unity of the body; self-healing; interrelated structure-function relationships in the body; "rational treatment -- all the services of modern, scientific medicine"; and the use of manipulative therapy techniques. How osteopathy works is not well known or well understood. Dr. Wood predicted that in the future, "osteopathic medicine will continue to evolve as a 'parallel and distinctive' profession."

Interdisciplinary Approaches to Delivering Care

Andrew Weil, M.D., director of the Program in Integrative Medicine and professor of medicine at the University of Arizona, Tucson, described the poor state of the conventional medical profession in the U.S. He cited hospitals going bankrupt, low morale among M.D.'s, a drop in applications to medical school, and scores of unhappy patients. Factors that can play a part in the problem, he said, include the training process; prejudice of different kinds toward "integrative" approaches; the challenges of obtaining academic support and funding for research on those approaches; and "territoriality."

Dr. Weil described a different approach in his interdisciplinary program at the University of Arizona, which he called a "new model for helping patients." In that program, listening to patients is very important, as is "taking them seriously"; considering as treatments not only drugs and surgery but CAM modalities; helping patients navigate through the maze of therapeutic options now available; and providing a comfortable, pleasing, healing environment. Patients, he said, are more motivated, cooperative, and realistic in expectations, and the staff finds their practices to be more rewarding.

He said that physicians need to be teachers of health and healthy living. "We need to restore the soul of medicine," he said, noting this is not solely a movement among patients but in academic medicine as well. Others needs, he said, are to restore patient satisfaction; improve health outcomes; and develop more rigorous definitions and standards in integrative medicine, "to help bring more order and clarity" to the field.

Lucy Bell of the Hammersmith Hospitals NHS Trust, U.K., spoke of the complementary cancer care the Hammersmith system offers. She noted that in the last 10 years there has been a large increase in the use of complementary therapies in the cancer care setting. Today, 70% of cancer centers in England and Wales offer at least one CAM therapy to their patients. In the Hammersmith Hospitals, within the NHS, they have pioneered the use of complementary therapies within their cancer center--aromatherapy, massage, reflexology, relaxation, visualization, acupuncture, and art therapy. These are, she said, "an integral part of a multidisciplinary approach to specialist cancer and palliative care," and useful for coping, especially with the side effects of treatment.

The complementary therapies at Hammersmith, she said, are easy to use, can be used anywhere, and are non-invasive and pleasant. Patients report enhanced quality of life and well-being. They feel they are taking back some control over their lives.

She emphasized, "The value of touch cannot be underestimated." Massage, even a 5-minute hand massage, is helpful. The staff teaches massage techniques to patients' relatives. It is also important to give patients individual attention and time, and an opportunity to talk.

David Spiegel, M.D., professor of medicine and biochemistry at Stanford University School of Medicine, Stanford, CA, described the current state of health care delivery in the U.S. as having turned doctors into "biomechanics" and "providers." They are drowning in paperwork, he said, especially when it comes to reimbursement for CAM modalities.

Physicians are becoming more open to CAM techniques and even to using them themselves, he said, and they need to learn about the different CAM disciplines. "They haven't been good in helping people reconstitute a relationship with their body and deal with the emotional effects of their disease," he said.

Dr. Spiegel noted that an adequate, comfortable, and attractive physical space makes a real difference in how people feel when they come to a center, whether as a patient or employee.

David Reilly, M.D., a physician, a homeopath, and the director of Glasgow (Scotland) Homeopathic Hospital, talked of his hospital as creating "a place of beauty and healing" within the NHS. The facility consists of an inpatient unit, a day care unit, and an outpatient-based service. The fact that 20% of general practitioners in Scotland have had homeopathic training testifies to the popularity of homeopathy in the U.K.

Dr. Reilly emphasized that, in his experience, the principal healing factor is the relationship between patient and carer. "This is not 'shopping cart medicine,'" he said. Also, he believes that healing comes "from within," not through the modality. This is achieved by helping people reintegrate the dimensions of their world: inner world, outer body, and life. He summarized the Glasgow model as "patient-centered, not system-centered" and one that utilizes the best of orthodox and CAM medicine. He closed with the comment, "We need to study Michelangelo's 'David,' not just the tools that made it."

Exploring the Science Base

Conference Themes

Certain themes threaded throughout the conference. There are differences, sometimes vast, between the United States and the United Kingdom with regard to CAM regulation, research, academic involvement, government support, and even public support. However, common ground and positive energy unified and electrified the conference--e.g., concerning progress that has been made; what each country has learned and how it could help the other; and the many examples of successful interdisciplinary systems. The latter area appears to be proceeding not as two parallel tracks (CAM and conventional medicine), but toward one track of interdisciplinary medicine. There is movement away from competing for patients and toward unity and cooperation to enhance human healing.

Physicians are becoming more open to CAM interventions, both in terms of training in the techniques and making referrals to CAM practitioners. A number of speakers who were conventionally trained doctors presented on their clinics and practices that successfully incorporate multidisciplinary approaches to health care.

Public use of, and demand for, access to CAM therapies has grown, and does not appear to be affected by insurance reimbursement factors. There are interesting differences between U.K. and the U.S. public awareness of, and knowledge about, certain specialties. For example, homeopathy is well integrated into the NHS; in the U.S., homeopathy is not institutionalized. Osteopathic medicine is a mature and fully integrated discipline in the U.S.; in contrast, osteopathy is an ancillary health system in the U.K.

There is major concern in both countries over licensure of CAM practice. A balance needs to be struck between (a) effectively regulating professions and preventing harm to patients and (b) respecting individuals' right of access and freedom of choice.

In education, the growing public use of CAM is having an impact upon the practice of conventional medicine and the goals of medical students and residents. Students are now expressing more interest in CAM therapies and in care approaches that center on management of the whole person. More consensus among institutions is needed on the elements of a core curriculum in CAM.

The quality of scientific research to date on CAM, based on well-designed clinical trials, has been variable and needs improvement. The NCCAM was praised as a leader in this area, and the House of Lords has cited its commitment to undertaking a similar effort.

In summing up this historic conference, Dr. Straus said, "Integration of CAM therapeutics into the routine delivery of medicine requires trust among practitioners; assurance that they are well-trained professionals; and modalities that work and are safe. This meeting was enormously successful in helping all of us in the U.K. and in the U.S. to achieve these three goals.