John WeeksSummary: What role will complementary, alternative and integrative practices and practitioners have in primary care of the future? Greg Garcia, ND, LAc here responds to the Integrator call for input to Primary Care 2025, a Kresge-funded project led by futurist Clem Bezold, PhD. Garcia reviews some trend-lines in the recent past before describing ethical and evidence issues that will shape what he believes is a preferred, more integrated future. Garcia is a principal with Natural Medicine Consultants who was for over a decade a member of the faculty at Portland, Oregon-based National College of Natural Medicine.
On April 24, 2011, the Integrator posted an alert on an opportunity to respond to an Institute for Alternative Futures (IAF)-funded project on the future of primary care. The project, Primary Care 2025, led by IAF’s Clem Bezold, PhD, is funded through a grant from the Kresge Foundation. Bezold shared with interested parties a set of perspectives developed via an IAF focus group with members of the New York Academy of Medicine. These included this view:
15.
Integrative
encounters in primary care – Integrative encounters address all
dimensions of health by bringing the knowledge of conventional, unconventional,
complementary, alternative, traditional and integrative medicine disciplines to
bear across the many different cultural traditions of persons cared for.
A first set of Integrator reader responses is posted here. Greg Garcia, ND, LAc, of Portland, Oregon-based Natural Medicine Consultants, subsequently sent a referenced historical perspective. Garcia focuses on barriers and openings that he argues will shape the integration of complementary and alternative medicine in the future of primary care. He notes the expansive pharmaceutical prescribing rights for naturopathic doctors in Washington and Oregon. His hop-scotching journey through the last 3
decades makes a case that a combination of patient preference, need,
economic and ethical consideration will drive more inclusion in the
coming years.
Garcia was a full-time member of the faculty of National College of Natural Medicine and served on the Oregon Board of Naturopathic Medicine. He currently focuses on helping health professionals
learn about natural medicine by offering continuing education through Natural Medicine Consultants LLC, an online company he is
developing. He can be reached at
greg@naturalmedicineconsultants.com.
_____________________________
The Future of Primary Care:
A Response to the New York Academy of
Medicine Focus Group
on the Question of CAM in the FutureGreg Garcia, MD
Natural Medicine Consultants, LLC“Most
of the feedback to the CAM question I am getting in the focused groups from
conventional primary care folks is that they will include use of the modalities
as they are proven effective/cost effective. Any
forecasts on the evidence on behalf of CAM modalities and/or CAM licensed
providers would be welcome.”— Clem Bezold, PhD, Integrator Blog, April 25, 2011
Greg Garcia, ND, lAcComplementary and alternative medicine (CAM) appeared to break
through several barriers when the New England Journal of Medicine published the
study by Eisenberg et al in 1993 on
the prevalence of unconventional medicine used by patients who subsequently
were not communicating about these behaviors with their primary care
(mainstream) doctors. Information regarding the sheer number of patient visits
to unconventional practitioners, the amount of out-of-pocket money spent on
CAM, and the apparent communication barriers between patients and doctors
created an undeniable jolt to the status quo in mainstream medicine.
Funding and research into various CAM techniques and practices
became possible through the National Institute of Health. Numerous mainstream
medical institutions developed centers of CAM research so that 10 years later
it was not uncommon to find continuing education offered at some of the most
prestigious medical institutions on subject matters ranging from natural
medicine and psychiatry to mind-body medicine. Communication and interpersonal
skills in medical education became required subject areas for assessing
competency.
“A barrier that has yet to be overcome
is revealed in
the posted comments on
behalf of the Institute for Alternative Futures
that
question the effectiveness
or cost effectiveness of CAM.”
A barrier that has yet to be overcome, however, is revealed in
the posted comments on behalf of the Institute for Alternative Futures that
question the effectiveness or cost effectiveness of CAM. Raising concerns about
the effectiveness or other parameters of CAM is certainly not new or
surprising. Concerns in the past emphasized safety issues or speculated on ethical
problems if CAM modalities with unknown mechanisms of action or effectiveness
were incorporated into treatment plans.
What’s seems apparent with all of these mentioned concerns about
CAM is an underlying assumption that mainstream medicine is in a superior
position by virtue of its having a more science-based foundation. Furthermore,
if the mainstream medicine is scientific assumption is a priori accepted, then the implication to the public of its
safety, effectiveness, and economic worthiness seems to go without question.
The goal of a science-based foundation for medicine is as old as
the AMA itself. As recently as 1980, the American Medical Association (AMA)
code of ethics included the principle that “A physician should practice a
method of healing founded on a scientific basis; and he should not voluntarily
associate professionally with anyone who violates this principle.”[i]The emphasis on the
scientific basis of conventional medicine was described in 2002 as a reflection
of the AMA’s “lasting concerns to eradicate quackery and other non-allopathic
forms of medicine”.[ii]
“The emphasis on the
scientific basis of
conventional medicine was described in
2002 as a reflection
of the AMA’s “lasting
concerns to eradicate quackery and other
non-allopathic
forms of medicine”.
The AMA’s current version of this principle, titled Opinion 3.01,
continues their organizational emphasis on the scientific basis of medicine.
Opinion 3.01 declares “it is unethical to engage in or aid and abet in
treatment which has no scientific basis and is dangerous, is calculated to
deceive the patient by giving false hope, or which may cause the patient to
delay in seeking proper care”.[iii] According to the AMA, the
present language sets “ethical parameters on the practice of complementary and
alternative medicine”.[iv]
While the prohibition against associating with non-scientific
practitioners (widely viewed at the time as a prohibition against associating
with chiropractors) was eventually found to be a violation of the Sherman
Antitrust Act in 1987, the more profound probing of the ethical and scientific
qualities contrasting mainstream medicine and CAM occurred this past decade.
A probable historic turning point between mainstream medicine and
CAM was the rising advocacy for pluralism within the medical ethics community
that occurred this past decade. Pluralism allowed for accommodation (Kaptchuk
and Miller, 2005, and Tilburt and Miller, 2007) by supporting the ethical
principle of patient autonomy and freedom of choice in medical options, without
compromising the importance or value of scientific evidence for mainstream
medicine.[v],[vi]Though pluralism may seem a near fait
accompli in bioethics, the debate over the credibility of CAM as seen
through the prism of scientific evidence and cost-effectiveness has been
on-going and vociferous.
[Of note: The final appeal to the Supreme Court by the AMA
regarding the 1987 court decision against their organization was denied in
November, 1990. The national telephone survey conducted by Eisenberg et al as the basis for their 1993
article previously cited was undertaken in the last 3 months of 1990.
Interestingly, the genesis of the term ‘evidence based medicine’ appeared
initially at McMaster University about a year later (1991 or 1992). The now
ubiquitous phrase ‘evidence based medicine’ is a common standard for justifying
efficacy and is widely adopted as a requirement in health related policies and
for funding purposes by state and federal agencies.]
“Upon examining components of practice
and scientific
knowledge, the ethical preceptto do no harm, and the need to not waste money,
Morreim concludes that holding both sides
accountable to these
standards may well be
more deleterious to mainstream medicine.”
Perhaps one of the more astute commentaries on the role of
science in medicine (Morreim 2003) held the same standards of scientific
evidence and cost-effectiveness to mainstream medicine as critics wish to apply
to CAM. Upon examining various components of clinic practice and scientific
knowledge, the ethical precept to do no harm, and the need to not waste money,
Morreim concludes the outcome of holding both sides accountable to these
standards may well be more deleterious to mainstream medicine. With regard to
cost-effectiveness, for instance, Morreim cites examples such as arthroscopic
debridement and lavage for osteoarthritis of the knee, coronary angiography,
and internal mammary artery ligation, where costs were both substantial
(totaling over $10 billion annually for the first 2 procedures alone) and the
evidence supporting the techniques scientifically questionable.[vii] Another example Morreim
cited, coronary bypass surgery, only has “4 to 13% of patients who now undergo
this operation would meet the eligibility criteria for the randomized
controlled trials that established its efficacy…and [it’s] used significantly
more in the United States than in Canada and Europe, with no conclusive
justification in terms of patients’ illness or infirmity”.[viii]
Others critiqued the use of randomized clinical trials (RCTs) as
the gold standard of evidence in mainstream medicine, particularly as they are
applied to CAM. Barry (2005) utilized an anthropological perspective on the
development (and the rhetoric) of ‘evidence’ in medicine. Highlighted in her
research are some of the difficulties encountered when measurement standards
used in RCTs are applied to CAM practices that result in the removal of
context, setting, and other elements inherent in many patient’s (and CAM
practitioner’s) perspectives of what works and is beneficial.[ix]
The dichotomy between these
different ways
of knowing leads Keshet to conclude that the
boundaries
established by biomedical scientists
as a method of “distinguishing their field
andits practitioners from less authoritative,
non-science practitioners” are
untenable.”
A final commentary with regard to the role of science in CAM and
mainstream medicine borrowed techniques from Sociology of Knowledge to explore
how both sides attempt to preserve or gain legitimacy. Keshet (2009) initially
collected 600 English language international abstracts of and responses to
articles published over a 3 year period (ending in 2001) that dealt with the
efficacy of CAM in general or with specific CAM techniques such as homeopathy,
acupuncture, or spinal manipulation. After narrowing down the number of
articles to those specifically addressing how to appropriately evaluate the
effects of CAM, Keshet makes some interesting observations about the complexity
and diversity of knowledge in mainstream medicine and CAM and with how
proponents for each side use that knowledge. The dichotomy between these
different ways of knowing leads Keshet to conclude that the boundaries
established by biomedical scientists as a method of “distinguishing their field
and its practitioners from less authoritative, non-science practitioners” are
untenable.[x]
Even as
the role of science in mainstream medicine becomes less opaque than once
casually assumed, the concern for patient safety remains a given across all
primary care professions. In one of the few legal articles addressing CAM
practitioners and patient safety, Doyle (2001) states a finding of malpractice
will likely depend on the seriousness of injury as well as misdiagnosis or other
cause for delay in [seeking] conventional treatment.[xi]It’s generally been well accepted for licensed professionals to be judged by
members of their own profession (unlike someone without a license who would
probably be compared to the standard of a medical doctor). Doyle, however,
writes of a case, Rosenberg v. Cahill, adjudicated in 1985, where the court
allowed a medical doctor to “testify as to the standard of care expected of
chiropractors”.[xii]
According
to Doyle, the court allowed the medical doctor’s testimony because of an
overlap of expertise in certain conditions or circumstances. Specifically, the
court “found an ‘overlap’ of expertise in the professionals” use “of x-rays and
diagnosis of certain conditions
(emphasis added).”[xiii]
Doyle states “in terms of overlap, the alternative provider is usually held to
the heightened standard of care – the standard of the reasonable, competent
physician”.[xiv]
“With the growing need for more primary care
physicians in this
country already well established,
the role of licensed naturopathic physicians
and
other primary care CAM providers should be
expanded rather than restricted
or disallowed.”
Although the above ethical, philosophical, epistemic, and legal
citations are by no means definitive, together they suggest trends that can
help shape and optimize the preferred future of licensed CAM providers in the
United States. With the growing need for more primary care physicians in this
country already well established, the role of licensed naturopathic physicians
and other primary care CAM providers should be expanded rather than restricted
or disallowed.
Already in Oregon and Arizona, the legend formulary available to
naturopathic physicians significantly parallels that of mainstream primary care
medical providers. The ‘overlap’ and gradual merging of certain portions of
clinical practice, already seen in physical examination, laboratory diagnosis,
clinical diagnosis, and now the adding of prescriptive rights, will eventually
require licensing boards and future policy makers to consider new ideas and
methods for addressing public safety.
Perhaps the question of safety is best considered from the
patient perspective. Should it make a difference which primary care profession
prescribes the legend medication or provides a CAM technique as part of their
treatment plan? In other words, can the patient expect the same quality of
consideration, understanding, and training whether or not a particular
treatment involves an antibiotic or a botanical formula? If not, what steps can
be taken now and in the future to strengthen the clinical encounter for
patients regardless of their primary care doctor’s professional background?
As Eisenberg et al and
many others since have demonstrated, patients would like both mainstream
medicine and CAM practices available. What has changed since then is the
increasing number of CAM practitioners that are or have become primary care,
including some with prescriptive rights such as naturopathic physicians. The
overlapping of clinical skills and scope of practice between separate
professions underscores the need to integrate or combine training opportunities
across professions. How else to strengthen the growing complexity of clinical
skills and judgment necessary to navigate this shared terrain amongst primary
care professions?
“With the advent of ‘overlapping’ scopes of practice, the development of
common educational experiences
and policy guidelines regardless of professional
licensure seem necessary.”
Purists may rebel against the perceived ethical or philosophical
threats to the status quo. The burden imposed by the patient’s right to choose,
however, has to be shared within our entire health care system and amongst all
primary care providers. The principle of patient autonomy, which bestows upon
the patient the right to choose their medical options and treatment, should not
inadvertently force the patient to bear the burden alone should their primary care
doctor’s background or disparate professional training opportunities negatively
impact the quality of their treatment. While all professions require their
members to have a strong sense of their own competencies, the systemic lack of
opportunity for all professions to gain access to and learn their given scope
of practice cannot be resolved by individual practitioners.
The best and most appropriate response to support the principle
of patient autonomy is the obligation we incur as providers to ensure patient
safety. With the advent of ‘overlapping’ scopes of practice, the development of
common educational experiences and policy guidelines regardless of professional
licensure seem necessary.
“If CAM and mainstream medicine keep the
perspective and needs of the patient in
the
forefront, and follow through on developing
greater accommodation for all
primary care
professions, together they will create the
primary care experience
patients haveshown they would like to have.”
Medicare will likely have to add more CAM professions and techniques
beyond the current chiropractic coverage offered since 1974, improving access
for seniors to all primary care options. In addition, the funding of mainstream
medical residencies through Medicare and other federal funds will likely have
to expand as well to include other primary care professions lest it be found
discriminatory. Expansion of the types
of residency funded to include all primary care professions may provide a
method and means for integrating training opportunities in the future.
The philosopher Martha Nussbaum once provided a definition of
ethics during an interview given on the radio. She stated, “Ethics is about
what matters, and how one should behave.”[xv]
If CAM and mainstream medicine keep the perspective and needs of the patient in
the forefront, and follow through on developing greater accommodation for all
primary care professions, together they will create the primary care experience
patients have shown they would like to have.
[i] Principles of
Medical Ethics, Judicial Council, American Medical Association, June 7, 1958. www.ama-assn.org/ama/upload/mm/369/1957_principles.pdf Site accessed September 17, 2009.[ii]
Riddick FA, Morin K. Highlights of the Code of Medical Ethics of the American Medical
Association. Metro Doctors 2002;Jan-Feb:20-21.
[*Riddick was Chair, Council on Ethical and Judicial Affairs – AMA when he
authored this article]
[iii]
Ibid.[iv]
Ibid.
[v]
Kaptchuk TJ, Miller FG. What is the
Best and Most Ethical Model for the Relationship Between Mainstream and
Alternative Medicine: Opposition, Integration, or Pluralism? Academic Medicine 2005; Vol
80:pp286-290.[vi]
Tilburt JC, Miller FG. A Principled
Ethical Approach. Journal of the American
Board of Family Medicine 2007; Vol 20(5):489-494.
[vii]
Morreim EH. A Dose of Our Own
Medicine: Alternative Medicine, Conventional Medicine, and the Standards of
Science. Journal of Law, Medicine &Ethics 2003; Vol 31:222-235.
[viii]
Ibid.
[ix]
Barry CA. The Role of Evidence in
Alternative Medicine: Contrasting Biomedical and Anthropological Approaches. Social Science & Medicine 2006; Vol
62:2649-2657.
[x] Keshet Y.The Untenable Boundaries
of Biomedical Knowledge: Epistemologies and Rhetoric Strategies in the Debate
Over Evaluating Complementary and Alternative Medicine. Health: An Interdisciplinary Journal for the Social Study of Health,
Illness and Medicine
2009. Vol 13(2):131-155.
[xi] Doyle A, Alternative Medicine and Medical Malpractice Emerging
Issues. The Journal of Legal Medicine2001; 22:533-552.
[xii]
Ibid.
[xiii]
Ibid.[xiv]
Ibid.
[xv] Backlar P. (2006). Making Medical
Decisions for the Profoundly Mentally Disabled [Review of the book Making Medical Decisions for the Profoundly
Mentally Disabled, by Normal L. Cantor]. New England Journal of Medicine, 354;20: 2199-2200.
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Comment: I posted this shortly after spending the better part of two days wrestling with the re-framing of the evidence game in David Freedman’s fascinating The Triumph of New Age Medicine. Garcia’s citation of Morreim, in particular, was an interesting match. Morreim’s pragmatic project, to assess relative scientific basis and costs for CAM and conventional treatment, fits with Freedman’s real world weighing of evidence and practice. Garcia’s interweaving of medical ethics and evidence reaches a similar conclusion to Freedman’s examination of evidence and patient experience. Garcia, via Morreim, brings to mind Freedman’s assessment, cited by Taylor Walsh in his article on Freedman: “This notion that alternative
medicine is a legitimate response to mainstream medicine’s real shortcomings is
one I heard, in variations, from everyone I spoke with at the Mayo
Clinic.”
I hope that one of Freedman’s conclusions, reinforced by Garcia’s article, finds its way to Bezold: “Yet to focus on alternative medicine’s placebo effect
ignores what may be its largest benefit – it’s adherence to a ‘healing’ model
of patient care.” One hopes that amidst the technological gizmos that US medicine cannot stop manufacturing and selling, this model will be the basis of primary care 2025.
johnweeks@theintegratorblog.com
for inclusion in a future Your Comments Forum.
Dr. Judith Orloff MD
Barry Bittman MD
Dr Jacob Teitelbaum MD