Complementary and alternative medicine (CAM) can be defined as “those practices that aren't part of the politically dominant medical system of a country.”1 In the United States this means those practices that are not usually taught in medical schools, not available in most hospitals, clinics, and private practices, and often not reimbursed or otherwise routinely accessible. This encompasses an amazingly wide range of practices, including, but not limited to, the general categories of bioelectromagnetic applications, dietary practices, nutritional supplementation, lifestyle behaviors, herbal medicine, manual manipulation, mind—body interaction, unconventional pharmacologic and biologic treatments, and alternative systems of medical practice. Within these categories are modalities such as acupuncture, phytopharmaceuticals, massage, art therapy, using music to support healing, ethnic and cultural healing rituals, chiropractic manipulation, Chinese herbology, pet therapy, imagery and visualization, tai chi and other movement therapies, and even aromatherapy.
The prevalence of the use of these CAM treatment modalities in the United States is widespread and increasing. The first formal recognition of just how common unconventional medical practices were in the United States was revealed in Eisenberg's 1993 article in The New England Journal of Medicine.2 It showed that (1) about one third of Americans in 1990 were regular users of complementary medicine modalities; (2) more office visits were made to physicians practicing complementary medicine than to primary care physicians; and, of special note, (3) close to 75% of patients who were utilizing these CAM modalities never told their primary care physicians about it. It also pointed out that approximately $14 billion per year were being paid out-of-pocket on nontraditional practices because insurance rarely covers any of them. Additional studies have repeated this type of survey with similar results.3 Surveys have indicated that the populations using CAM are not homogeneous, with patients using the kinds of practitioners they believe can best help their particular problems.4
SORTING OUT VIABLE CAM MODALITIES
Many people believe that because some CAM practices have been around for thousands of years, or are “natural,” or that because some CAM products can be purchased over the counter or in a health food store, there are minimal risks and few unwanted side effects. Indeed, many believe that such practices are virtually harmless. Patients report that they don't tell their allopathic physicians what they are doing because of experienced or expected disapproval. This prevents many physicians and patients from communicating potentially useful information. The risks (sometimes severe) inherent in the underinformed use of CAM practices make it imperative that today's physicians become educated about CAM therapies, research, risks, and appropriate applications so that they can advise and manage their patients' care.
Sorting out the viable CAM modalities can be a difficult task. Some CAM modalities, such as acupuncture, have been part of health care systems for centuries, and have stood the test of time. Others, such as past-lives regression therapy, have come to the fore with “New Age” thinking, without supporting empirical research or clinical evidence. Concerns from medical physicians about CAM include poor and inadequate dialogues with CAM practitioners, doubts about practitioners' competence, a lack of readily identifiable and recognized qualifications, and the risk of offering unrealistic hope of a cure, especially if the patient does not include conventional medicine as part of his or her treatment protocol.5
Complementary healing modalities should not be seen as homogeneous. The diversity that exists within CAM, just as in conventional medicine, needs to be explored on an individual-modality basis and viewed within the cultural and political sphere in which it occurs.6 Understanding the cultural and political as well as the medical relevance of CAM modalities will allow the physician to respond more appropriately to his or her individual patients.
When CAM providers ignore conventional medicine or do not refer their patients to standard medical practitioners, incorrect diagnoses and insufficient treatment may result.7 A patient's decision to rely wholly upon cultural healers or CAM practitioners to the exclusion of conventional treatment could be critical to his or her survival. To ensure adequate communication between conventional medical physicians and CAM providers, a robust and coordinated commitment must be taken to evaluate CAM modalities and systems for appropriate integration of those that are viable into health care practice and policy.8
The issue is not just finding those CAM modalities that warrant application, but also discovering ways to encourage physicians to consider the exploration of CAM approaches. One major shortcoming of conventional medicine is that “doctors commonly fail to concern themselves directly with the everyday personal issues that impact happiness and physical well-being.”9 Conventional medicine tends to look at the parts of the person while CAM tends to focus on the person as a whole. The World Health Organization defines health as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.”10 A complete physical examination alone is insufficient. Today's medicine must also include an understanding of the person as a whole entity, functioning within a social environment.
Nevertheless, in spite of historical bias against alternative approaches to conditions generally treated exclusively within the domain of conventional medicine, the increase of public awareness and usage of CAM has fostered the collection, review, and initiation of research at the national level on some specific CAM modalities. In 1995, the National Institutes of Health (NIH) held a Consensus Development Conference reviewing the use of relaxation and behavioral techniques as a treatment for chronic pain or insomnia, where it was concluded that the research regarding the usefulness of these techniques in managing pain had been clearly demonstrated.11 Likewise, in the fall of 1997, the NIH held a similar conference on acupuncture,12 concluding that “there is sufficient evidence of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value.”13
THE RESPONSIBILITY OF PHYSICIANS
With national policymaking organizations such as the NIH recommending that some CAM treatment modalities be incorporated into mainstream medicine, what then is the responsibility of physicians who oversee the treatment plans of their patients? How much do they need to know about the areas contained in complementary medicine? It is certainly not realistic or even possible to expect medical students to learn entirely new fields of medicine. It is expected, by patients in most populations, that their conventional health care providers be knowledgeable about the major areas of CAM and be able to offer advice as to the usefulness—and possible risks—relative to their patients' particular situations.
In the last several years physicians have increasingly sought training to answer patients' questions, and some are already recommending a variety of CAM therapies.14 Addictionally, medical students are also requesting information and training about CAM therapies and providers.15 The need to be adequately informed can be seen by the increasing number of medical schools that are becoming involved in CAM education. In 1995, 27 medical schools reported having some aspects of CAM included in their curricula. Such inclusions ranged from one lecture in one course to a fully comprehensive training program in a specific CAM modality.16,17 By 1998, over 70 medical schools offered at least one lecture or course on CAM.18 Based on the prior rate of growth, it is reasonable to expect that this number will continue to increase as the need for CAM-related information is understood and medical schools attempt to respond appropriately. A British Medical Association report in 1993 emphasized the need for postgraduate courses about CAM but felt it would take a long time to integrate CAM into regular medical education.19
EDUCATING PRESENT AND FUTURE PHYSICIANS ABOUT CAM
Indeed, an enormous commitment is needed to face the challenges of educating the present and upcoming physicians in such a way that they can comprehend CAM sufficiently to make effective referrals; receive and direct communication among the themselves, CAM providers, and patients; and understand the financial arrangements involving CAM.20,21 The goal is to have knowledgeable physicians who would be comfortable in prescribing a course of treatment that includes CAM modalities when appropriate. To do so would enhance a more comprehensive approach that ultimately benefits the patient. In order to accomplish this, the physician must have a basic level of familiarity with CAM approaches. Often patients want and need some guidance in these areas and welcome the opportunity to confer with their doctors about these approaches once they realize that the doctors are able and willing to do so openly and objectively.
The most obvious place to assimilate CAM approaches within conventional medicine is in medical school. For almost two decades, a small number of medical schools have been involved with research and training in various CAM modalities. National examples of this include the The Center for Frontier Sciences at Temple University and the University of Southern California. More recent involvement can be seen with the development of continuing medical education (CME) courses in CAM sponsored by medical schools such as those at Harvard, Duke, and the University of Arizona. Another example of the expansion of CAM within medical schools is the number of CAM centers developed over the last five or six years. Some of these have been supported by NIH center grants or foundations interested in the expansion of CAM. Programs within medical schools have been small, often consisting of a limited number of lectures, or an even more limited number of clinical observations, but very little, if any, systematic integration of CAM over the four-year educational program. This hit-or-miss type of CAM curriculum development cannot provide the necessary understanding of even the basic or most prevalent CAM therapies. Despite the rapidly increasing number of U.S. medical schools involved in CAM over the past decade, the form and depth of these efforts have been insufficient to meet the need. Most physicians are ill equipped to answer even the most routine questions concerning the myriad CAM treatments being contemplated. In addition, the advent of the Internet has brought a deluge of CAM information into the home without the slightest concern for accuracy, risk identification, educational level of the reader, or scientific verification.
Incorporating CAM into the new curriculum comes with its own set of unique problems. Since CAM is a broad set of emerging and not-yet-proven-sound medical practices, it is not a matter of simply putting the content into the appropriate educational framework. First, the content must be collected, reviewed, critiqued, and understood. This requires access to a broad set of experts in CAM and CAM-related areas. Once the appropriate content has been sifted out, it must be transformed into the methodologic approaches now being used by medical schools. This transformation requires the skills of competent educators with experience in responding not only to curriculum development but also to the psychological attributes associated with change within a health care delivery system.
CAM education in U.S. medical schools is presently a limited catch-as-catch-can approach with no general over-view or faculty member responsible for its development. To present CAM educational materials to medical students and to reach medical school faculty at the same time, an integrated longitudinal theme approach that allows for CAM to have its own designated teaching hours as well as to be directly woven into pertinent content areas would provide the necessary depth and breadth.
Medical schools have an important role in reducing the isolation of their students from CAM health beliefs, practices, and systems of health care that is common in our communities. This can be accomplished by integrating knowledge of, information about, and exposure to CAM into the medical school curriculum through lectures, multimedia presentations, hands-on experiences, and observation of CAM practitioners. Discussions need to include scientific efficacy, legal and ethical considerations, and the role of spirituality in health and healing. Additional attention needs to include recognition of the limitations of science-based approaches and the reasons why CAM is popular with patients and some allopathic physicians.17
The effective teaching of CAM methods goes far beyond merely the mastery of technical information and skills. Physicians need to understand why patients seek out CAM. The curriculum must include patient motivation and explore the doctor—patient relationship, including the beliefs, attitudes, and stereotypes of both doctor and patient. Communication skills must be developed that allow the physician not merely to listen to patients even when he or she believes what the patient is doing with respect to CAM does not reflect evidence-based medicine, but also to actively inquire about the possible applications of CAM.
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