Greg 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
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
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." |
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."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 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". |
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 precept to 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." |
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 and its practitioners from less authoritative, non-science practitioners" are untenable." |
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. 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"
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).] 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".[
"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." |
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 have shown they would like to have." |
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."] 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.
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