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A Physician's Guide to Complementary and Alternative Medicine

A Physician's Guide to Complementary and Alternative Medicine

"Savior or Quack?" That was the caption under the photo of internist John C. Pittman in a 1991 North Carolina newspaper article. Pittman became the focus of the article after beginning to integrate oxidative therapies with conventional medicine as part of his clinical practice to treat HIV patients.

Pittman, currently the medical director of the Carolina Center for Integrative Medicine in Raleigh, N.C., says things have definitely changed in the last two decades when it comes to how patients and his fellow physicians view the use of everything from yoga to herbal remedies in healthcare.

"Back then, the viewpoint was extreme — if you were doing something outside convention, you were either walking on water or the devil incarnate — there was nothing in between," he notes. "Now, there is more moderate thinking and acceptance that people doing this kind of thing are a little bit ahead of their time … There is much more supporting the approaches and you can point to an enormous amount of published data."

Both the reception to and the use of complementary and alternative medicine (CAM) by patients has evolved in the United States.

In a 1998 study in the Journal of the American Medical Association, the use of at least one of 16 alternative therapies — including massage and homeopathy — increased from 34 percent in 1990 to 42 percent in 1997. More recent data shows consistent, ongoing use of CAM by patients.

According to a 2007 National Health Interview Survey, a federal data collector, 38 percent of adults were using some form of CAM to promote wellness or to treat various diseases or conditions. In 2009, a subsequent study found that Americans spent $34 billion out-of-pocket for CAM services.

That level of patient use and personal spending has brought CAM to the forefront of physician attentions, but it still suffers from negative perceptions by much of the medical community. Should it? Or could CAM offer you more options for successfully treating your patients? Could it have a role in your practice? Let's find out.

What is CAM?

According to the National Center for Complementary and Alternative Medicine (NCCAM), a research division of the National Institutes of Health, defining CAM is not as easy as it sounds, given that the field is ever-changing. The NCCAM defines CAM as "a group of diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine," with "conventional" meaning Western or allopathic medicine.

"Complementary" medicine usually refers to using such methods in conjunction with conventional medicine; "alternative" generally means in place of it. And "integrative" or "integrated medicine" refers to a practice combining both conventional and CAM approaches, "for which there is evidence of safety and effectiveness," according to NCCAM.

Many CAM approaches — encompassing everything from use of probiotics, meditation, acupuncture, massage therapy, and energy medicine — have long histories, but their use alongside mainstream medicine is still evolving, especially when it comes to physician acceptance.

"Physicians are appropriately, I believe, thinking hard about which of these practices are useful to people and which are dangerous," says Josephine P. Briggs, NCCAM's director. "Our goal at the NIH is to make sure there is good science being done so that these distinctions can be made and so people can base this on real evidence."

Originally called the Office of Alternative Medicine when established in 1992, NCCAM's creation, Briggs says, was based on "heavy use by the American public" and "a feeling there were some health practices the public wanted to know about."

With those practices have also come rules, in the form of state laws and licensure about who is able to perform CAM treatments. CAM credentialing varies from state to state and by method. For example, all 50 states and the District of Columbia require licensure for chiropractic practitioners, while only 42 states and D.C. have licensure rules for acupuncture, according to NCCAM. Then you have licensure for homeopathic physicians, present in only three states.

Michael H. Cohen, an attorney specializing in legal issues for physicians and CAM practitioners based in California, says that the growing number of state laws and licensure does legitimize the use of CAM. But he also notes practitioners still need to be wary of "broadly drafted medical licensing laws" and the threat of regulatory and legal sanctions for unlicensed medical practice. "Ignorance of the law is not a defense," Cohen says.

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