Held January 23–24, 2001, London, England
Sponsored by NCCAM and the Royal College of Physicians
- Perceptions of CAM
- Exploring Issues of Clinical Evidence
- Education on CAM
- CAM Regulation and Certification
- Interdisciplinary Approaches to Delivering Care
- Exploring the Science Base
- Conference Themes
On January 23–24, 2001, NCCAM co-sponsored an extraordinary conference in London, England, titled “Can Alternative Medicine Be Integrated into Mainstream Care?”. Lead investigators and spokespersons for integrative medicine, medical education, and research in the United States traveled with Stephen E. Straus, M.D., Director of NCCAM, and Richard Nahin, Ph.D., Director of NCCAM’s Division of Extramural Research, Training, and Review, to meet with their counterparts in the United Kingdom (U.K.).
The Royal College of Physicians (RCP) also sponsored the conference, which was held at RCP headquarters overlooking London’s Regent Park. The RCP is a very active professional organization in the U.K. and is also England’s oldest medical institution, founded by King Henry VIII in 1518. The College conducts examinations, training, education, and research in medicine, and advises the British Government, physicians, and public.
The goals of the conference were to conduct dialogue and share knowledge on: research and development in complementary and alternative medicine (CAM); approaches to the integration of CAM and conventional medicine; and the American and British governments’ interest and participation in the field so far. The timing of the joint conference followed the release of recommendations by the U.K.’s House of Lords in its Select Committee Report into Complementary Medicine. In conjunction with the conference, the British Medical Journal published a theme issue on integrated medicine (no. 7279, January 29, 2001).
“This was an exciting, history-making event,” Dr. Straus said. “The British people are as intrigued about CAM as are we Americans. Dialogue with our British colleagues showed that each of our countries has come up with unique approaches and solutions from which we all can benefit.”
The conference opened with a warm welcome from Professor Carol Black, M.D., vice president of the RCP. A videotaped message from Charles, Prince of Wales, followed. The Prince described the concept of integration in medicine as one that is “close to my heart,” and one on which he has worked to make a contribution during the past 19 years. He believes that health care treatments should maximize the contributions of both Western medicine and the “well-tried” experience of other traditions; and it should “involve the body, mind, and spirit of each individual,” instead of simply “looking at the clinical problem and ignoring the whole person.” His overarching interest is in “the better welfare of patients that can be achieved by integrated health.”
Perceptions of CAM
George T. Lewith, M.D., director of the Center for the Study of Complementary Medicine, in Southampton, England, and a senior research fellow at the University of Southampton, kicked off the “Public and Professional Perceptions of CAM” module, with an overview of CAM practice in the U.K. He discussed the results of an RCP survey of its members about their use of CAM. One-third of the 3,000 respondents practiced CAM, which he termed a “significant minority.” Of those who practiced CAM, 14% had formal training in CAM and 86% did not: “This poses an interesting problem,” he noted. Forty-one percent referred patients for CAM treatments—in most cases acupuncture, osteopathic medicineOsteopathic Medicine is a complete system of medical care that employs a “whole person” approach to health care and is based on the body’s natural tendency toward health and self-healing. Osteopathic physicians (DOs) can use osteopathic manipulative treatment, a system of manual therapy, to treat mechanical strains affecting all aspects of the anatomy, relieve pain, and improve physiologic function., or hypnotherapy. The rate of referral to NHS physicians (the National Health Service is Britain’s government-funded health care system) and non-NHS physicians was similar, so there appeared to be no financial incentive. CAM was most often used in palliative care, pain control, and rheumatology.
Dr. Lewith commented that indications are that conventional doctors in the U.K., rather than being reluctant or resistant about the potential of CAM, really do not know much about CAM.
Dr. Straus, Director of NCCAM, spoke next. “In establishing NCCAM,” he said, “the American public decided through its elected representatives that it deserves cogent guidance in navigating the complex issues of CAM.” Dr. Straus described the growth in Americans’ interest in and use of CAM modalities, and in the array of health professions (for example, there are now more than130 allied health professions recognized in the U.S.). He presented NCCAM’s major strategic areas, which are articulated in its strategic plan for 2001-2005, Expanding Horizons of Health Care; cited NCCAM’s “good fortune” in being able to partner in research endeavors with some of the other Institutes and Centers at the National Institutes of Health; and explained the various support mechanisms of financial support now offered by the Center, including many types of grants and training fellowships. NCCAM is supporting the largest, best-designed trials of their kind to provide the public with the high-quality information they need to make informed decisions about their health care.
Next, John A. Astin, Ph.D., an assistant professor in the Complementary Medicine Program of the University of Maryland School of Medicine, Baltimore, presented. Dr. Astin has surveyed Americans on their use of CAM (published in the Journal of the American Medical Association in 1998: 279, 1548-53, and in more recent work). His hypotheses concerned whether CAM use is associated with: (1) levels of satisfaction with conventional medicine; (2) desire for personal control; and (3) philosophical congruence (in other words, an agreement in values). Dr. Astin did not find an association with the first two factors, but did with the third. While cautioning that the survey results are complex and should not be oversimplified, he identified the following patterns among 1,035 users of CAM. They tended to:
- Be highly educated, with at least some college background;
- Have poorer overall health status;
- Be more likely to suffer from anxiety, back problems, chronic pain, or urinary tract problems;
- Have a holistic orientation, or a belief of the importance of body, mind, and spirit in health;
- Have had a transformational life experience that causes them to see the world differently; and
- Be members of a “values subgroup” that he calls “cultural creatives.” He defined all three subgroups as follows:
- “Heartlanders,” who subscribe to more traditional values. (30% of the population; 38% of those use CAM);
- “Moderns,” who subscribe to the dominant values of the cultural mainstream. (47% of population; 34% of those use CAM); and
- “Cultural creatives,” who are committed to environmentalism, feminism, personal and psychological growth, and who are interested in esoteric spirituality and the foreign and exotic (24% of population; 55% of those use CAM).
CAM Consultations vs. Conventional Medicine Consultations
Adrian Furnham, Ph.D., of the department of psychology at University College, London, presented hypotheses he has developed on how CAM consultations differ from conventional consultations, including:
Dr. Furnham suggested that at least some of these hypotheses could be tested.
A Patient’s Perspective
Jane Laportaire, an English actress, presented a patient’s perspective. An engaging speaker, Ms. Laportaire acted out some of her points with quotations from Shakespeare and other great writers. She related her experiences in France and Britain after being diagnosed with a subarachnoid hemorrhage, which helped form her views on what good care is and what it is not. While in intensive care, for example, she was not asked how she was, told what was happening to her, touched, or given important information about effects that would impact her life.
Ms. Laportaire asked the audience to consider what it means to use a term like “client” or “customer” instead of “patient.” A client or customer is “someone who is buying a service, and a patient is “a suffering person who seeks or needs care and is worthy of compassion, succor, and relief.” There are also differences between “human resources” and “humans,” and customer service “as it is talked about in executive suites” and as it is carried out in practice. She urged the physicians in the audience, “Only connect… Don’t treat the illness, treat the person.” She asked them to “remember why you went into medicine in the first place.”
Exploring Issues of Clinical Evidence
The Cochrane Collaboration
Joseph Kleijnen, M.D., director of the NHS Center for Reviews and Dissemination at the University of York, U.K., described The Cochrane Collaboration (CC), with which his center is affiliated. The CC is an international nonprofit organization, and a part of Britain’s National Health Service, that “prepares, maintains, and promotes the accessibility of systematic, up-to-date reviews of health care interventions.” CC reviews are carried out by of dozens of review groups and by review “fields” that cut across the groups. The CC has many published reviews on CAM topics. Essential elements are:
- A well-formulated question;
- A comprehensive data search;
- An unbiased selection and abstraction process;
- A critical appraisal of the data;
- The synthesis of data; and
- Production of a structured report.
CC reviews are unusual in that they are maintained and kept up-to-date, and offer a process for reader comments and criticism. Dr. Kleijnen acknowledged challenges in systematic reviewing, such as identifying “proof” vs. “not proof” and identifying quality, which he suggested is an “unbiased estimate of effect.” CC reviews are not restricted to randomized trials, but based on the “best available evidence.” He suggested, “The main issue is not ‘CAM vs. mainstream,’ but is an intervention effective or not, and is it safe or not?”
The CC issues its findings electronically via CD-ROM or paid Internet subscription (more information: www.york.ac.uk/inst/crd). A number of medical libraries in the US subscribe to the Cochrane service. Abstracts of CC reviews are available on the National Library of Medicine’s MEDLINE database.
Klaus Linde, M.D., of the Center for Complementary Medicine Research, Germany, also spoke on systematic reviews. While he believes the systematic review (SR) is the best tool to get an overview of the available scientific evidence on a defined topic, he thinks SR’s are often misinterpreted. He suggested asking, is a SR objective? Is it valid? Does it answer relevant questions of the healthcare provider and patient? The answers to these questions, in many cases, are not simple—and this, he said is a problem that is not unique to CAM research. Dr. Linde showed examples of authors of different SR’s reaching different observations and conclusions about the same studies. He suggested that the use of transparent and systematic methods does not automatically mean the results are “true”; that inclusion criteria should be checked, and also, if possible, comprehensiveness of the search and selection process; and that it might be better to define SR’s as “annotated bibliographies,” unless there are clear, predefined hypotheses.
Jonathan Davidson, M.D., of Duke University Medical Center, Raleigh, NC, spoke on prospective studies of St. John’s wort. Dr. Davidson is principal investigator of a large-scale clinical trial, funded by NCCAM and administered through the National Institute of Mental Health (NIMH), of St. John’s wort for depression. The trial compares St. John’s wort with the antidepressant sertraline and with placebo; results are expected to be released this summer. Dr. Davidson discussed the NCCAM/NIMH trial and other large multicenter studies on St. John’s wort. He identified a number of reasons for long-term studies of St. John’s wort, including to better understand the placebo response, optimum dosages, what happens upon cessation of therapy, mechanism of action, and other issues. Dr. Straus of NCCAM commented in follow-up, “Systematic reviews provide some guidance; but one single, large, well-conducted study gets us closer to the truth.”
Dan Cherkin, Ph.D., affiliate professor at the Center for Health Studies at the University of Washington, Seattle, spoke on research methodology in CAM. Some individuals, he said, have urged that an alternative science is needed to study alternative therapies and that conventional scientific methods are not appropriate for this purpose. This skepticism may originate from distrust of the “medical establishment,” a preference for a “holistic” versus a “reductionistic” worldview, and a perception that medical researchers are biased or ignorant about CAM. Dr. Cherkin noted that while there are indeed significant challenges for conducting scientifically rigorous evaluations of CAM therapies, conventional research methods can work well—if they are “applied creatively and within an appreciation of the broad context within which CAM is provided.” He gave examples showing creative solutions to research problems such as formulating comparison (control) groups and blinding. He noted that current research on CAM therapies is not perfect–“It’s a compromise, but that’s true of all research.” An alternative research method is not the answer. He predicted that the best science will occur when conventional researchers and CAM clinicians collaborate in a manner that is based on mutual respect and the common goal of helping patients.
Education on CAM
The final portion of Day 1 of the conference concerned conventional medical education and CAM.
CAM Education in the United States
Brian Berman, M.D., director of the Complementary Medicine Program at the University of Maryland School of Medicine, Baltimore, presented an overview of CAM medical education in the United States, including the following statistics about the 125 U.S. medical schools:
- At least 66% offer some form of CAM education.
- 66% report including CAM information in the core curriculum.
- 50% offer elective courses in CAM.
- 5 schools offer clerkships/rotations in CAM.
- At least 92 family practice residency programs (35%) address CAM issues.
- 12 schools offer continuing postgraduate education in CAM.
Dr. Berman noted that surveys show that doctors and medical students are increasingly interested in CAM therapies, yet barriers exist, including restricted curriculum space, students’ limited time, and the explosion of information across the board in medicine. While CAM is being taught in numerous conventional medical schools, there is great variation in approach, content, and depth of the programs. Dr. Berman recommended greater consensus on the ingredients of a core curriculum on CAM and its goals, which could include better knowledge of CAM therapies; an acquaintance with the pertinent legal/regulatory/insurance issues; the ability to advise patients and make decisions about the use of CAM; and the ability to make referrals when appropriate to CAM practitioners. He discussed initiatives to include CAM in medical education in the U.S., including funding at academic institutions and NCCAM funding initiatives to support (1) the development of CAM curriculum and (2) career development and training.
CAM Education in the United Kingdom
David K. Owen, M.B., B.S, M.R.C.S., L.R.C.P., M.F.Hom., of Winchester Homeopathic Practice, England, discussed CAM medical education in the U.K. Almost 40% of general practices in England offer some form of complementary therapy for their patients who are on the NHS. There has been an increase in the past few years in CAM courses for medical students. Overall, however, CAM is provided largely outside the conventional care framework. Funding for complementary medicine research has to compete with funding for all other clinical disciplines.
Dr. Owen identified a need for doctors and their professional organizations to become more familiar with CAM in terms of core curriculum content; training in CAM for established physicians; and integrating CAM techniques into patient care. Like Dr. Berman, he highlighted benefits that CAM approaches can bring to conventional medicine—including an approach of greater holism, intuition, and empathy, to the benefit of clinical care and physician career satisfaction.
Dr. Owen directs a multidisciplinary teaching module for CAM at the University of Southampton, U.K., that has been taken by nurses and student chiropractors and has received very positive feedback. CAM education, he said, very much concerns attitudes, not just knowledge and skills. “There are as many therapies as there are therapists,” he said.
CAM Regulation and Certification
Day 2 of the conference opened with a module on regulation and certification, a critical area of interest in both countries.
Regulation in the United Kingdom
Simon Mills, M.D., Director for Complementary Health Studies at the University of Exeter, U.K., and an herbal practitioner, described regulation in the U.K. as radically different from regulation in the rest of Europe and the U.S. In the U.K., citizens have a common-law right to choose their own treatment. It is perfectly legal for a person to put out a shingle as as an acupuncturist, for example, and deliver acupuncture services, as long as he or she does not claim to be a “registered medical practitioner” and refrains from certain protected practices, such as dentistry, midwifery, and veterinary medicine. Despite legal recognition, groups of CAM practitioners are able to organize their own training and professional standards.
“We have found,” he said, “that most organizations in CAM are run pretty much as conventional professional bodies; they publish formal codes of ethics and practice codes and member registers, and subscribe to insurance plans. The handling of complaint procedures, however, has been a consistently disappointing area.”
As CAM organizations and practitioners have become a larger part, over the last decade, of the health care system and more common as a first career rather than a second,” he said, “we will need to have clearer and more overt systems in place, including in professional codes. Most in the field agree with the principle that they need to develop their own standards under their own title, towards potential statutory regulation. Some think this is too burdensome and are lobbying for a unitary regulation, perhaps a kind of council for CAM.”
Simon Fielding OBE, chairman of the General Osteopathic Council, U.K., spoke on osteopathic medicine in the U.K. Mr. Fielding described osteopathic medicine in his country as “a complementary form of health care espousing complementary medical principles.” A central tenet is that disease originates from problems in musculoskeletal systems. As recently as the 1970s, osteopathic medicineOsteopathic Medicine is a complete system of medical care that employs a “whole person” approach to health care and is based on the body’s natural tendency toward health and self-healing. Osteopathic physicians (DOs) can use osteopathic manipulative treatment, a system of manual therapy, to treat mechanical strains affecting all aspects of the anatomy, relieve pain, and improve physiologic function. was considered a “fringe profession” in the U.K., and it was a crime to refer someone to an osteopath. Mr. Mills emphasized the importance of having a future research effort in the field: “We desperately need clinically relevant research.” With regard to regulation, he identified a schism in osteopathic medicine between those who want to be regulated and those who do not.
Regulation and Certification in the United States
Michael Cohen, Esq., lecturer on medicine at Harvard Medical School, Boston, MA, spoke on regulation and certification in the U.S. from a legal perspective.
In contrast with the U.K., every state in the U.S. has its own licensing scheme, different laws, regulations, and courts and judicial documents that interpret these rules. “Who is authorized to practice which specialty” is determined by state. Further, the system is often “patchwork” from town to town and county to county. Mr. Cohen explained the four levels of the U.S. model: (1) mandatory licensure, the most common; (2) title licensure: needing a license to claim a particular title such as “massage therapist”; (3) registration, with the designated state agency; and (4) exemption from licensure requirements. A hypothetical example of number 4, exemption, would be a religious healer who is allowed to practice only under the tenets of a recognized church and only by using prayer, not prescribing medications.
He discussed boundary issues that arise between the professions; e.g., a healer who crosses the line of his own scope of practice can be prosecuted for unlicensed medical practice. The outcome of these situations depend on each state’s own interpretation.
Douglas Wood, D.O., Ph.D., president of the American Association of Colleges of Osteopathic Medicine (of which there are 19 in the U.S.), gave a presentation on osteopathic medicine—its history in the U.S. and an overview of the current state of osteopathic medical education. Important components in osteopathic medicine include: physical, social, and other environments; holism, or unity of the body; self-healing; interrelated structure-function relationships in the body; “rational treatment—all the services of modern, scientific medicine”; and the use of manipulative therapy techniques. How osteopathic medicine works is not well known or well understood. Dr. Wood predicted that in the future, “osteopathic medicine will continue to evolve as a ‘parallel and distinctive’ profession.”
Interdisciplinary Approaches to Delivering Care
Andrew Weil, M.D., director of the Program in Integrative Medicine and professor of medicine at the University of Arizona, Tucson, described the poor state of the conventional medical profession in the U.S. He cited hospitals going bankrupt, low morale among M.D.’s, a drop in applications to medical school, and scores of unhappy patients. Factors that can play a part in the problem, he said, include the training process; prejudice of different kinds toward “integrative” approaches; the challenges of obtaining academic support and funding for research on those approaches; and “territoriality.”
Dr. Weil described a different approach in his interdisciplinary program at the University of Arizona, which he called a “new model for helping patients.” In that program, listening to patients is very important, as is “taking them seriously”; considering as treatments not only drugs and surgery but CAM modalities; helping patients navigate through the maze of therapeutic options now available; and providing a comfortable, pleasing, healing environment. Patients, he said, are more motivated, cooperative, and realistic in expectations, and the staff finds their practices to be more rewarding.
He said that physicians need to be teachers of health and healthy living. “We need to restore the soul of medicine,” he said, noting this is not solely a movement among patients but in academic medicine as well. Others needs, he said, are to restore patient satisfaction; improve health outcomes; and develop more rigorous definitions and standards in integrative medicine, “to help bring more order and clarity” to the field.
Lucy Bell of the Hammersmith Hospitals NHS Trust, U.K., spoke of the complementary cancer care the Hammersmith system offers. She noted that in the last 10 years there has been a large increase in the use of complementary therapies in the cancer care setting. Today, 70% of cancer centers in England and Wales offer at least one CAM therapy to their patients. In the Hammersmith Hospitals, within the NHS, they have pioneered the use of complementary therapies within their cancer center—aromatherapy, massage, reflexology, relaxation, visualization, acupuncture, and art therapy. These are, she said, “an integral part of a multidisciplinary approach to specialist cancer and palliative care,” and useful for coping, especially with the side effects of treatment.
The complementary therapies at Hammersmith, she said, are easy to use, can be used anywhere, and are non-invasive and pleasant. Patients report enhanced quality of life and well-being. They feel they are taking back some control over their lives.
She emphasized, “The value of touch cannot be underestimated.” Massage, even a 5-minute hand massage, is helpful. The staff teaches massage techniques to patients’ relatives. It is also important to give patients individual attention and time, and an opportunity to talk.
David Spiegel, M.D., professor of medicine and biochemistry at Stanford University School of Medicine, Stanford, CA, described the current state of health care delivery in the U.S. as having turned doctors into “biomechanics” and “providers.” They are drowning in paperwork, he said, especially when it comes to reimbursement for CAM modalities.
Physicians are becoming more open to CAM techniques and even to using them themselves, he said, and they need to learn about the different CAM disciplines. “They haven’t been good in helping people reconstitute a relationship with their body and deal with the emotional effects of their disease,” he said.
Dr. Spiegel noted that an adequate, comfortable, and attractive physical space makes a real difference in how people feel when they come to a center, whether as a patient or employee.
David Reilly, M.D., a physician, a homeopath, and the director of Glasgow (Scotland) Homeopathic Hospital, talked of his hospital as creating “a place of beauty and healing” within the NHS. The facility consists of an inpatient unit, a day care unit, and an outpatient-based service. The fact that 20% of general practitioners in Scotland have had homeopathic training testifies to the popularity of homeopathy in the U.K.
Dr. Reilly emphasized that, in his experience, the principal healing factor is the relationship between patient and carer. “This is not ‘shopping cart medicine,’” he said. Also, he believes that healing comes “from within,” not through the modality. This is achieved by helping people reintegrate the dimensions of their world: inner world, outer body, and life. He summarized the Glasgow model as “patient-centered, not system-centered” and one that utilizes the best of orthodox and CAM medicine. He closed with the comment, “We need to study Michelangelo’s ‘David,’ not just the tools that made it.”
Exploring the Science Base
The final module of the NCCAM-RCP conference addressed “The Science Base for CAM: Strategies and Tactics.”
Ji-Sheng Han, M.D., of Peking University, China, spoke first. Dr. Han is a renowned researcher in the field of acupuncture, which he has studied for 35 years. Dr. Han did the first research showing how acupuncture produces analgesia (pain relief). More recently, he has explored this process in greater depth, including its neurochemical aspects.
It is interesting, Dr. Han pointed out, that most people are “responders” to acupuncture; some people are non-responders; and dogs, cats, and rabbits “all respond.”
He gave highlights of his acupuncture research in animals and humans, including basic findings about its analgesia; how acupuncture induces the release of neurotransmitters in the central nervous system; the role of serotonin and endogenous opiate-like substances in analgesia; the interesting fact that electroacupuncture has proven very effective in lessening morphine withdrawal symptoms in rats and humans, though the mechanism is not yet well understood; and his interest in the role inherited genetic factors probably play in explaining individual differences in response to pain and the management of pain. Dr. Han’s continuing research in the field has implications for treating pain, emotional disorders, addiction, and other medical problems.
Michael Hyland, Ph.D., C. Psychol., professor of health psychology at the University of Plymouth, U.K., spoke on his vision of “complexity theory” and CAM. Complexity theory has developed within the past 15 years, propelled by the findings in the fields of mathemaics and computer science. It deals with “synthesis within complex systems and consequent emergent properties.”
The basic assumption of modern Western medicine, he said, is the body functions like a mechanical system, e.g., a jumbo jet. Pathology is seen as originating from a specific error in this system. Treatment requires correction of that error. This model does not account, however, for certain phenomena such as self-healing, he said, which, in principle, complex systems could explain. Living systems are organized in a different way from mechanical objects such as jumbo jets. Complexity theory is based on networks; networks function differently from other sequential systems. Thus, they may offer explanation of how CAM therapies work and of chronic diseases, such as their variability, multiple risk factors, and varied triggers.
Dr. Hyland acknowledged that his is “a speculative theory that needs more development and understanding, e.g., of learning rules and contextual factors.”
House of Lords Report on Complementary and Alternative Medicine
Stephen Holgate, M.D., MRC clinical professor of immunopharmacology at the University of Southampton, U.K., served as an advisor on a House of Lords Report on Complementary and Alternative Medicine, authored by the Select Committee on Science and Technology and released in November 2000. Dr. Holgate discussed the report’s major findings and the challenges that lie ahead. (You can browse this report on the Web at www.parliament.the-stationery-office.co.uk/pa/ld/ldsctech.htm; select “Session 1999-2000.”)
The report acknowledges that the use of CAM is widespread and increasing across industrialized nations. Among its major recommendations are:
- Improving the research knowledge base of CAM therapies. The Committee has accepted some CAM therapies—namely, osteopathic medicine, chiropractic, and herbal medicine—as “having established efficacy in the treatment of a limited range of ailments,” but finds more knowledge is needed about the modes of action of many others. The Committee recommends a “central mechanism” for coordinating and advising on research-related matters and establishing training opportunities, including “pump-priming” through developing a few “centers of excellence,” citing the NCCAM CAM Centers Program as a successful model. Funding for these research endeavors is proposed to be by the government and, possibly, the charitable sector.
- Providing “balanced, fair” guidance to the public on which CAM therapies work or do not work, and which are safe.
- Improving regulation, by statute when possible. One example is better identification and standardization of herbal products to the British public.
- Having clear guidelines for regulation and training in CAM practice among statutory regulated health professionals (such as doctors and nurses) “who wish to incorporate a CAM therapy in to their personal clinical repertoire.”
- Enhancing consistency in CAM training courses with regard to content, depth, and duration, through each discipline developing one professional regulatory body.
- Increasing students’ familiarization with CAM within schools of medicine and nursing and providing is continuing professional development.
The House of Lords Report assigns CAM therapies into three categories, based on the Committee’s consideration of each therapy’s organization, the extent to which it is complementary with conventional medicine, and the strength of its scientific evidence base. It refrains from recommending any specific therapies for availability under the NHS. However, it recommends that any therapy to be covered by public funding shall not only have its base of established evidence considered, but be “statutorily regulated or have robust mechanisms of voluntary self-regulation.”
Certain themes threaded throughout the conference. There are differences, sometimes vast, between the United States and the United Kingdom with regard to CAM regulation, research, academic involvement, government support, and even public support. However, common ground and positive energy unified and electrified the conference—e.g., concerning progress that has been made; what each country has learned and how it could help the other; and the many examples of successful interdisciplinary systems. The latter area appears to be proceeding not as two parallel tracks (CAM and conventional medicine), but toward one track of interdisciplinary medicine. There is movement away from competing for patients and toward unity and cooperation to enhance human healing.
Physicians are becoming more open to CAM interventions, both in terms of training in the techniques and making referrals to CAM practitioners. A number of speakers who were conventionally trained doctors presented on their clinics and practices that successfully incorporate multidisciplinary approaches to health care.
Public use of, and demand for, access to CAM therapies has grown, and does not appear to be affected by insurance reimbursement factors. There are interesting differences between U.K. and the U.S. public awareness of, and knowledge about, certain specialties. For example, homeopathy is well integrated into the NHS; in the U.S., homeopathy is not institutionalized. Osteopathic medicine is a mature and fully integrated discipline in the U.S.; in contrast, osteopathic medicine is an ancillary health system in the U.K.
There is major concern in both countries over licensure of CAM practice. A balance needs to be struck between (a) effectively regulating professions and preventing harm to patients and (b) respecting individuals’ right of access and freedom of choice.
In education, the growing public use of CAM is having an impact upon the practice of conventional medicine and the goals of medical students and residents. Students are now expressing more interest in CAM therapies and in care approaches that center on management of the whole person. More consensus among institutions is needed on the elements of a core curriculum in CAM.
The quality of scientific research to date on CAM, based on well-designed clinical trials, has been variable and needs improvement. The NCCAM was praised as a leader in this area, and the House of Lords has cited its commitment to undertaking a similar effort.
In summing up this historic conference, Dr. Straus said, “Integration of CAM therapeutics into the routine delivery of medicine requires trust among practitioners; assurance that they are well-trained professionals; and modalities that work and are safe. This meeting was enormously successful in helping all of us in the U.K. and in the U.S. to achieve these three goals.”