Complementary and Alternative Medicine (CAM) - An Introduction
CAM’s Growing Popularity in the United States
Patients were the first to embrace alternative medicine while the medical establishment slowly began to acknowledge its merits. In the United States, alternative therapies are fast becoming an integral part of mainstream health care. In the year 2000, over 40% of Americans spent over 27 billion dollars out of their own pockets on alternative remedies. The number of visits to CAM providers has increased by over fifty percent in the last ten years. According to an informal 2001 survey, there are as many as 220,000 massage therapists, 59,000 chiropractors, 11,000 acupuncturists, 3,000 homeopaths, and 2,000 naturopaths practicing in the United States today.
The massive shift toward alternative medicine began with the results of the 1993 Harvard study, which estimated that one-third of the population used some type of CAM treatment. The results from this study conducted by its primary investigator, David M. Eisenberg, MD, were based on a 1990 telephone survey of 1,539 English-speaking adults.
The Harvard study found that of the individuals surveyed using CAM:
- 44% were college educated
- 39% were middle-class with incomes over $35,000
- 44% were adults aged 25 to 49
- 96% were seeing a physician in addition to using CAM
- 72% of this 96% hadn’t informed their physician about receiving alternative therapy
- 0% answered yes when asked if they used a CAM provider solely for cancer, diabetes, respiratory conditions, skin ailments, high blood pressure, urinary tract symptoms, or dental problems
The final projections from this study showed that in 1990, approximately
- 61 million Americans used at least 1 of 16 CAM therapies.
- 22 million Americans saw a CAM provider.
- 2/3 of the respondents who used CAM did so through self-treatment.
- 1/3 of the respondents treated by a CAM provider averaged 19 visits during the 12 months preceding the study, totaling 425 million visits to CAM providers.
A comparative analysis of these results showed that the 425 million visits to CAM providers exceeded the number of visits to all primary care physicians by about 47 million. Astonishing results at that time—results that had a profound effect on mainstream awareness about the rising popularity of CAM modalities in American society.
The following chart shows CAM usage outside the United States as reported in the British Medical Journal in 1996:
Britain One person in ten consults a CAM practitioner each year. Germany The national health payment system covers many CAM treatments. France 1/3 of the population uses CAM. Russia CAM was legalized in Russia in 1993 when they officially recognized reflexology, chiropractic, homeopathy, and a breathing technique. Australia 1/3 of the population regularly visits a natural therapist and two-thirds regularly take vitamins and receive other “natural” treatments. Japan Western medicine and CAM co-exist, and two-thirds of the Tokyo population reported using CAM treatments. More than 600 herbal medicines are available under the national health insurance system.
With the advent of CAM comes a growing need for additional, substantial scientific information to demonstrate the effectiveness, safety, and positive clinical outcome of CAM treatments. In 1998, Congress established The National Center for Complementary and Alternative Medicine (NCCAM) as a branch of the National Institute for Health’s (NIH) Office of Alternative and Complementary Medicine. The NCCAM was created to fund research to study the effects of CAM on various illnesses; to explore CAM practices within a rigorous, scientific context; to train CAM researchers; and to disseminate authoritative information. The budget of the NCCAM is $100 million, funding several large clinical trials and supporting fifteen specialized research centers.
In March of 2000, former President Clinton formed the White House Commission on Complementary and Alternative Medicine Policy (WHCCAMO). Clinton stated As we enter the 21st century, we need to get better information to ensure American families have access to the best and most cost-effective health care. I know I join the Congress, the policymakers, and the American public in saying how much we look forward to the results of the commission’s work. The commission’s task is to address the following:1. Coordination of research on CAM practices and products 2. Appropriate training and certification for CAM and conventional health care practitioners 3. Dissemination of reliable information on CAM to health care providers and to the public 4. Public access to and delivery of CAM health care services
An increased number of medical schools are now teaching courses on CAM. A recent report in the Journal of the American Medical Association (JAMA) found that nearly two-thirds of US medical schools include CAM content as part of a required course. This report found that 41% of the medical schools included a required course or clerkship which addressed the use of alternative therapies. It was also reported that half of the schools offered an elective course in CAM.
Among the topics discussed in these courses are:
37% Nutritional supplement therapy 35% Herbal Medicine 33% Spirituality 30% Acupuncture 22% Homeopathy 20% Meditation 15% Manual Healing
A recent survey of 46,000 subscribers to Consumer Reports magazine found:
60% of patients using alternative therapies told their doctors they were doing so; of that 60% 55% of doctors approved 40% of doctors were neutral 5% disapproved
- Nearly one in four patients who tried an alternative therapy did so as a result of the recommendation of a doctor or nurse.
In September 2000, the Consortium of Academic Health Center for Integrative Medicine was formed by representatives from 11 medical schools, including University of Arizona, Duke, Harvard, Georgetown, and the University of California, SF. This trend is representative of the ongoing initiative of US medical schools to include integrative medicine in their curricula.
The popularity of CAM is also being noticed in the insurance industry. This trend is exemplified in results from a year 2000 survey done by the International Society of Certified Employee Benefit Specialists (ISCEBS) to investigate the desire of 1200 members to include non-traditional medical care in their employee benefit plans. CAM benefits offered to employees in this survey included:
- 86% chiropractic
- 75% acupuncture
- 41% massage therapy
- 28% nutritional counseling
- 18% naturopathy
- 17% relaxation/stress reduction
- 14% biofeedback
- 10% homeopathy
- 9% Chinese medicine
- 6% yoga
- 4% other
When employees were queried about their personal use of CAM care, the survey found: 45% use of some method of alternative care in the past year 33% would pay more toward employer sponsored health care coverage if it included CAM care 67% sensed a movement toward increased employer offerings or discounts for CAM benefits coverage
When employers were queried about CAM benefits to employees, the survey found: 30% provided CAM benefits because employees asked for them 18% had no reason why they offered CAM benefits 3% cited potential for cost-savings through CAM benefits 42% offered no benefit coverage for CAM care due to lack of sufficient proof of effectiveness.
In 1997, Oxford Health Plans, a large managed care company predominantly in the Northeast and Mid-Atlantic States, began offering a CAM co-pay plan or discount program. This was spurred on by an Oxford Health Plans telephone survey in 1996, which found that one-third of the 400 members were already using some form of CAM therapy. When respondents were asked if they’d like their health insurer to cover CAM therapies, 75% responded affirmatively. Oxford then asked the same question of approximately 100 benefits administrators at major corporations and found 89% answered yes as well. Oxford subsequently established advisory boards of leaders in six CAM disciplines and began an application and review process leading to their current CAM health insurance component.
From the desire of the people to integrate alternative medicine into their health care treatment plan, to government involvement, to increasing insurance coverage, to inclusion in medical school curriculum and hospital programs — CAM is being acknowledged and finding its place in today’s American health care system.
American Academy of Pediatrics Stance on CAM
The 55,000 member American Academy of Pediatrics (AAP) has announced recommendations for physicians regarding their patients’ use of complementary and alternative medicine. The AAP states that “parents who are frustrated by traditional scientific methods may turn to CAM, and that it is in the pediatrician’s best interest to understand these therapies.”
The following policy was developed by members of the AAP’s Committee on Children with Disabilities, led by Adrian Sandler, MD, with the Huff Center in Asheville, North Carolina. (Source: Counseling Families Who Choose Complementary and Alternative Medicine for Their Child Pediatrics, 2001; 107(3), 598-601)
- Seek information for yourself and be prepared to share it with families.
- Evaluate the scientific merits of specific therapeutic approaches.
- Identify risks or potential harmful effects.
- Provide families with information on a range of treatment options (i.e., avoid therapeutic nihilism).
- Educate families to enable them to evaluate information about all treatment approaches.
- Avoid dismissing CAM; it communicates a lack of sensitivity or concern for the family’s perspective.
- Recognize when you feel threatened and guard against becoming defensive.
- If the CAM approach is endorsed, offer to assist in monitoring and evaluating the response.
- Actively listen to the family and the child with chronic illness.
A Family Practitioner’s View of CAM
The March 2001 issue of Family Practice Management included an article that also attempts to guide physicians away from an adversarial relationship with their patients in regards to CAM. “Complementary and Alternative Medicine: A Primer” by Terrence Steyer, MD, includes the following recommendations:
- Ask open-ended questions such as: “Are you doing anything else for this condition?” Avoid using the words “alternative therapy,” at least initially.
- Don’t dismiss the therapy as a placebo. Look into it. If it could be harmful, let the patient know. If it is not harmful and the patient feels better, consider including it in your care plan.
- Discuss providers as well as therapies. Urge patients to use licensed practitioners and to ask CAM providers about their background.
- Discuss CAM therapies with all your patients at every visit. Charting the details of their use will remind you to raise the issue.
Dr. Steyer urges physicians to “learn more, keep the lines of communication open, and become effective guides for our patients.”
Questions and Answers About CAM
What Is CAM?
CAM stands for “complementary and alternative medicine.” It represents a broad range of philosophies, approaches, and treatments of healing that conventional medicine does not commonly use, accept, study, understand, or make available. CAM modalities are those that are used for prevention and treatment of disease, yet not taught widely in medical school or generally available in a hospital setting.
The CAM body of knowledge is vast; hundreds of modalities exist and new forms are still in development. CAM includes, but is not limited to, modalities such as chiropractic, acupuncture, naturopathy, Ayurvedic medicine, energy medicine, massage, herbology, yoga, homeopathy, and crystal healing. Its practitioners claim an imbalance of forces within the body as the cause of disease or symptoms and believe in the body’s ability to heal itself naturally. A CAM provider normally designates a treatment based on an individual’s specific needs; this can oftentimes lead to different treatment strategies for patients with identical symptoms.
Why Do People Seek CAM Treatments?
Many people desire ways to heal themselves naturally without using strong allopathic medicines or resorting needlessly to surgery. Or, they are disenchanted with the conventional medical approach to health and healing. Reasons for this dissatisfaction include, lack of reasonable treatment options, covering up of symptoms rather than treatment of the root cause, being treated as a disease rather than as a whole being. For others, a simpler reason is that someone told them CAM therapies could help and they were willing to give them a try. Still others are attracted to CAM as a prophylactic measure to ensure continued overall balance and health. For many, it is a last resort.
During the year 2000, the Employee Benefit Specialists Study investigated and found the most salient reasons for using CAM to be:
62% for enhancement of overall well-being 60% for effectiveness in treating conditions 50% for prevention and health maintenance 24% due to alignment with personal values 9% due to referral by primary care physician 9% due to low cost 4% due to other reasons
The 1997 Portland study analyzed CAM use by 113 patients from four family practices in Portland, Oregon. The English-speaking respondents were asked if they used CAM, what problems they used CAM for, why they used CAM, and whether they also visited their primary care physician for the problem in question. Results of this study showed that 57 of the 113 patients reported using some type of CAM treatment most often for common, medical conditions that were difficult for their physicians to cure, such as back pain, anxiety, depression, and chronic pain. Other conditions mentioned included infections, neck pain, and various musculo-skeletal problems.
Respondents from this Portland study were asked about their motivations for using CAM and answered with the following reasons:
- 30% to prevent illness or injuries
- 44% for wellness
- 79% to treat a specific health problem
The 1993 Harvard Survey found that respondents used CAM most often for ten troubling, but non life-threatening, conditions. These conditions in descending order of frequency were back pain, allergies, arthritis, insomnia, sprains or strains, headache, high blood pressure, digestive problems, anxiety, and depression.
Which CAM Modalities Are Most Commonly Used?
An individual’s choice of CAM modalities is influenced by availability, familiarity, personal preference, and influence from a referral source. The availability of a certain modality varies from state to state and region to region. Familiarity varies according to media coverage, Internet use, culture, and one’s life experience. Personal preference varies between individuals and is based on lifestyle, history, education, intuition, openness, and personality. Influence from a referral source varies and is based on how convinced a person is that they need to experience a particular modality. Often the most convincing referral is from someone else who has been treated by a particular modality for the same or similar problems with successful results.
Many of the respondents of the 1993 Harvard study reported supplementation of conventional medicine with relaxation techniques, self-help groups, biofeedback, and hypnosis. Other popular forms of CAM cited in this survey were chiropractic, massage, imagery, spiritual healing, commercial weight-loss programs, and lifestyle diets such as macrobiotics, herbal medicine, megavitamin therapy, energy healing, homeopathy, acupuncture, and folk remedies. Thirty-six percent of people who reported back problems relied on CAM, most commonly chiropractic or massage.
The actual percentages of CAM therapies used by participants in this study were:
42% chiropractic 32% massage 30% herbal medicine 24% megavitamins 9% due to referral by primary care physician 21% meditation 10% homeopathy, naturopathy, and acupuncture.
According to the British Medical Journal, the most popular treatments in Britain in 1996 were acupuncture, chiropractic, osteopathy, homeopathy, herbal medicine, and hypnotherapy. In France and Norway, homeopathy is the most popular CAM practice. Norway also reported that acupuncture and aromatherapy were next in line to homeopathy. In Australia, the most popular therapies are vitamin therapy, chiropractic, naturopathy, massage, herbal medicine, and homeopathy. The favorite choices reported in Japan include herbal medicine, acupuncture, and shiatsu.
The year 2000 survey done by the International Society of Certified Employee Benefit Specialists (ISCEBS) found the following percentages of its respondents used:
54% massage therapy 50% herbal medicine 40% chiropractic 31% relaxation/stress reduction 17% nutritional counseling 16% yoga 10% acupuncture 9% homeopathy 4% Chinese medicine 2% naturopathy 2% biofeedback 3% other modalities
What Should One Expect To Pay For A CAM Treatment?
The fee for service for an initial visit with a CAM provider may be lower than that of a conventional physician, although the frequency and duration of CAM treatments may end up being much more. The fees of CAM practitioners vary depending upon who they are, their training and experience, the particular modality they use, how much time they spend with the client, the particular economic standards of their region, and other variations resulting from a practitioner’s particular approach to treatment.
One should expect to pay more for the first visit due to the added time necessary for the initial evaluation. The best way to know if a fee is “normal” and customary is to call several practitioners within the same area and compare answers. If the fees vary greatly, ask the office staff why their fee for service differs from other practitioners.
It’s important for the practitioner or office staff to advise the client/patient as to the actual cost prior to providing treatment. Some practitioners offer a sliding scale based upon economic ability. As more insurance companies provide coverage for CAM, more CAM providers are accepting third party reimbursement—although most ask for payment upon receipt of service and have the insurance company reimburse the patient directly.
Which Insurance Companies Cover CAM?
Most CAM treatments, other than chiropractic, are not reimbursed by health plans or insurance companies. It is becoming more and more prevalent for other CAM modalities, such as acupuncture and massage to be covered by insurance policies. People have been “paying out of pocket” for their CAM treatments for many years and continue to do so, regardless of insurance coverage.
In 1995, Washington State became the first state in the US to pass a law requiring health insurance companies to cover CAM therapies. The law was then challenged by health insurers and is currently in litigation. Regardless of the litigation, there are a considerable number of insurance companies covering CAM due to consumer demand.
Since 1996, several managed care companies on the West Coast began covering CAM treatments such as Group Health Cooperative of Puget Sound in Washington State, Blue Cross of Washington and Alaska, PacifiCare and Regents’ Blue Cross/Blue Shield of Oregon, and Health Net in California. Most of the largest HMOs in California now offer optional acupuncture and chiropractic care.
On July 1, 1997, Matthew Thornton Health Plan in New Hampshire began offering optional, direct access to chiropractic, homeopathy, naturopathy, and acupuncture. Some aspects of CAM are covered under this company’s basic benefit plan and members can receive discounted rates from a select list of massage therapists.
Several insurance companies, such as Oxford, Horizon Blue Cross Blue Shield, Landmark, and Ameri-Health are offering a discount program to cover various CAM practices. Most of these companies arrange for a reduced fee for service with the particular member practitioner. Sometimes the CAM modality can be provided for a $10 co-pay, but this is only when the patient is employed by a large company that has elected this option for their employees.
Suburban Health Plan in Connecticut and Alignis Health System in the upper Midwest offer CAM coverage as well. Suburban allows licensed naturopaths to serve as primary care physicians.
Today, most insurance plans do not reimburse for CAM therapies although the number that do provide coverage increases every year. The easiest way to find out about coverage is to consult your agent. Many of the agents can make recommendations as to the company that will most likely provide CAM coverage.
Does Medicare Provide Reimbursement For CAM Treatments?
Medicare only covers chiropractic at this time.
HR 747, the “Federal Acupuncture Coverage Act of 2001” was reintroduced by Congressman Maurice Hinchey (D-NY) on February 27, 2001 for Medicare and the Federal Employee Health Benefit plan.
How Often Do People Consult A CAM Practitioner?
The frequency with which people consult a CAM practitioner really depends on the philosophy of the practitioner and on the specific modality they are providing to the client/patient. The treatment recipient?s age, attitude, health status, and severity of symptoms are also key factors affecting the frequency of treatment.
A general rule is one month of treatment for every year that a person has suffered an illness or symptom. An acupuncturist might see a patient one or two times a week for ten to fifteen weeks of treatment, a homeopath sees a patient once a month for ten months, or a chiropractor three times a week for six months. There are such variations within each CAM modality that it is difficult to provide a definitive answer to this question.
Are There Risks Associated With CAM?
As with any other medical profession, CAM providers are concerned with risks associated with misdiagnosis, improper modality or medical systems used in treatment, and treatment given by unqualified professionals. A major concern has to do with individuals who are practicing CAM on others or themselves without sufficient education.
Another concern has to do with quality control standards for the preparation of herbal products. CAM is in its infancy and regulatory agencies are mobilizing to enact state guidelines to ensure the safety and welfare of the public.
An unpublished study conducted by Beth Israel Deaconess Medical Center’s Center for Alternative Medicine Research, in collaboration with David Studdert, JD and Troy Brennan, MD, JD, reviewed malpractice claims filed from 1990 through 1996, provided by principal chiropractic, acupuncture, and massage therapy insurance carriers. This review indicated that the rates and severity of claims against licensed providers of CAM are lower than those made against medical doctors. Furthermore, survey data provided to the National Acupuncture Foundation by the California Acupuncture Board revealed that, from 1992 to 1999, an average of 25 complaints, representing 0.5% of licensed acupuncturists were filed per year. This data is in contrast the 10,751 complaints, representing 10.16% of licensed conventional physicians, filed against physicians as reported in the 1998-1999 Annual Report of the Medical Board of California.
How Often Do People USE Self-Help CAM Techniques?
Those surveyed in the 1993 Harvard Study commented on the frequent use of exercise and prayer as a self-help CAM technique. Not including these activities, one in three respondents said they had used at least one form of CAM during the year.
What Is Integrative Medicine?
“Integrative medicine” is the practice of medicine that combines the best from both conventional and alternative methods to maximize the body’s innate potential for healing. The term was coined by Dr. Andrew Weil, a physician, author, educator, and proponent of integrative medicine who directs the Program in Integrative Medicine at the College of Medicine of the University of Arizona.
Do People Utilize CAM In Conjunction With Their Primary Care Provider?
Some factors influencing the usage of CAM in conjunction with conventional medicine is dependant upon legal requirements, availability, and commonly accepted behavior within a particular state. An acupuncturist in California and New Mexico is considered primary care whereas one in Pennsylvania must work under the supervision of a medical doctor. A naturopath who is often used as primary health care may practice legally in Connecticut, but not in New Jersey.
The 1997 Portland survey found that 36% of patients were also seeing a physician for the problem they were treated for with CAM. They reported a belief that the combination of conventional and alternative treatment would relieve symptoms quicker. Thirty-six percent of other patients who used only CAM believed alternative care to be more effective than conventional medical care. However, these patients also claimed to feel their problems were not serious enough to require the care of a physician, or they did not want to rely on pills and surgery. Fifty-three percent reported their use of CAM to their family physician.
What Is The Difference Between Alternative/Complementary (CAM) and Holistic Medicine?
“Holistic” is a term describing an approach which encompasses the whole person, including the mind, emotions, body, and spirit. "CAM"’ is a term referring to a general type or body of medicine which is non-conventional. Many alternative therapies are described as “holistic” due to their basic premise of viewing and treating the patient as an integrated, whole being. The important distinction here is that just because a modality is alternative does not automatically mean it is holistic, and vice versa.
What Type Of Credentialing Is Necessary To Practice CAM?
Of the various CAM practitioners, only chiropractors are required to be licensed in all states. State regulations for other CAM practitioners vary widely and a profession unregulated in one state may be regulated in others. Only chiropractic, acupuncture, and naturopathy have accrediting bodies recognized by the U.S. Department of Education.
There exists a Federation of State Medical Boards that can be contacted to find out which professions are regulated by a state along with the type of regulatory board.
When investigating a modality, it’s helpful to first notice whether “certification,” “registration,” or “licensing,” is required in a particular state. Secondly, it is important to research the specific standards set for each of modality. The standards should provide useful information about educational and/or experience requirements, necessary examinations, and scope of practice.
What Can You, As A Health Provider, Do To Best Protect Your Patients When It Comes To CAM Treatments?
- Be better informed about alternative treatments.
- Follow the research about CAM treatments in regards to efficacy.
- Evaluate your patients, taking into consideration both conventional and CAM treatment options.
- Encourage your patients to talk to you about CAM.
- Clarify your conventional and/or alternative position for your patients.
- Discuss your patient’s case with his/her CAM provider. This may include information regarding history, diagnosis, medications, (including herbs), current treatment strategies, blood disorders, implanted devices, and known treatment outcomes.
Are Practice Guidelines Available In CAM?
Currently, practice guidelines are not available in CAM. This will not be possible until there is more evidence from well-designed clinical trials. Even then, it may be very difficult to create practice guidelines for CAM. The goal of practice guidelines is to reduce variations in practice. This is just the opposite of the CAM approach that evaluates and treats each patient on an individual basis.
Should Patients Address Their CAM Provider As “Doctor”?
Whether or not a CAM practitioner calls him/herself “doctor” depends on the particular state, education, and modality. Chiropractors in all states are called doctor, acupuncturists in some states are called Doctor of Oriental Medicine (DOM) and are referred to as doctor, naturopaths are commonly called doctor although only a few states sanction the practice of naturopathy.
It is uncommon for any of the other CAM practitioners to be called doctor unless the practitioner holds a doctorate degree in another field. In this case, the practitioner needs to inform the patient/client that the doctorate is in another field so as not to mislead to the public.
A practitioner may have been trained and licensed as a physician in another country. Oftentimes, these practitioners ask that their patients/clients call them doctor. This may be misleading to the patient/client because the practitioner hasn’t received his/her medical training in the United States, and medical education standards vary greatly from country to country.
It is the responsibility of practitioners to set the guidelines for their patients/clients as to how they would like to be addressed. This mode of address should be consistent with the state regulations within which they are practicing.
How Can Consumers Be Assured Of The Quality Of CAM Practices And Products In The Future?
The following are recommendations put forth by the National Commission for the Certification of Acupuncture and Oriental Medicine (NCCAOM):
1. CAM practitioners should graduate from accredited schools and demonstrate competency as measured by national certification standards.
2. Federal and private sector funding should be increased to improve the number and quality of surveys, outcomes research, randomized clinical trials, and laboratory investigations pertaining to CAM.
3. Only certified or licensed practitioners should dispense CAM products (such as herbs).
4. Medical school curricula should be standardized to include alternative medicine theory, practice, safety, and efficacy.
5. Continuing education courses should be developed and designed to provide allopathic physicians with sufficient knowledge and management skills to responsibly advise patients who use or request CAM.
6. Cross residency training opportunities should be created for allopathic physicians and students to study under CAM practitioners and likewise for CAM practitioners and students to study in allopathic hospitals and clinics.
7. Federal funding should be appropriated for the development of public awareness campaigns about CAM. For example, public service announcements could urge consumers to seek care from certified CAM practitioners and increase consumer awareness of the need to disclose to their health care provider all CAM self-care products in use.
8. Consistent national standards need to be developed for CAM credentialing, malpractice insurance, and scope of practice.
9. Standardized CAM curricula should be developed pertaining to effective research methodology.
10. A full-text database should be created for peer-reviewed studies, systematic reviews, meta-analyses, and selected texts involving CAM therapies.
11. A comprehensive toxicology index should be created for herbs, vitamins, and supplements commonly available over-the counter.
12. Expand the student loan prepayment plan to include CAM students for work in underprivileged settings and chemical dependency centers.
13. Include acupuncture and Oriental medicine coverage in federal health insurance programs.
14. Develop an Office of Herbal Products within the FDA.