21st century ushers in integrative medicine: but many questions remain about how the health care system will react - Integrative Medicine

Physician Executive, July-August, 2003 by Marc S. Micozzi

First recognized by the medical and scientific community during the 1990s, integrative medicine today is attracting interest from medical practitioners, administrators, academicians and scientists seeking to incorporate it into their research, practice and teaching.

Consider these developments:

* Health systems, insurers and state and federal governments are investing more deeply and broadly in integrative medicine.

* In recent years, it's estimated that there were more visits by the American public to alternative practitioners than to primary care physicians.

* Use of herbal remedies and dietary supplements is now supported by a $30 billion industry in the U.S.

* Until recently when only limited insurance or tax benefits became available, American consumers paid for most of the costs for these products and services out of pocket.

* It is also estimated that the out-of-pocket amount spent by consumers for alternative care exceeds the out-of-pocket co-payments and deductibles consumers make for health care covered by insurance.

An irony for physicians is that one last bastion of traditional fee-for-service medicine resides among alternative practitioners.

Names and labels

In trying to develop names for these alternative types of care, various labels were advanced such as nontraditional, unconventional, unorthodox, holistic and "wholistic--a revival from the 1960s.

In the midst of the call for greater scientific evidence and objectivity, these labels betrayed cultural values, prejudices and judgments about the validity and appropriateness of such types of care.

The more properly descriptive terminology of alternative and complementary medicine became generally accepted. Alternative came to imply a mutual exclusivity between these types of care and the regular practice of medicine. Complementary was more accurate in describing a compatibility between the utilization and acceptance of these treatments as an adjunct to--not a replacement for--regular medicine.

Institutions such as Thomas Jefferson University Hospital in Philadelphia pioneered use of the term (and the practice of) integrative medicine. Integrative medicine implies an active, conscious effort by the health professions and medical science to seek out and sort out the evidence and application of various complementary types of care for appropriate incorporation into the continuum of health care.

Types of care

Meditation, talk therapies, bioenergetic manipulation, massage, physical manipulation, insertion, ingestion, injection and surgery, are one array.

Alternative/complementary practices are then organized around the use of one or more of these techniques. For example:

* Chinese medicine uses bioenergy ("qi") manipulation (tui na, qi gong), insertion (acupuncture needles) and ingestion (herbs and foods) for medicinal purposes, approximating a more "complete" system of care.

* Chiropractic is traditionally limited to manipulative therapy.

Furthermore, individual practitioners within one system of care may incorporate use of other healing practices from outside that system of care such as the physician or chiropractor who incorporates acupuncture.

Finally, individual techniques practiced in a manner that is removed from the traditional system of care--what may be called "formulary approaches"--are increasingly proven to be effective.

For example, in the traditional practice of Chinese medicine, the client generally seeks the services of a seventh-generation Chinese practitioner who may also wish to incorporate herbs, manipulation and other remedies for the treatment of a medical condition.

Meanwhile, in the U.S., a licensed physician may attend a six-week course in acupuncture in California and become a licensed acupuncturist. Research shows that acupuncture provided by the physician on a "formulary" basis is effective.

Availability

The availability of complementary care is determined by:

* Existence, numbers and locations of practitioners trained (and licensed, where applicable) to provide these services

* Access to these practitioners through clinics, hospitals, academic medical centers, and health care systems and networks.

Individual practices exist and often thrive independent of the mainstream health care system. Given the dimensions of the movement, it is often striking how few "alternative" providers presently exist relative to the mainstream medical workforce.

Manual and manipulative therapies are relatively well represented with approximately 100,000 massage therapists and over 50,000 licensed chiropractors. There are approximately half that number of osteopaths, with perhaps fewer than one-quarter maintaining any practice in manipulative therapy.

Manipulative therapy is also relatively well regulated, with licensure for chiropractic in all 50 states and the District of Columbia and accreditation of graduate schools of chiropractic. Meanwhile, osteopathy has been fully subsumed under the credentialing processes of mainstream medicine.

By contrast, other fields of complementary medicine are sparsely represented: