Considering the alternatives - Complementary and Alternative Medicine - What's alternative?

Physician Executive, Nov-Dec, 1998 by David O. Weber

Therapies variously described as alternative, complementary, or unconventional because they lie outside the realm of scientific medicine practiced by graduates of orthodox U.S. medical schools are gaining mainstream respectability despite many questions about their efficacy and safety. Depending on definitions, surveys indicate that fewer than 10 percent to nearly 40 percent of Americans supplement or substitute for conventional health care with alternative systems of medical practice. Spending for complementary and alternative medicine (CAM) nationwide has been estimated at up to $14 billion a year. Establishment of an Office of Alternative Medicine in the National Institutes of Health in 1992 has heartened advocates of CAM, increased interest and government funding for research into unorthodox therapies, and lent credibility to CAM modalities. Embracing marginal therapies may represent an opportunity for physicians and health systems to reduce inappropriate consumption, offer a wider range of choices to pat ients, and profit from a lucrative market.

Key Concepts: Alternative Medicine/Complementary and Alternative Medicine (CAM)/Unconventional, Alternative, or Complementary Therapies/Unorthodox Modalities

BY ALL OUTWARD CREDENTIALS, RICHARD SHEFF, MD, is a physician of the old school. He's an Assistant Professor of Family and Community Medicine at the prestigious Tufts University School of Medicine in Boston, a former Chairman of the research committee of the Massachusetts Academy of Family Practice, and a member of American College of Physician Executives whose resume includes senior administrative positions at a physician-hospital organization, an independent practice association, and a major hospital. Recently, he founded his own innovative disease management company.

"I approach things as a skeptic and a scientist," Sheff asserts. Yet, when the 44-year-old doctor/entrepreneur suffers back and neck pain, he seeks relief from a chiropractor. And when his children developed allergies and asthma, he readily endorsed a therapeutic regimen that included acupuncture and Chinese medicinal herbs.

Sheff, like as many as one in three of his fellow Americans, is convinced that benefits can be derived from what are variously termed "unconventional," "alternative," or 'complementary" therapies. Indeed, according to an influential and endlessly cited survey by David Eisenberg. MD. published in the New England Journal of Medicine in 1993. Americans may be more apt to take their medical problems to practitioners of healing arts not taught in traditional medical schools than they are to bona fide primary care physicians. (1)

Extrapolating from 1,500 telephone interviews, Eisenberg calculated that spinal manipulation, acupuncture, biofeedback, massage, and a dozen other non-textbook treatments accounted for 425 million visits to alternative health care providers nationwide in 1990, as against 388 million visits to primary care doctors. What's more, he reckoned, patients spent almost $14 billion for those unorthodox ministrations, fully $10 billion of it out-of-pocket.

Sheff resembles his fellow consumers of unconventional therapies in several other ways. Studies have shown that they tend to be well educated, not the opposite, and that they embrace alternative modalities not so much because they are dissatisfied with mainstream medicine as because, according to John Astin, PhD, a researcher at the Stanford University School of Medicine, they find non-traditional approaches to healing and wellness "congruent with their own values, beliefs, and [holistic] philosophical orientations toward health and life." (2)

Wallace Sampson, MD, an oncologist who has taught courses on holistic health care to Stanford medical students since 1979 and edits the quarterly journal The Scientific Review a/Alternative Medicine, takes a decidedly jaundiced view. He dismisses consumers of fringe therapies as "the disaffected" who have "abandoned rationality. They've been swept up in a mass delusion."

The establishment is fretting

And just how palpable that mass may be is open to question. Critics of Eisenberg's research charge that he significantly inflated his consumption numbers by including as "unconventional therapies" such pedestrian practices as meditating (use of "relaxation techniques" was the practice reported most often by those in his sample, 13 percent), joining a commercial weight-loss program, trying a "lifestyle" diet, or taking part In a self-help group. When alternative therapies were winnowed to a hard-core four--chiropractic, acupuncture. relaxation techniques, and therapeutic massage--only 10 percent of Americans could be considered the market, according to a recent analysis of the 1994 Robert Wood Johnson Foundation National Access to Care Survey. Still, noted L.C. Paramore, of the Project HOPE Center for Health Affairs in Bethesda, Maryland, in the February 1997 Journal of Pain Symptom Management, that's almost 25 million people. (3)

More than 400 of 1,000 men and women randomly surveyed by Astin had relied on some form of alternative health care during the past year. he reported in the May 20 issue of the Journal of the American Medical Association. They were most often seeking to alleviate such nagging and often nebulous conditions as chronic pain, anxiety, muscle strain, addiction, arthritis, or headache. (2) Interestingly, in another recent study of patients at a primary care clinic, reported in the Journal of the American Board of Family Practice in May, fewer than half of the 28 percent who had gone to alternative practitioners came away satisfied, although 82 percent acknowledged some improvement in their condition. (4)