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From the Townsend Letter for Doctors & Patients
April 2005

Pathways to Healing
by Elaine Zablocki
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IOM Report on CAM Highlights a Decade of Change

In mid-January the prestigious Institute of Medicine released a 330-page report called Complementary and Alternative Medicine in the United States. The work of a 17-member committee, based on five public hearings plus an extensive search of the literature, this report will influence US attitudes and actions towards integrative medicine for years to come. It exemplifies how much progress we've made, and also how far we still have to go.

The committee that wrote the report included 10 MDs, 5 PhDs, and two members with a master's degree in public health; all the committee members play influential roles within the conventional medical establishment. Initially the committee also included two members with closer ties to the CAM community, but after the first meeting they were removed, "due to concerns about conflicts of interest or bias," according to a spokesperson for the IOM.

Even though one of the remaining committee members is a licensed acupuncturist, and one is a certified massage therapist, it's fair to say that this committee generally represents the views of conventional clinicians. Their report could be subtitled "what conventional medicine thinks about CAM."

A Decade of Progress
The most striking thing, when you first glance through this report, is how much the landscape has changed in little more than a decade. When David Eisenberg, MD, published his landmark article on CAM usage in January 1993, pointing out that Americans were spending $10 billion a year out of their own pockets on alternative therapies, the news came as a big surprise to most healthcare leaders.

Today, when Stuart Bondurant, MD, executive dean of Georgetown University Medical Center, opened the press conference on the report, he announced that "CAM is here to stay," adding that "more than one-third of American adults routinely use CAM, spending more than $30 billion a year of their own money."

This change is reflected in the report's key recommendations:

1. Doctors, nurses and other health professionals should receive education about CAM treatments during their professional training.
2. Healthcare licensing boards and accrediting agencies (for both CAM and conventional medicine) should set competency standards in the appropriate use of both conventional medicine and CAM therapies, consistent with practitioners' scope of practice.
3. CAM practitioners should formulate practice guidelines for their own therapies.
4. Product quality of nutritional supplements should be improved, with increased accuracy in labeling and stronger enforcement against misleading claims.
5. NIH and other public and private agencies should sponsor research to compare outcomes and costs of combinations of CAM and conventional medical treatments, and varying models of care delivery.
6. CAM practitioners should be involved in research in order to ensure that research reflects as much as possible the actual ways in which CAM is used.

The most fascinating chapter in this report (and one that really shows how far we've come) is chapter 4, on innovative research methods for CAM. The traditional gold standard for medical research is the randomized controlled trial, in which researchers hand out a real pill to some patients, a fake pill to other patients, and neither the physician nor the patient knows who's getting what. It's difficult to do this sort of research with many CAM treatments, for many reasons. Practitioners often use a combination of methods. Treatment is so individualized that four patients with the same symptoms may receive very different advice and therapies.

But it is possible to find other ways to study CAM, the committee said. "Addressing the special challenges for research in CAM will require a broadening of thinking about the types of study designs that can produce valid evidence of treatment effectiveness." In particular they mention observational studies, case control studies, and studies of bundles of therapies, as possible research methods to evaluate CAM.

Also take a look at chapter 6, which presents an ethical framework for CAM research, practice, and policy. The committee acknowledges that there are "multiple valid modes of healing" and that "investigation of CAM practices entails a moral commitment of openness to diverse interpretations of health and healing." It warns against co-option of CAM therapies by conventional medical practices.

Guarded Optimism
Joseph PizzornoRepresentatives of the CAM professions have greeted the report with guarded optimism. "In general this is a pretty good report, in fact better than I expected," says Joseph Pizzorno, ND, president emeritus of Bastyr University, and editor of Integrative Medicine: a Clinician's Journal. "I like the orientation towards research, and the emphasis on product quality in botanicals and nutritional supplements. I like the fact that practice guidelines for CAM therapies will be developed by CAM practitioners. Frankly, I think these recommendations are good and I hope they're implemented."

Reed Phillips, DC, PhD, agrees. "While barriers to fulfilling these recommendations have existed in the past, preventing CAM from full access to the 'research dollar,' now is the time for CAM to become fully integrated into the research enterprise. This represents a much-needed change in culture, in both the CAM world and the 'traditional' world of healthcare." Phillips is a board member and immediate past president of the Council on Chiropractic Education.

Reed PhillipsPizzorno also particularly appreciates the committee's support for licensure of CAM professionals. "This is important because licensure is essential in developing high-quality CAM standards. Without licensure, you have a situation where anyone can call themselves a CAM practitioner. That means the public has no way of separating qualified practitioners from those who lack training, so it's a huge public safety issue."

Dietary Supplements
The chapter that has grabbed almost all the news headlines is chapter 9, on dietary supplements (including vitamins and herbal products). Currently the supplements are regulated under the Dietary Supplement Health and Education Act of 1994 (DSHEA), which says they should be regulated as if they were foods. Under this law, the FDA was supposed to establish "good manufacturing practice regulations" for dietary supplements. "We're on the edge of our seats waiting for those regulations," says Karen Robin, director of communications for the American Herbal Products Association. "Our organization, and others across the nation, submitted comments on FDA's proposed good manufacturing practices back in August 2003."

The IOM report calls on Congress to amend DSHEA to strengthen quality-control standards for supplement manufacturing, and to enforce more accurate labeling and other consumer protections. However, whether DSHEA should be amended, or simply implemented, is likely to be a key point of debate whenever Congress does address the issue.

During the IOM press conference, committee member Eisenberg spoke to this point, explaining that, "to do research on botanicals and dietary supplements, if you're an investigator, you need to have reproducible product. As a committee, we said 'we have a problem. We're not sure that what's in the bottle is what it says on the label.'" Eisenberg added, "much of this may have more to do with implementation of existing law, rather than remediation or alteration of the law. We did want to say that as a research community, and as clinicians who have to advise patients, we're at an impasse. Challenging the way the law is written, versus the implementation of the law, that really wasn't our purview."

In fact, throughout the report, the committee often describes what is needed, without specifying how those goals should be achieved. "We are describing the problems we face as medical clinicians" they say. They don't propose detailed, specific plans to solve these problems. They tell us what the problems are; then they call upon many other segments of society, including Congress, researchers, consumers, supplement manufacturers, CAM practitioners, and private foundations, to join together in seeking and implementing solutions.

From the CAM Viewpoint
As we read this report, it's striking how often it refers to various CAM therapies, and how rarely it refers to the CAM professions or disciplines. In fact, the phrase "CAM therapies" appears 299 times, while "CAM professions" is used eight times and "CAM disciplines" is used only twice. The report envisions a world in which MDs may recommend or use certain CAM therapies as part of their practice; it doesn't express a vivid sense of the CAM professions as whole systems.

When you speak with members of the CAM professions, they say that they practice comprehensive systems of care, based on philosophies that differ from those underlying conventional care. These theoretical underpinnings guide clinical decisions, such as how and when to use which treatments for a particular patient. It's not just that the CAM disciplines use herbs or acupuncture needles instead of pills; the process and guiding mental structure are different.

"Sometimes people in conventional medicine would like to believe they can practice alternative medicine simply by using the tools of alternative medicine," comments Pizzorno. "They are missing the point. It's not just what we use, but how we use it. Simply discussing CAM therapies in isolation trivializes the philosophic basis of CAM practice."

Asked for an example, Pizzorno explains that when he sees a patient with depression, he looks at the whole picture. "Naturopathic medicine has a way of understanding the patient and the patient's illness that goes beyond conventional Western practice," he says. "We consider all possible factors, including nutritional deficiencies, social stresses, lifestyle activities, and environmental toxins. We look for the underlying cause of the problem. If someone offers a depressed patient St. John's wort without first comprehensively evaluating the situation, that's not what I consider natural medicine."

Lack of CAM Funding is Key
Many MDs today are motivated by sincere respect for the various CAM disciplines. That respect is bearing fruit in the growing number of medical schools that offer courses about CAM, and the growing number of joint research projects. Conventional academic medical centers with a special interest in CAM have organized themselves into the Consortium of Academic Health Centers for Integrative Medicine (see Appendix B of the report).

A similar organization of CAM academic institutions has been formed, including councils of colleges and accrediting agencies for all the licensed CAM professions. Called the Academic Consortium for Complementary and Alternative Healthcare, it will be able to engage in a productive and effective dialogue with conventional academic health centers, to the benefit of all.

But the hidden giant in the room, the rarely discussed key point, is the lack of sufficient public funding for CAM colleges and universities. In order to achieve the goals envisioned in the IOM report on CAM, this is a problem that must be addressed.

The entire IOM report, Complementary and Alternative Medicine in the United States, is available on the National Academy of Sciences website in "open book" format at This isn't designed for download, it's designed for online searching and reading. You can print out any page that interests you, but you have to print it out one page at a time. To buy a copy of the full report, go to It's available both as a hardcover book and as a downloadable pdf file.

To listen to the IOM press conference in streaming audio, go to

Elaine Zablocki is the editor of CHRF News Files, a bimonthly emailed newsletter about the emerging integrative medicine industry, published by the Collaboration for Healthcare Renewal Foundation.



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