By Belinda Anderson, Ph.D., L.Ac.
The move towards integrated medicine (IM) is now at its greatest momentum thus far. The recent Institute of Medicine Summit on Integrated Medicine and the Health of the Public, and the healthcare agenda of the Obama administration have taken IM into a new arena of possibilities, which may well materialize quite quickly. Integrative medicine is basically a system of medicine that embraces patient-centered care, focuses on prevention and wellness, embraces the significance of lifestyle, environmental and psycho-social factors as determinants of health, and selects appropriate treatments according to effectiveness based on evidence.
For IM to develop in the United States, there is the necessity for education of both the general public and of health care providers, and for greater communication between medical practitioners and patients. New models for practicing medicine both within medical settings and at home are being developed. The methodological approach used in research studies investigating alternative medical interventions is being scrutinized and efforts made to develop innovative approaches. There is also the need to better understand the mechanistic basis of alternative medical modalities. Such research could significantly change the paradigms governing our understanding of modern biology. The economic aspects of the healthcare system in the US need serious attention. Most importantly, cost benefit reevaluation, economic incentives for wellness and prevention, and an insurance system that is inclusive of effective alternative medical approaches to patient care need to be discussed.
As we move towards an IM model for healthcare, the term Complementary and Alternative Medicine (CAM) will start to disappear. Interventions will not be judged according to conventional or alternative, but rather according to effectiveness. This will bring many changes to the way that medicine is practiced. Practitioners will need to be knowledgeable about different approaches and communication between different types of practitioners will be integral to the success of IM. CAM practices that already have strong educational and licensing infrastructure (like Oriental medicine and chiropractic) will be more readily integrated. For practitioners of Oriental medicine (OM), this will bring significant changes and opportunities to the profession. The focus of this article is to explain the important aspects of IM as they relate to how OM practitioners can adapt to become part of the IM movement.
Development of CAM and IM
Recognition of the magnitude of CAM usage was the primary factor that lead to its acknowledgment and investigation. The seminal papers published by David Einsenberg and colleagues from Harvard Medical School (Einsenberg et al, 1993; Einsenberg et al, 1998) in 1993 and 1998 demonstrated that significant numbers of people in the US were seeking CAM and were willing to pay for these treatments out-of-pocket. At that time, the out of pocket spending was valued at $27 billion per year, and this has grown significantly since then. The latest statistics published by the Centers for Disease Control (Barnes et al, 2008) show that in 2007, about 38 percent of adults and about 12 percent of children used CAM therapy in the past 12 months. Between 2002 and 2007 the use of acupuncture increased from 1.1 percent to 1.4 percent of the population. With this relatively low level of usage, there is plenty of room for expansion (8.6 percent of the population had chiropractic or osteopathic care in 2007).
The greatest factor holding back the broader use of CAM is the lack of insurance coverage. Most consumers of CAM are in the upper socioeconomic brackets and pay out of pocket. When insurance coverage expands, acupuncture services will be more accessible to people from lower income levels through hospitals and other IM clinical settings. This will bring many more possibilities for acupuncturists in terms of employment opportunities and the size of patient bases for private practices. The greatest factors influencing the likelihood of insurance coverage are research outcomes that demonstrate that acupuncture is effective.
The Role of Research
CAM research has grown significantly over the past 15 years. The vast majority of funding for this research comes from the National Institute of Health (NIH), mainly through the National Center or Complementary and Alternative Medicine (NCCAM) (the 2008 budget was $121.5 million), but also collectively from several of the other NIH 26 centers and institutes (total CAM research spending from the NIH in 2008 was $298 million). To date, there have been over 500 randomized controlled trials on acupuncture and there are over 50 systematic reviews on acupuncture in the Cochrane Collaboration database (see below). Although there are significant issues associated with this research (e.g., placebo effect, appropriate methodology, reported inadequacies etc; Birch, 2004 and references therein) there is a critical mass of good quality studies that have demonstrated the efficacy of acupuncture for a growing list of conditions (Park et al, 2008). These studies are available via internet searches of appropriate databases (see below), enabling medical practitioners to recommend acupuncture based on research outcomes (evidence based medicine). This has lead to a much greater number of people seeking acupuncture as a result of referrals by other medical practitioners (MDs, PTs, RNs etc).
Going forward, we are going to see a shift in research funding towards mechanistic (understanding how acupuncture works) and effectiveness studies. The latter studies investigate the beneficial effects of acupuncture within authentic settings (practitioner's offices, acupuncture clinics, etc), as opposed to within the context of a randomized controlled trial. Such research will enable much better assessments to be made about the true impact of acupuncture on illness. The mechanistic studies will further legitimize acupuncture by providing insight into the biological effects. Such lines of investigation are already encouraging scientists to look more critically at the current ways in which biology is understood and will likely result in paradigm shifts.
Evidence Based Medicine
Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients (Sackett et al, 1996). This approach to medical practice developed in the 1990s and is now the dominant paradigm in modern medical practice and education. From a practical standpoint, what this means is that medical practitioners cannot endorse a particular intervention unless there is evidence in the literature to support it. To facilitate the ability to get access to good quality researchbased evidence, the Cochrane Collaboration (www.cochrane.org/) was established in 1993. This is an international non-profit independent organization that produces and disseminates systematic reviews of healthcare interventions (Cochrane Database of Systematic Reviews). The precursor of the systematic review was the narrative review, which lacked specific publishing guidelines to ensure inclusion of all evidence and a system to evaluate evidence based on quality. Systematic reviews are undertaken according to strict guidelines pertaining to information (literature) searches and quality rating of evidence such that the conclusions of such reviews are accurate and unbiased. Usually, they also include a meta-analysis of the collective data from all of the trials included in the review.
Systematic reviews are the highest form of evidence to endorse a medical intervention. When such a review is not available, forms of evidence in order of decreasing reliability (quality) are as follows:
- Evidence obtained from at least one properly designed randomized
- Evidence obtained from a well designed controlled trials without randomization.
- Evidence obtained from well designed cohort or case-control analytic studies, preferably from more than one center or research group.
- Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
- Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Practitioners in an IM setting need to practice EBM. In fact, this is a critical aspect of IM because medical interventions are chosen based on evidence, instead of whether an intervention is conventional or is the usual standard of care. However, this is not as easy as it sounds for several reasons. First, the database is not complete, that is, it does not contain information about the efficacy of all commonly available interventions to treat all possible conditions. For example, there is no systematic review (or readily available clinical trial, or well-designed cohort or case-controlled analytic study etc. in the mainstream literature) for the use of acupuncture to treat uterine prolapse. However, acupuncture has been used to treat this condition for thousands of years.
This brings us to the second issue. The types of evidence that are most highly rated, as shown above, are those that are undertaken within a Western scientific context. The opinions of respected authorities are the lowest, and this would include the vast amount of information that is in our OM textbooks and taught in OM college curriculums. Anecdotal evidence, the bedrock of OM practice, is not recognized as good evidence. The problem is not simply overcome by continuing to do more clinical trails because the data from the efficacy trials has its own inherent issues and challenges. For example, there is a growing trend in the scientific literature suggesting that placebo acupuncture is equally as effective as real (verum) acupuncture for many conditions (Moffet, 2009). This has led some to conclude that OM theory, which dictates specific points for specific conditions, is questionable.
The methodological approach of acupuncture clinical trials has been criticized (Birch, 2004 and references therein), and may be in part responsible for these and other types of outcomes ‘disproving' the efficacy of acupuncture. This approach to providing evidence to support the practice of acupuncture may not be ideal (MacPherson et al, 2008). However, for now it is the best that we have, and OM practitioners wishing to practice IM need to understand the subtleties of this, and how to treat and advise patients using all the information available to them both from their OM education and from modern research.
Communicating with Other Medical Practitioners
The ability of IM to improve healthcare and provide patients with better choices is also reliant on communication: between practitioners and patients, and between practitioners of different medical disciplines. Choosing the best approach for treating a condition is dependent upon knowing what works most effectively and having buy-in from the patient. Trying to make a patient seek out a treatment option they are afraid of and/or do not trust may well be counterproductive, even though the literature supports its effectiveness.
Communication and education are key to providing the information to both practitioner and patient about different treatment choices. Practitioners need to educate each other by forming collegial relationships, which will also generate referrals and provide mutual benefit. Practitioners need to seek out education about other medical approaches and keep abreast of research findings so they can best communicate with their patients and provide optimal advice.
There are many ways to improve the volume and quality of communication with Western medical providers and there are a couple of important aspects to keep in mind. Some readily available ways to develop relationships include following up on patient cases with Western medical providers (joint case management); giving talks at hospitals, clinics, medical practices, and special interest groups; sending informational material to practitioners and following up with a phone call and/ or office visit; joining networking groups (in person and on-line) etc. General impressions are very important, so being informed, knowledgeable, articulate, and respectful of all medical practices, professionally dressed, and focused on optimal patient care will help foster worthwhile IM networks.
Giving a talk about OM to a Western medical audience is a great opportunity to educate that community, dispel myths (e.g., acupuncture only treats pain), form relationships, generate referrals, get job offers, and learn a great deal in the preparation phase. Many new OM practitioners are uncertain as to how to handle the research aspects of our profession. The research can strongly legitimize the medicine for this audience and will give you a lot of buy-in if handled well. There are several key factors: think carefully about who your audience is and what information would resonate best with them (Western medical audiences respond better to scientific information); don't talk about something you do not feel you really understand (make sure you really understand the science if you are going to talk about it); limit the amount of time you spend on Chinese medicine theories to explain illness and how acupuncture works (the limited amount of time in a talk does not allow for sufficient explanations of Chinese medicine theories and they end up sounding overly simplistic).
Internet Resources for IM
There is a wealth of resource material on the internet that can help OM practitioners learn about and practice IM. The following is a list of useful categories of information (it is by no means exhaustive):
- Education programs - many institutions offer certificate and degree programs in integrated medicine. Programs that have gained significant recognition are offered at the University of Arizona, Duke University and Georgetown University. Forty-two academic medical centers are part of the Consortium of Academic Health Centers for Integrative Medicine (www.imconsortium.org/). All members are active in developing CAM curriculum within MD programs and fostering IM.
- Institute of Medicine Summit on Integrative medicine and Health of the Public (www.iom.edu/CMS/28312/52555.aspx) held in February 2009. This site containscommissioned pre summit white papers, slides and audio recordings from the talks.
- Evidence based medicine databases - Cochrane Collaboration (www.cochrane.org/), National Center for Biotechnology Information (NCBI) - Entrez PubMed (www.ncbi.nlm.nih.gov/sites/entrez).
- IM organizations - American Association of Integrative Medicine, Integrative Medicine Alliance, American Holistic Medical Association.
- Philanthropic organizations - The Bravewell Collaborative, The George Family Foundation.
- Journals - Integrative Medicine, Journal of Alterative and Complementary Medicine, Alternative Therapies in Health and Medicine, Journal of Complementary and Integrative Medicine, Journal of Integrative Medicine.
- Clinics - many high profile hospitals and clinics have integrative medical programs, e.g., Mayo Clinic, Memorial Sloan Kettering Cancer Center, Scripps
- Research - NIH National Center for Complementary and Alternative Medicine (http://nccam.nih.gov/; this is an excellent resource).
- News and politics - The Integrator Blog (http://theintegratorblog.
- Supplement/herbal medicine information - Natural Products Foundation (www.supplementinfo.org/), Memorial Sloan Kettering Cancer Center natural product monograms (www.mskcc.org/mskcc/html/11570.cfm), Columbia University Rosenthal Center herbal monographs (www.rosenthal.hs.columbia.edu/Botanicals.html).
- Networking groups - Integrative Practitioner (www.integrativepractitioner.
com/), LinkedIn (www.linkedin.com) Integrative medicine Networking group.
- Statistics - Center for Disease Control 2008 CAM statistics (www.cdc.gov/nchs/data/nhsr/nhsr012.pdf).
Adapting your practice of OM to an integrative medical model is fundamentally an exercise in education and outreach. Integration implies the harmonious co-usage of all possible medical approaches according to what works best, cost effectiveness, and patient well being. To adapt, OM practitioners need to reach out to other medical practitioners, find out about other CAM modalities and conventional approaches, form relationships for shared patient case management, develop professional networks, and keep abreast of research findings. The integrative medical movement offers many extraordinary opportunities for our profession. OM
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Belinda Anderson, P.h.D, L.Ac. Dr. Anderson earned her P.h.D in Molecular Biology from the University of Sydney (Australia), and her Masters degree in Chinese and Japanese Acupuncture and Chinese Herbal Medicine from the New England School of Acupuncture (NESA, Boston, MA). Dr. Anderson has over 20 years of teaching, academic administrative, andresearch experience. Recent research positions were at the Sloan Kettering Institute and at NESA in collaboration with the Osher Institute at Harvard Medical School. Dr. Anderson's current research interests include the mechanism of acupuncture, and acupuncture and IVF. She is widely published, serves as an editor for several complementary and alternative medical journals, and regularly participates on National Institute of Health (NIH) National Center for Complementary and Alternative Medicine (NCCAM) expert panels to determine research-funding allocation. Dr. Anderson is currently the Academic Dean at Pacific College of Oriental Medicine in NY, and practices as an acupuncturist and Chinese herbalist in NYC.