The nine presenters of the Alternative Medicine Colloquium offered their thoughts to a small audience (less than 60 people) and the medical board. The presentations outlined the research efforts of the Office of Alternative Medicine (OAM); addressed the experiences of various Canadian provinces relative to alternative care; explored the ethical and legal questions associated with the incorporation of alternative forms of health care into the practice of medicine.
It was abundantly clear listening to the speakers that the practices commonly referred to as "alternative health care" have gotten the attention of even the most conservative elements of medicine's inner circle. Further, the desire of medicine to not let this parade go by without being a part of it is undeniable.
Some of the specific comments and data offered by the presenters included:
David Spiegel, MD, professor of psychiatry and behavioral sciences at Stanford University, began by posing questions: Why is the use of alternative medicine growing? What is alternative medicine? And what should be done about it? Spiegel said, "Each side has some truth; neither is 100% right."
Dr. Spiegel commented that the problem for medicine is that it has focused on a "cure" model following the successes of antibiotic therapy, but the kinds of health problems most people encounter are progressive, chronic and deteriorating, and not subject to cure. People are approaching medicine and medicine is approaching the public in a cure model, but there is no cure to be had; therefore the public is looking elsewhere for their "cure." As to the reasons why people are seeking alternative health care, 56% go because of pain; 22% go because of stress; and 7% go for health promotion.
Dr. Spiegel also mentioned that the $12 million annual budget of the OAM represents only 3/10ths of one percent of the NIH budget. He finished by saying, "There are risks to not using alternative methods when appropriate."
Michael Carlston, MD, course director and faculty principal at the University of California San Francisco School of Medicine, reported on a survey of 124 medical schools and 380 directors of family medicine residency programs. The survey showed a 77.9% response rate in response to questions about the presence and extent of course or program information about alternative health care. Among the medical schools, 34.8% are presenting some coursework on alternatives; 6% are beginning the same, and 6.3% have the subject under consideration.
The greatest interest was found in the northeastern portion of the U.S. Of those schools that do offer coursework, 75% are elective, and 25% are required. There was a 50-50 split on didactic and clinical emphasis, and 40% of the schools taught something related to chiropractic.
What will this question look like in 10 years? Among the answers:
- "Integrated medicine" as a concept will replace conventional and alternative care;
- Complementary and alternative medicine (CAM) will be found useful;
- CAM will be found to not be as good as some think;
- Conventional medicine will continue to be useful;
- Conventional medicine will be found to not be as good as some people think.
Ken Pelletier, PhD, clinical associate professor at the Stanford University School of Medicine, detailed the elements of consumer demand as he understands them:
- a general dissatisfaction with medicine;
- recognition of the limits of the biomedical model;
- a desire to consume fewer medications, and a concern about side-effects of the medications;
- a greater awareness of health care procedures and practices from other cultures;
- a belief that diseases are linked to emotional, lifestyle, and mind/body factors.
Dr. Pelletier further discussed a study that will be published in November 1997 addressing the extent of insurance involvement in the offering of coverage for alternative care and the reasons for interests in the area. Eighteen companies and programs were identified. All of them provided coverage for chiropractic care; 17 offered coverage for acupuncture; 17 offered psychotherapy; and 11 covered nutritional counseling. As for the future, all 18 plan to continue to offer the coverage they presently do. Since Jan. 1997, 10 additional companies and programs have indicated they will be offering similar coverage.
What is motivating the interest on the insurers? Factors include:
- Alternative care may be less expensive than biomedical treatment;
- There may be a savings in the treatment of specific conditions.
- The offering of coverage for alternative care may attract a healthier pool of insureds.
- The offering of alternative care may attract new ethnic populations.
- Many persons interested in complementary and alternative medicine focus more on preventive efforts and procedures.
An analysis shows that Blue Shield subscribers (from any one of six plans) shifted to the Shield 65 plan because it offered chiropractic, acupuncture and podiatric services.
Ellen Hughes, PhD, MD, associate clinical professor of medicine at the University of California School of Medicine, discussed survey results about people who had sought the care of an alternative provider. Ninety-one percent of those surveyed were "very satisfied" or "satisfied" with the care they received, and 80% said they would seek out such a provider if the need rose again. Dr. Hughes offered her ideas on why people were moving toward alternatives:
- the high-tech nature of medicine, versus the low-tech nature of alternatives;
- the emphasis of alternative providers to offer care to the "whole person" rather than to the disease or organ;
- the emphasis of alternative providers on the well-being of the person and on prevention in general;
- the care from alternative providers tends to be individual, intensive and interactive.
She also noted the evolution of what are now known as alternatives: from new age to holistic, to alternative, to complementary care. She see the next step as integrated care. At UCSF, four specific courses are offered and have been widely accessed. These include:
- Complementary Paths of Healing;
- The Healer's Art;
- Homeopathy
- History of Alternative Medicine
Lawrence Schneiderman, MD, professor at the University of California School of Medicine, offered his thoughts on the ethical matters that alternative care brings to the table for medicine, and began his talk with the question, "What does it mean to profess medicine?"
Dr. Schneiderman's presentation was less data driven. He outlined a series of ideas and reflections on the comments of previous presenters. In general, he questioned if medicine should be more concerned about the practices and procedures that are calling themselves "medicine" in one form or another. He offered the only direct derogatory remark about chiropractic care, indicating his view that the range of conditions for which chiropractic care was found effective was limited to a few isolated musculoskeletal conditions. Dr. Schneiderman's emphasis was placed on medicine's responsibility to itself, and to the public.
Deborah Senn, attorney at law and insurance commissioner for the state of Washington, was introduced and identified by Ralph Nader as "the best insurance commissioner in the country." She began by offering some thoughts about the pressures physicians find themselves subject to and offered two sources of that stress -- managed care and alternative providers. She indicated that the Washington alternative provider law was the "single biggest issue" she has heard about from the public as the insurance commissioner.
Ms. Senn added that this area is consumer driven, with 40% of the people in Washington seeking care such as chiropractic care; she also related that 70% of HMOs have reported increased requests from consumers for alternative care. From her perspective, the biggest issues driving costs of health care in the next two decades will be the costs related to technology, and the impact of baby boomers on the system. Senn indicated that insurers in Washington have attempted to make an issue of the effectiveness of various forms of care. She reminded the audience of a report by Dr. White of the U.S. Office of Technology Assessment, which indicated that only 10-20% of medical procedures have been shown to be effective by means of clinical trials.
Throughout the proceedings, the board routinely accepted feedback and comment from the public. They heard horror stories of persons who were abused by their physicians for seeking alternative care, and detailed accounts of illness and recovery under the care of alternative providers. It was my luck and good fortune to be the final person to comment from the public. I attempted to correct some of the errors of fact and omission that had been offered relative to chiropractic care.
For example, the Carey cost study from North Carolina was cited repeatedly as showing that chiropractic care was more costly than orthopedic care. A few thoughts on the weaknesses of the study being based on estimated costs rather than real costs were offered. I brought to their attention the serious omission of the data regarding patient satisfaction, which showed as much as a 50 percent higher satisfaction factor with chiropractic care.
During the course of the colloquium, it was noted that there is an entrepreneurial interest on the part of some physicians in certain aspects of alternative health care. Specific references were made to physicians being involved in acupuncture and other areas. I offered caution to the board about the increasing frequency of reports from our clinic and faculty about patients who have seen other providers untrained in manual spinal procedures, who have attempted to adjust or manipulate them.
My final comment related to the concerns expressed by Dr. Schneiderman about what is presently being called medicine. The view that chiropractors were also concerned about these kinds of classifications was offered. For example, the Office of Alternative Medicine (OAM) classifies chiropractic care under the heading "chiropractic medicine." This classification is inappropriate in the eyes of many of our colleagues and confusing to the public.
The unfortunate part of the conference was that all that was presented was medicine's view of alternatives. The views of those experienced, trained and skilled in various forms of non-medical care were not part of the consideration. It was a courageous beginning, and the board should be applauded, but if it is to led anywhere, the range of input needs to be rethought.
Gerard W. Clum, DC
President, Life Chiropractic College West
San Lorenzo, California
Dr. Gerry Clum served as president of Life Chiropractic College West for 30 years. He also is a former founding board member and president of the Association of Chiropractic Colleges and World Federation of Chiropractic. Currently, he is a member of the executive committee of the Foundation for Chiropractic Progress.