Physicians News Health news for doctors and patients.
By Doris G. Bartuska, M.D.
Complementary Medicine or Alternative Medicine refers to diagnostic methods, treatments and therapies that do not conform to standard medical practices, or are not generally taught at accredited medical schools. At the June meeting of the American Medical Association, the Council of Scientific Affairs presented an excellent report on “Alternative Medicine”.
In a recent national survey by Eisenberg published in New England Journal of Medicine, at least one-third of persons claimed to have used at least one alternative therapy in the past year, and one-third of these persons saw a provider of alternative medical therapy. Among those using an unconventional healer, 83 percent also saw a medical doctor for the same condition, but nearly 75 percent of them did not report the use of alternative care to their traditional physician. The survey data estimated that in l990 the out-of-pocket cost of unconventional therapy in the United States, including the cost of herbal medicines and health food/nutrition therapy, exceeded $l0 billion. Another $3 billion of these costs were borne by third-party payors. The total estimated cost, $l3.7 billion, exceeded the cost of hospital care in the United States in l990 ($l2.8 billion) and is about half of all the out-of-pocket expenses to physician services ($23.5 billion). The authors suggest that the total number of annual visits to alternative practitioners may exceed those to primary care physicians.
The Oxford Health Plan, based in Norwalk, CT, is currently adding a network of about l000 holistic providers from which plan participants will be able to obtain chiropractic, acupuncture and naturopathic treatment without prior approval of a “gatekeeper” at a cost of 2 percent to 3 percent added to the premium. Plan managers may believe that alternative therapies can decrease costs by decreasing utilization of conventional services. However, the Eisenberg study showed that the cost of alternative therapies averaged $27 per provider visit and totaled over $500 per year among those who used alternative methods, who usually sought simultaneous care from conventional physicians.
Americans seek alternative care for a wide variety of conditions. In one national study, the most common complaints presented to unconventional practitioners were back complaints (36 percent), anxiety (28 percent), headache (27 percent), chronic pain (26 percent) and cancer or tumors (24 percent). About one-third of patients in the same survey reported using alternative healers for health promotion and disease prevention advice, or for nonserious conditions not related to their chief complaint.
What do physicians think about alternative medicine? It is likely that most physicians are unaware of the scope, breadth and extent of use of unconventional therapies in the United States. The level of interest among physicians in learning more about alternative therapy, however, seems to be high. A regional survey of family physicians in the Chesapeake Bay area showed that more than 70 percent were interested in training in such practices as herbal medicine, prayer therapy, acupressure, vegetarian and megavitamin diet therapy, acupuncture and biofeedback.
In an unpublished survey of all l25 U.S. medical schools, it has been found that just over 50 schools offer elective, for-credit courses on alternative therapy, and l8 other schools offer lecture series or seminars on the subject. This survey reveals that most are being given by “supporters or proponents of alternative methods,” and that the “scientific view” is offered in only 7 courses.
An editorial by Alpert, published in Archives of Internal Medicine, argues that alternative medicine should not be “condemned out of hand,” but suggests that traditional medicine approach alternative therapy based on five principles. Convinced that many unconventional treatments will eventually become mainstream, he proposes that physicians:
• Maintain an open-minded attitude about all potentially new therapeutic interventions that include those commonly referred to as alternative.
• Encourage carefully performed and appropriately controlled studies of these new therapies.
• Do not ignore or ridicule the potential of the placebo effect to produce marked therapeutic benefit.
• Do not accept all new therapies as efficacious on first acquaintance. Practitioners of quack medicine continue to abound as in all earlier times. Claims of therapeutic efficacy should be rationally examined and tested.
• Avoid hubristic and arrogant attitudes toward alternative medical practices because one might be embarrassed by the subsequent demonstrations of their clinical efficacy.
The Council on Scientific Affairs made the following recommendations:
• There is little evidence to confirm the safety or efficacy of most alternative therapies. Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies.
• Physicians should routinely inquire about the use of alternative or unconventional therapy by their patients and educate themselves and their patients about the state of scientific knowledge with regard to alternative therapy that may be used or contemplated.
• Courses offered by medical schools on alternative medicine should present the scientific view of unconventional theories, treatments and practice as well as the potential therapeutic utility, safety and efficacy of these modalities.
• Patients who choose alternative therapies should be educated as to the hazards that might result from postponing or stopping conventional medical treatment.
The report covered mind-body interventions, diet and nutrition, herbal remedies, manual healing methods, chiropractic, energy healing, pharmacologic methods (such as chelation, ozone, DHEA, colloidal silver, asparagus extract, etc.), acupuncture, homeopathy, naturopathy, ayurveda and folk therapies.
Recommendations regarding folk therapies included:
• That the American Medical Association does not recommend the sole use of unvalidated folk remedies to treat disease without evidence regarding their safety or efficacy.
• That the AMA encourage research to determine the safety and efficacy of folk remedies.
• That physicians should be aware that the use of folk remedies may delay patients from seeking medical attention or receiving conventional therapies with proven benefit for disease treatment and prevention.
• That practicing physicians should routinely ask patients whether they are using folk medicine or family remedies for their symptoms. Physicians can educate patients about the level of scientific information available about the therapy they are using, as well as conventional therapies that are known to be safe and efficacious.
I agree with these recommendations and welcome your comments.
Doris G. Bartuska, M.D., FACP, FACE, is Emeritus Professor of Medicine, Endocrinology, Diabetes and Metabolism at Allegheny University of the Health Sciences, Medical College of Pennsylvania in
