Friday, April 24, 2015
National Center for Complementary and Integrative Health - New Name, Fresh Look
4:47 PM | 
Posted by
Kaplan Center for Health and Wellness
A Long-Time CAM Supporter Takes a Timely Look at the ‘Mushy’
Vocabulary of Complementary and Alternative Medicine
On the
occasion of the name change at the National Institutes of Health, I have found
it necessary to provide some background into the terminology that current
exists in the courses I teach and the larger world I inhabit. Many of my students find the CAM terminology
to be confusing. Often, they are fully
aware of the perspectives of mainstream medicine but unaware of what CAM is and
where it is going. Indeed, logical minds
are not comfortable with the constantly changing, "mushy" terms of
CAM. Given the conceptual differences between CAM and mainstream
medicine, and their competition for influence in our culture and economy, one will
not find permanent precision and absolute clarity. It is more of a process of jumping in and
feeling your way around.
In order to understand the vocabulary of CAM, I think it is important to note that there was really no such thing as CAM until the very late 1900’s, when it was referred to as “Alternative Medicine.” According to the NCCIH website1, in 1991, an office was established in the National Institutes of Health to collect information on promising, unconventional therapies that were in use in order to begin evaluating whether any of them had potential benefits. In 1993, that office became the Office of Alternative Medicine (OAM).
In 1998, OAM was elevated to the status of a Center within the National Institutes of Health and the name was changed to the National Center for Complementary and Alternative Medicine (NCCAM). To me, that move represented progress in the process of bringing CAM into the realm of respectability within the medical community. The addition of the word, “complementary” furthered the notion that even a conservative physician could recommend a CAM practice to a patient when it appeared to be reasonable and helpful.
It was
no longer a battle between Mainstream and Alternative Medicine, which in the
1970’s had led to a U.S. District Court ruling (the U.S. Court of Appeals
affirmed and the U.S. Supreme Court declined to review the case) forcing the
American Medical Association to stop trying to destroy Chiropractic.3 That
case made it clear that there were limits on how mainstream medicine (e.g., the
once powerful AMA – the American Medical Association) could limit individual
access to practices that the public found useful and appealing. Since the AMA was unable to prove that
Chiropractic was a fraud and ineffective, the stage was set for expanded State
licensing of non-mainstream health practices and the growth of more practices
that might eventually find their way into mainstream society and medicine.
In
November of 2014, the name of NCCAM was changed to the "National Center
for Complementary and Integrative Health" (NCCIH). This change brings clearer recognition of a truce
between mainstream medicine and at least those practices that have received
validation through the process of mainstream scientific research.
CAM is an umbrella term (concept) that was developed to include all of the medical and health practices that exist which do not fall into the accepted confines of mainstream, conventional, allopathic medicine. Clearly, this is a mixed bag, with some practices having substantial scientific validation and other practices having none. Therefore, what one person considers CAM may be considered “quackery” to another person and mainstream medicine to yet another individual. It all depends upon one’s perspective.
To
further confuse things, there is also no such thing as mainstream medicine,
either. There is no clear cut way to describe all of mainstream medicine,
other than to include everything commonly taught in medical schools and
reimbursed by insurance companies. Such
a broad term, of course, has many exceptions and mainstream medicine includes
many thousands of practices that are unproven and still in stages of
development and research. Mainstream
Medicine is, therefore, just a rough, collective term for the diverse, but generally
accepted, practices, in western medicine today.
An earlier edition of Micozzi’s groundbreaking textbook on CAM2 was named “Fundamentals of Complementary and Integrative Medicine.” Perhaps the author and Publisher were anticipating a change in terminology or perhaps they were hoping to trigger such a change. The various names (complementary, alternative and integrative) have different intentions and meanings, depending upon the context.
Currently, I think that the recent change to "Integrative Health" (NCCIH) is probably motivated to work around the resistance of mainstream medicine to the term "Alternative” medicine. It is also driven by a desire to avoid opposition from mainstream doctors who don't like the term "Medicine" being used for something that is not mainstream medicine, and even practiced by non-M.D.’s. Doctors often assert that only M.D.'s (and D.O.'s) are able to legally practice Medicine and that therefore nobody else should use that term. Thus, we may have just witnessed an important negotiated settlement making it easier for un-researched modalities to be studied by mainstream researchers.
An earlier edition of Micozzi’s groundbreaking textbook on CAM2 was named “Fundamentals of Complementary and Integrative Medicine.” Perhaps the author and Publisher were anticipating a change in terminology or perhaps they were hoping to trigger such a change. The various names (complementary, alternative and integrative) have different intentions and meanings, depending upon the context.
Currently, I think that the recent change to "Integrative Health" (NCCIH) is probably motivated to work around the resistance of mainstream medicine to the term "Alternative” medicine. It is also driven by a desire to avoid opposition from mainstream doctors who don't like the term "Medicine" being used for something that is not mainstream medicine, and even practiced by non-M.D.’s. Doctors often assert that only M.D.'s (and D.O.'s) are able to legally practice Medicine and that therefore nobody else should use that term. Thus, we may have just witnessed an important negotiated settlement making it easier for un-researched modalities to be studied by mainstream researchers.
Words
such as therapy and practice are among other choices for describing
not-specifically-medical interventions. Perhaps the safest way to carve
out different approaches to health and wellness is to put them outside the
domain of “medicine” and into “health.”
Some will see this as mere politics and public relations, but this is
the medico-legal world in which we live, and in which practitioners seek the
freedom to practice in ways that are meaningful and successful to them.
Physicians are technically free to use or recommend complementary and
integrative therapies to the extent that organized medical societies don’t
decide that they have endangered patients and the reputation of medicine.
In the bigger picture, I think that mainstream doctors sometimes take defensive postures against unconventional practices out of concern for patients, but also to confront serious challenges to mainstream medicine orthodoxy. Instead of the reductionist “Disease Model”, many consumers, health practitioners and physicians are in favor of a holistic “Health and Wellness Model”. In the midst of this change, transformation and struggle, here is my understanding of the differences between the different terms:
In the bigger picture, I think that mainstream doctors sometimes take defensive postures against unconventional practices out of concern for patients, but also to confront serious challenges to mainstream medicine orthodoxy. Instead of the reductionist “Disease Model”, many consumers, health practitioners and physicians are in favor of a holistic “Health and Wellness Model”. In the midst of this change, transformation and struggle, here is my understanding of the differences between the different terms:
Underlying the confusion
with the various terms is the fact that these terms apply to how a given
practice is used, rather than anything inherent about the practice,
itself. Therefore, if someone treats
cancer by using acupuncture and herbs, and avoiding standard medical
treatments, that is an “Alternative Medicine.”
If someone uses acupuncture and herbs in addition to standard medical
treatments, that is “Complementary” or “Integrative,” depending upon the
scientific basis in the treatment.
So, a treatment plan is
“Mainstream” if it relies solely upon mainstream medicine. It is “Complementary” if it relies upon both
mainstream and other practices that have some credibility. The treatment plan is “Integrative” if it
relies upon mainstream and other practices that have a scientific basis. It is “Alternative Medicine” if the treatment
plan has no scientific basis and avoids all mainstream medicine.
Hierarchy of Acceptance and Scientific
Validation
of Medical and Health Practices
1. Mainstream Medicine requires scientific proof of relative
safety and efficacy unless grandfathered in as standard practice. Note
that half of mainstream medicine practices are not validated by clinical
research studies.
2. Integrative Medicine requires some scientific evidence of
safety and efficacy, but not mainstream acceptance.
3. Complementary Medicine (or Complementary Health practices)
requires some general evidence of safety and the willingness of doctors to try
it, but does not require mainstream acceptance.
4. Alternative Medicine requires no scientific evidence of any
kind and is generally rejected by mainstream medicine. In a way, anything
goes, since Alternative Medicine also entirely rejects mainstream medicine.
Some doctors use some Alternative Medicine practices as complementary or integrative,
however.
5. Traditional Medicine practices are ancient/aboriginal practices
that are “Alternative”, but may be used at times as Complementary or
Integrative if a doctor thinks it is appropriate.
The state
of the various CAM terms is in constant flux. Therefore, if you are
certain that you understand the precise meanings of all of these terms, you are
probably wrong. Instead, I'd suggest approaching these terms as dynamic,
evolving and used by different parties in different ways. It is important not to overlook that there is
an ongoing, historical process of upheaval in the conceptual base of our health
care system.
Notes
2Micozzi,
Marc S., Fundamentals of Complementary and Integrative Medicine, Third Edition,
Saunders/Elsevier, 2006.
3Wilk v. American Medical Association, 895 F.2d 352 (7th Cir. 1990).
The case was affirmed by the 7th Circuit U.S. Court of
Appeals and review was declined three times by the U.S. Supreme Court.
4According
to their website, “At Duke Integrative Medicine, you experience a new approach to medical
care that brings you and your provider together in a dynamic partnership
dedicated to optimizing your health and healing. Our approach
focuses on all of who you are, recognizing that the subtle interactions of
mind, body, spirit and community have a direct impact on your vitality and
well-being.” http://www.dukeintegrativemedicine.org/, retrieved 3/25/2015.
Earon S. Davis has been involved with the world
of Alternative Medicine, CAM/CIH since the late 1970’s. He has a master’s degree in public health from UCLA and a law degree from Washington University. Earon has had careers in law, environmental
regulation, health advocacy, nonprofit management, massage and bodywork, and
university teaching, along with awards and recognitions.
Currently, Earon is a full-time adjunct faculty
at Kaplan University’s School
of Health Sciences, in the Health and Wellness
Department, where he
teaches courses on CAM, Stress Management and the
Capstone course
in the undergraduate Health and Wellness bachelor’s
degree program.
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1 comments:
Hello Earon,
I like the conclusion remarks you presented when you said "I'd suggest approaching these times as dynamic, evolving and used by different parties in different ways. It is important not to overlook that there is an ongoing historical process of upheaval in the conceptual base of our healthcare system."
In my experience with the mainstream medical profession; especially over the past two years while living in Los Angeles County, California; I see a slow change in accepting the CAM practices as valid, and integrating them into clinical practice. My perception of why this is so goes beyond the reasoning of whether these modalities are useful and effective. If they are to be integrated in a cost effective way, the medical practices and procedures must be carried out so as to maintain an overall monthly income capable of supporting the practitioners and staff operating a practice.
The government and insurance company regulations dictate what services and treatments are allowed for most of the patient population. Within what is allowed are some services and products that are quite lucrative and others that are time-consuming and costly. A wise business manager focuses on gaining and treating clients with conditions and symptoms that will produce the highest income at the lowest output of staff time and expenditure. It is not so much which modality offered is the most useful and effective for a patient but rather what consideration of the patient's needs, insurance payouts, and government limitations and regulations will afford the best combination of chances for financial gain.
In Los Angeles County the population is so dense that the office managers are afforded the opportunity to practice medical acuity in the decision-making processes. No matter what terms or definitions are applied to the myriad of treatment options they must tow their weight and contribute equitably to the practice to be beneficial and acceptable.
Joe Packard
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