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."
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
4. Product quality of nutritional supplements should be improved, with
increased accuracy in labeling and stronger enforcement against misleading
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
methods for CAM. The traditional gold standard for medical
research is the
randomized controlled trial, in which researchers hand out a real
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
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
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
Representatives 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
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
Pizzorno 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
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
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
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
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 http://www.nap.edu/books/0309092701/html/.
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 http://www.nap.edu/catalog/11182.html.
It's available both as a hardcover book and as a downloadable
To listen to the IOM press conference in streaming audio, go to http://www.nationalacademies.org/topnews/.
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.