The last two decades have seen a remarkable and sustained increase in the use of complementary and alternative (CAM) therapies by U.S. consumers, despite minimal coverage for these services by conventional health insurance programs, and despite their relative unavailability through conventional care settings.1–3 Indications are that this trend will continue.2–6 Overall, these data suggest that consumers are perceiving benefits from the use of CAM and that CAM therapies are providing desired services and outcomes. The American Medical Association (AMA) has charged that “physicians should routinely inquire about the use of alternative or unconventional therapy by their patients, and educate themselves and their patients about the state of scientific knowledge with regard to alternative therapy that may be used or contemplated.”7 Meanwhile, many physicians feel they lack sufficient knowledge about CAM safety and efficacy, and they desire more education about CAM modalities.8 Although health professions education in CAM is increasing, it is uneven and not well integrated into mainstream health education. In this article, we review current information about the use of CAM in the United States, and we present and discuss rationales used by 15 National Center for Complementary and Alternative Medicine (NCCAM) CAM educational grantees in their original applications for funding for incorporating CAM content into conventional health professions curricula. Fourteen of the grantees were from major U.S. medical and nursing schools, and one was from a medical student foundation. Awards were for five-year periods (with the exception of one three-year grant) from 2000 to 2008.
Defining Complementary and Alternative Health Care
CAM is an umbrella term for an array of healing modalities “not presently considered … a part of conventional medicine.”9 The National Institutes of Health (NIH) NCCAM categorizes CAM practices into four domains, for purposes of research: (1) mind–body interventions, (2) biologically based therapies (diet, supplements, and herbals), (3) manipulation- and body-based therapies, and (4) energy therapies (acupuncture, Reiki, magnets, therapeutic touch, and others). NCCAM also recognizes that whole medical systems, such as naturopathy and homeopathy, cut across these domains.9 Despite the orderliness and inclusiveness of this classification system, it cannot adequately describe the variety and uniqueness of these disparate therapies, which include recently developed therapeutic methods, such as neurofeedback, millennia-old practices, such as meditation, and comprehensive healing systems, such as traditional Chinese medicine. CAM therapies encompass a wide variety of practices with varying certification and licensure requirements. They are outside mainstream U.S. health care for historical, cultural, and other reasons, including the 20th-century rise to prominence of the conventional biomedical health care paradigm, with its emphasis on pharmaceuticals, surgery, biotechnology, controlled clinical trials, and traditional scientific methods.
Demographics of CAM Use
Annual visits to alternative practitioners grew from 470 million to 629 million from 1990 to 1997.2 Those estimated 629 million visits to complementary care providers far exceeded the 386 million visits to all U.S. primary care physicians that year. Out-of-pocket expenditures for CAM therapies were $27 billion, comparable with those of all U.S. physician services combined. In the 1998 Eisenberg et al2 follow-up study, 42% reported using CAM, with the most frequently used therapies being relaxation techniques (16%), herbal medicine (12%), massage (11%), and chiropractic (11%). Folk remedies, energy healing, homeopathy, hypnosis, biofeedback, and acupuncture were used less commonly. The more recent U.S. Centers for Disease Control (CDC) national survey found that, in 2002, 35% of U.S. adults used some form of CAM (excluding megavitamin therapy and prayer), 21% used biologically based therapies (excluding megavitamin therapy), 17% used one or more forms of mind–body therapies (excluding prayer), 11% used manipulative and body-based therapies, 3% used alternative medical systems, and 0.5% used energy therapies.3
Diversity of CAM Users
CAM is used by a wide range of socioeconomic and cultural subgroups. In the recent CDC study, CAM (excluding prayer and megavitamin therapies) was used by 40% of females and 30% of males; by 26% of blacks, 36% of whites, 43% of Asians, and 55% of Hispanics or Latinos; and in higher proportions among those who had attended college.3 Although more highly educated and economically advantaged segments of the population use CAM, those with limited access—both financial and geographic—to conventional health care services also regularly use CAM. For example, those living in isolated, rural areas, particularly those who are impoverished, are often high users of folk remedies.10–13 A few studies have looked at CAM use in the United States, with a focus on undersampled, lower socioeconomic groups, such as urban minorities,14 and have found that cultural minorities, or new immigrants from other cultures in which CAM therapies are practiced, are also frequent users of some types of CAM. As an example, Native Americans living on reservations and Hispanic populations recently immigrated to the United States are high users of their traditional health care systems.15,16
Conditions for Which CAM Therapies Are Used
CAM is used for general self-care, disease prevention, and treatment of a variety of illnesses and symptoms, including back and neck pain, colds, joint pain and joint stiffness, allergies, fatigue, arthritis, headaches, high blood pressure, sprains or muscle strains, insomnia, pulmonary problems, dermatological disorders, digestive disorders, depression, and anxiety.2,3 The vast majority of users of CAM modalities also use conventional care, often for the same condition.2,3
Why Are Consumers Using CAM?
This age of information and global consciousness has brought increased awareness of other systems of health care and greater public access to health information. Philosophical preferences also play a role in health care choices. Many health care consumers are attracted to natural/organic products and treatments and to the philosophies and beliefs associated with many alternative practices.17
One national survey17 found that for those who used both CAM and conventional care, use of CAM therapies was primarily correlated with holistic values and beliefs. For example, those who agreed with the statement, The health of my body, mind and spirit are related, and whoever cares for my health should take that into account were more likely to use CAM (46%) than those who did not endorse this item (33%). Other significant predictors were having had a personal transformational experience, and being a “cultural creative” (having a commitment to cultural change and innovation, including environmentalism and personal growth). These holistic philosophical perspectives are found in most CAM therapies. Other common responses regarding reasons for using CAM therapies are that they are effective for a particular health problem, promote health rather than just focusing on illness, and enhance the likelihood of a successful health care outcome.17 The national CDC survey of CAM use3 asked CAM users about their reasons for using a particular CAM therapy, giving them options for selecting more than one answer. Positive responses included
- CAM therapy combined with conventional medical treatment would help (55%);
- it would be interesting to try (50%);
- conventional medical treatments would not help (28%);
- it was suggested by a conventional medical professional (26%); and
- conventional medical treatments were too expensive (13%).
Those who seek effective treatment for chronic or incurable diseases often use CAM. For example, patients in rehabilitation clinics18 and with diagnoses of cancer,19–23 HIV,24,25 multiple sclerosis,26,27 and Alzheimer disease28 use CAM therapies in greater percentages than the general population. In addition, those suffering from chronic diseases or conditions with symptoms that are poorly understood and/or treated with partial success by conventional care—such as arthritis,29,30 diabetes,31 hypertension,32 cardiovascular disease,33,34 chronic fatigue, fibromyalgia,35 irritable bowel syndrome,36 hematologic disorders,37 chronic pain,38 and aging18,39,40—may seek benefit from alternative therapies.
Patient–Practitioner Disconnect about CAM in Conventional Health Care
Given that there is widespread use of CAM by the U.S. public, and that most patients who use CAM are also using conventional care, often for the same illness,2,17 it is striking that the majority of patients do not discuss their CAM use with their conventional practitioners.1,2 Reasons given by patients for not discussing alternative therapy use with their physicians include (1) the belief that it was not important for the doctor to know, (2) the doctor never asked, (3) it was not the doctor’s business, (4) the doctor would not understand, (5) the doctor would disapprove, and (6) the doctor would discourage use.41 Research affirms that conventional providers often fail to ask their patients about their use of alternative modalities.42
It is easy to link poor communication about use of CAM to greater risk of suboptimal care, including the potential for drug–herb or drug–supplement interactions, noncompliance, possible duplication of services, and greater health care costs, in addition to obscuring understanding of the exact causes of specific outcomes.
Why Educate Health Professionals about CAM?
We reviewed the CAM education grant proposals of all 15 funded institutions to gain information about stated rationales for the development of CAM education initiatives. Interestingly, several rationales were shared widely among most institutions, although not all institutions mentioned all rationales. We grouped major rationales into 10 themes. These are listed below, along with the number of grantees referring to them:
- responding to prevalence and growth of CAM use in the United States (15);
- responding to U.S. governmental, legislative, and other mandates (14);
- need for enhanced patient–provider communication about CAM (14);
- need to enhance safety of CAM uses, including reducing risks of negative interactions with conventional or other CAM treatments (14);
- CAM education’s positive impact on broadening core competencies for conventional health care professionals (12);
- CAM education’s positive impact on enhancing cultural competency and patient-centered care (14);
- need for better communication between CAM and conventional providers (12);
- improving health care coordination through creating knowledgeable and culturally competent providers (5);
- CAM education’s potential impact on increasing CAM research quality and capacity (3); and
- potential for enhancing quality of care through informed CAM use and integration with conventional care (8).
These themes will be discussed below.
Responding to prevalence and growth of CAM use in the United States
The sustained growth in CAM use by the public, along with projected future trends, has been mentioned previously and was the primary rationale voiced by all CAM education grantees. The projections for future growth of CAM use are supported by the increasing numbers of CAM practitioners, increased numbers of states licensing CAM providers, and the growing number of states with Health Freedom legislative initiatives that enhance legitimacy of alternative care providers.
Responding to U.S. governmental, legislative, and other mandates
The formation of the NIH NCCAM was often cited by grantees as an indicator of CAM’s growing importance as a focus for health care research, and as legitimizing the need for CAM integration into conventional medical curricula. The National Conference on Medical and Nursing Education and Training in Complementary Medicine, cosponsored by NIH’s Office of Alternative Medicine in 1996, was cited as another legitimizing influence. In this consensus conference report, recommendations were made for incorporating CAM education into health professions schools. Another rationale cited was the American Medical Association’s (AMA) recommendation for physicians to ask patients about their CAM practices. Without being knowledgeable about CAM, physicians are not willing or able to ask the right questions or to understand and deal appropriately with the information their patients provide them.
Enhancing patient–provider communication through educating health care providers about CAM
The need to improve communication between patients and conventional providers about the use of CAM was frequently mentioned as a rationale for integrating CAM education into medical school curricula. A primary reason patients cite for not communicating with their conventional providers about CAM use is their perception that physicians are not knowledgeable about CAM. Although the AMA encourages physicians to ask patients about their CAM use, physicians often fail to inquire, which may be attributable in part to lack of knowledge and training in CAM.
For the conventional practitioner, the most compelling rationale for learning about CAM is the growing use of these therapies by their patients. Although there are positive aspects of consumer-driven health care, there are also downsides. As consumers search for information and guidance from multiple sources—some of which are inaccurate or misinformed—they risk making choices that may be dangerous, inefficient, or unnecessary. Because the vast majority of consumers who use CAM also use conventional care, it becomes the responsibility of the conventional provider to become at least minimally knowledgeable about CAM. Although many patients do not discuss CAM with their conventional providers, others seek their validation or clarity about CAM therapies, or they request referrals from them to alternative caregivers.
If conventional practitioners are to serve their patients well, they need to be able to include questions about CAM use in obtaining a medical history, listen to their patients’ experience with alternative care therapies and providers, respond to questions about alternative therapies, be knowledgeable about the range of CAM therapeutic options currently available, and be aware of the risks, benefits, and costs of these options. Equally important is the understanding that the best health care choices are made when there is a true partnership between patient and caregiver—when directing therapy becomes a shared responsibility. This partnership is, in essence, an opportunity to communicate with and learn from each other.
Enhancing safety of CAM use and interactions
Specific concerns about the safety of CAM practices, and possible untoward interactions of CAM therapies with conventional therapies, are concerns shared widely by conventional providers. Thus, CAM safety and risk reduction was often used by grantees as a rationale for CAM education. Although statistics on medical errors and pharmaceutical risks attest to the need for concern about the safety of conventional medicine practices,43 widespread CAM use raises additional questions and concerns about the safety of specific therapies and methods. Minimal regulation in the production and use of herbals and supplements, and a lack of standards for providers, add to the perceived risk of CAM use. In addition, inaccessibility to, or lack of information on, effectiveness and risks of alternative therapies can be frustrating.44
Many conventional practitioners, insurers, and health care organizations—particularly those unfamiliar with CAM options—are concerned that there are not adequate data to provide confidence for implementation of some CAM therapies. Knowledge about safety and effectiveness of conventional as well as alternative therapies and their interactions is critical for health care providers. In addition, because all therapies carry at least the potential of some risk, it is important to include consideration of relative risk in any comparison of CAM and conventional care.
Broadening core competencies in conventional health professions schools’ curricula by introducing CAM education
Medical schools in the United States usually endorse a group of core competencies for trainees that typically include medical knowledge, patient care, professionalism, practice-based learning, system-based practice, and interpersonal and communication skills. Conventional medical school courses are designed to address these areas of training. Integration of CAM content into conventional medical curricula impacts each of these areas of training. Medical knowledge includes those areas of conventional and complementary care that are used frequently by patients. Patient care includes queries concerning use of CAM therapies and resulting effects. Professionalism is enhanced with focused inquiry about CAM use and knowledgeable, collegial interaction with CAM providers. Interpersonal and communication skills direct attention toward opening a dialogue on the use of CAM and the belief systems of patients. All patient interactions may include a discussion of use of CAM in terms of benefits, interactions with conventional care, expectations, and side effects. In addition, an emphasis on wellness and self-care, aspects of many CAM therapies, provides skills for health professions learners that may enhance professional growth and reduce vulnerability to fatigue and illness.
Enhancing cultural competency and patient-centered care through understanding and respect for other systems of healing
The need for cultural sensitivity and a patient-centered approach to care are now well established in conventional health professions educational programs. Patients’ use of CAM gives these issues added importance. Several grantees mentioned the importance of good communication with patients who hold diverse health-related belief systems as an essential skill for health professionals. Cultural competency in CAM requires awareness and understanding of the many concepts, paradigms, and approaches to healing found in the wide variety of CAM practices their patients are using. Practitioners must understand the health-related beliefs underlying a patient’s choice of a particular CAM therapy, appreciate the power of belief to heal or harm, and learn ways to harness belief for healing.45 Moreover, appreciation of a patient’s worldview and desired therapeutic approaches can be used skillfully to further empower the patient to take responsibility for their healing journey.
Improving communication between conventional and CAM providers
Several grantees mentioned involving CAM practitioners in educating conventional health professionals about CAM, as well as the importance of improving communication between conventional and CAM practitioners. An aspect of cultural competency includes the ability of a conventionally trained practitioner to communicate effectively with CAM providers, who may include chiropractic physicians, herbalists, massage therapists, and shamans, among many others. Better understanding of, and communication with, these practitioners can potentially result in increased ability to discriminate those who are well trained from those who are not. Developing an open and friendly professional relationship with individual CAM providers is likely to provide the basis for more effective, collaborative patient care. Practitioners of various healing traditions would do well to seek basic understanding of each other’s systems of care and the healing practices that flow from them. To use the cultural analogy, health care providers, both conventional and CAM, must be willing to become “bilingual,” or even “multilingual,” with respect to alternative care systems. Education will facilitate a shared understanding of the healing processes that are common to all human beings through the emergence of a common “vocabulary” with which to communicate.46
Improving coordination of health care by creating knowledgeable and culturally competent providers
It seems clear that many consumers seek the benefits of both CAM and conventional care, rather than choosing one form of care over the other. Unfortunately, in an educational system in which conventional providers are not sufficiently knowledgeable about CAM, management of this ad hoc approach to health care falls largely to patients rather than to knowledgeable health care professionals. To piece together their health care, patients must often navigate the conflicting claims and recommendations of different providers, compensate for the poor communication among caregivers, contend with limited information about local options, and endure a confusing excess of information via the Internet and other media. Although there is a “team leader”—the patient—in this effort, the various team members, from conventional and alternative practices, may be unaware of each other. Neither conventional nor CAM practitioners may be adequately informed about each other’s therapeutic approach or about interactions of treatments. This lack of communication about CAM use among conventional and alternative practitioners deters good health care. Without openness and knowledgeable prompting from providers of all types, patients may not communicate the fact of their use of alternative therapies to their conventional providers, and vice versa. Hence, treatment may be redundant, at cross-purposes, or even dangerous. For example, adverse drug–herb interactions may occur, producing symptoms for which the cause is not known or understood, either by patient or providers. This situation of noncommunication potentially creates great inefficiencies, such as duplication of therapies, lengthy searches for the “right” treatment, and multiple diagnostic procedures.
Increasing research quality and capacity through increased education about CAM and integrative medicine
This is a time of transition for health care. On the one hand, we are seeing the beginning of what is likely to be a revolution in biomedical research and its applications. Discoveries in genetics, for example, offer the promise of major new solutions to many health problems. At the same time, translational research in CAM is likely to yield a multitude of insights and discoveries that will affect patient care, including the power of the mind–body interaction, and the scope and mechanisms of self-healing capabilities.
The demand for research evidence on CAM safety and efficacy has given rise to concerns about the adequacy of conventional research methodology to provide that information. Although the randomized controlled trial (RCT) is the optimal method for proving the efficacy of a specific drug or treatment, the objectivity of the classic experimental method and the reductionist approach to assessment have come under scrutiny.47–48 Criticisms of RCT methodology range from concerns about the selection of participants and adequacy of control groups, to issues concerning measurement of key variables. At the heart of the criticisms is the question of whether evidence of experimental validity translates into practical clinical validity for individual patients. These concerns are particularly relevant with respect to research on CAM treatments.
Because consumers and clinicians need access to reliable information about appropriate uses of CAM therapies, additional research on alternative modalities is imperative, and health professions education about CAM is needed to provide the foundation for valid clinical and basic science research on CAM. In the last decade, the NIH has begun to make funding for CAM research and research training available, through NCCAM, providing an impetus for new and experienced researchers to address critical issues in CAM effectiveness, efficacy, and mechanisms of action. Although funding through NCCAM is currently limited compared with other funding priorities at the NIH, the existence of NCCAM is key to the expansion of research in CAM.
Enhancing the quality of health care by integrating information about CAM into health care education
The rationale that many patients are already using both CAM and conventional care, and that their uncoordinated use is potentially costly, inefficient, and unsafe, should be sufficient justification for incorporation of information about CAM therapies into health professions education programs. An additional, important rationale for health professions education in CAM is based on perceived limitations of conventional health care49 and the growing number of studies reporting that complementary and integrative approaches can enhance care outcomes.48,50 The dramatic statistics on medical errors and pharmaceutical risks have alarmed providers and focused concern about safety of conventional medical practices.51–53 The Institute of Medicine has reported high death rates from medical errors.51 Growing numbers of diseases that do not respond well to a “magic bullet” approach to health care, including fibromyalgia, irritable bowel syndrome, and lifestyle-related syndromes, are being successfully ameliorated with mind–body and other alternative treatments.54–59 Studies are beginning to show that integrative care offers expanded treatment options, enhanced patient and provider satisfaction, and enhanced health care outcomes.54–60 Moreover, integration of CAM approaches is bringing an added emphasis on, and tools for, wellness and health prevention. Greater numbers of health care practitioners are beginning to explore integrative approaches in their practices.46,60 Integrating education about CAM practices into mainstream health professions education will serve to raise health care to new and better standards.
Stated rationales by the 15 NCCAM grantee institutions for educating conventional health care trainees and professionals about CAM are still in keeping with the reality of health care resource use by the U.S. public today. It is anticipated that this educational effort will continue to improve three-way communication among conventional providers, CAM practitioners, and patients toward the goals of expanded treatment options, improved outcomes, reduction in adverse interactions, and enhancement of clinical and basic research in the underlying mechanisms of action of CAM therapies. The original NCCAM R-25 educational initiative was both innovative and practical in addressing major communication and knowledge gaps in health care provision. The 15 grantee organizations were largely in accord in terms of their perception of the need for integration of CAM and conventional care through an educational process, the challenges facing such an effort, and the major benefits to patients, providers, and practitioners alike of successful implementation of educational programs addressing integration.
This manuscript was developed with support from the National Center for Complementary and Alternative Medicine (NCCAM), National Institutes of Health, U.S. Department of Health and Human Services Grant No. 5-R25-AT00540-01.
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