Assessing the Effectiveness of Complementary & Alternative Medicine With support from the National Center for Complementary and Alternative Medicine (NCCAM) …

Integrating Complementary Alternative Therapies with Conventional Care

The Convergence of Complementary, Alternative Conventional Health Care: Educational Resources for Health Professionals

This publication is one in a series of educational resource materials on complementary and alternative health care issues published by the Program on Integrative Medicine, University of North Carolina at Chapel Hill entitled:

The Convergence of Complementary, Alternative Conventional Health Care: Educational Resources for Health Professionals
Titles in the series include: Understanding the Convergence of Complementary, Alternative Conventional Care in the United States Concepts of Healing Models of Care Evidence-Based Medicine Complementary Alternative Therapies Assessing the Effectiveness of Complementary Alternative Medicine Safety Issues in Complementary Alternative Medicine Evaluating Information Sources for Complementary Alternative Health Care Information Sources for
Complementary Alternative Therapies Integrating Complementary Alternative Therapies With Conventional Care Copyright 2004 The Program on Integrative Medicine, Department of Physical Medicine Rehabilitation of the School of Medicine of the University of North Carolina at Chapel Hill With support from the National Center for Complementary and Alternative Medicine NCCAM, National Institutes of Health, US Department of Health Human Services Grant No 5-R25-AT00540-01 This publication was funded by the National Center for Complementary and Alternative Medicine NCCAM and is thus in the public domain; it may be quoted freely with proper credit Please cite as follows: Mann, JD, Gaylord, SA, and Norton, SK Integrating Complementary Alternative Therapies With Conventional Care The Convergence of Complementary, Alternative and Conventional Health Care: Educational Resources for Health Professionals University of North Carolina at Chapel Hill, Program on Integrative Medicine,
2004
ACKNOWLEDGMENTS

Sheilah N Thomas, MS, editor Program on Integrative Medicine Department of Physical Medicine Rehabilitation UNC School of Medicine UNC-CH - CB 7200 Chapel Hill, NC 27599-7200 phone: 919 966-8586 fax: 919 843-0164 website: http://pimmeduncedu email: rcoble@meduncedu

Integrating Complementary Alternative Therapies with Conventional Care
Douglas Mann, MD, Professor, Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill Susan Gaylord, PhD, Director, Program on Integrative Medicine, Department of Physical Medicine Rehabilitation, University of North Carolina at Chapel Hill Sally K Norton, MPH, Project Manager, Complementary Alternative Medicine Education Project, Program on Integrative Medicine, Department of Physical Medicine Rehabilitation, University of North Carolina at Chapel Hill

Integrating Complementary Alternative Therapies with Conventional Care is one of a series of publications entitled The Convergence of
Complementary, Alternative Conventional Health Care, that has been developed as an educational resource for health professionals by the Program on Integrative Medicine, University of North Carolina at Chapel Hill These publications respond to the many questions raised as conventional health care practitioners encounter widespread and increasing use of complementary and alternative therapies The health care system today is, in fact, a dynamic, rapidly changing world of multiple healing modalities that overlap and interact on many levels Publications in the series The Convergence of Complementary, Alternative Conventional Health Care highlight many of the key issues facing health professionals today– including assessing information, effectiveness, and integration of conventional, complementary, and alternative health care Although the convergence of multiple health care models is not in doubt, there are many unanswered questions about how they will come together This publication
explores the issues raised as conventional health care providers move toward integrated practice, and describes a variety of options for doing so The Convergence of Complementary, Alternative Conventional Health Care was developed with support from the National Center for Complementary and Alternative Medicine NCCAM, National Institutes of Health

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Integrating Complementary Alternative Therapies With Conventional Care
preface
Thomas Edison once predicted, The physician of the future will give no medicine, but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease While his vision has not yet materialized, recent trends in health care indicate a shift in that direction Although it is likely that most 21st century health care providers will continue to give medicine
as well as prescribe other forms of hightech care, there are signs that these practices will more often occur in a holistic context that encourages selfcare and supports self-healing and wellness Health-care practice in the future — perhaps the very near future — could embrace and integrate a comprehensive array of therapies and healing approaches, drawing on both the technological advances of contemporary medicine and the modern versions of the diverse and sometimes ancient practices and concepts of complementary and alternative medicine CAM This potential convergence and integration of the different cultures of conventional and complementary care raises many important questions for contemporary health care providers What is integrative medicine? And what are its implications for conventional health professionals in terms of quality of care, training, resources, financial dynamics and legal issues? Our purpose is to begin to answer these and other questions and in so doing, to
provide encouragement and support to those practitioners now exPROGRAM ON INTEGRATIVE MEDICINE
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CONTENTS
CAM Use in the United States 2 Integrative Medicine: Definitions and Methodologies 5 Moving Towards Integrative Health Care: Benefits and Challenges 5 Case 1: Adult Outpatient Oncology Consult 6 Case 2: Pediatric Inpatient Consult 7 The Challenge of Change 10 System Resistance 11 Educational Needs 12 Financial Disincentives 13 Approaches to Integrative Health Care 15 Model 1: The Informed Clinician 16 Model 2: The Informed, Networking Clinician 18 Model 3: The Informed, CAM-Trained Clinician 19 Model 4: Multidisciplinary Integrative Group Practice 20 Model 5: Interdisciplinary Integrative Group Practice 22 Model 6: Hospital-Based Integration 23 Model 7: Integrative Medicine in an Academic Medical Center 24 Steps Towards Integrating CAM with Conventional Practice 25 Conclusion 28 References 29 Appendix 34

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ploring this new approach to health care Specifically, we hope to assist readers to:

Understand the factors supporting the integration of complementary and alternative practices with conventional health care; Appreciate the potential benefits of an integrative approach to care; Understand the factors that present barriers to change and limit options for integrating care; Become aware of different contemporary forms of integrative care;

Learn about steps towards integrative care for the individual practitioner In the final analysis, the path to new, integrated models of care will be shaped through a partnership effort between health care practitioners and their patients as well as through the evolving forces within the current medical system and society itself If all comers contribute with confidence, openness, and a spirit of seeking the best of health care, improved
health care services should follow A note about the terminology used here In recent years, the term CAM has come into common usage to describe, in the words of the National Center for Complementary and Alternative Medicine, a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine These therapies include highly specialized methods such as biofeedback, millennia-old practices such as meditation, and comprehensive traditional healing systems such as Traditional Chinese Medicine They encompass a wide variety of skills and training, with varying certification and licensure requirements Despite its convenient brevity, the acronym CAM has some unfortunate implications It suggests, for example, a homogeneity among the practices included under the umbrella term– something that is not at all true It also implies a clear and complete distinction between conventional and CAM systems of care That also is
inaccurate We therefore use the term CAM sparingly, as shorthand for that group of diverse medical and health care systems where the emphasis is on the word diverse

Douglas Mann Susan Gaylord Sally Norton

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Integrating Complementary Alternative Therapies With Conventional Care
The public is using alternative therapies on a broad basis To best serve them, health care professionals must learn the good and bad points of these therapies Enlightened professionals will work with informed patients to integrate the most useful and proven therapies into their standard practice In such a setting, patient satisfaction is bound to increase By applying scientific rigor in evaluating the alternative therapies, we will protect
our patients while offering them the best of care: the integrative care mode
–Victor S Sierpina, MD

ainstream medicine is changing The biomedical conceptual framework that evolved and ultimately defined the American health-care system in the 20th century continues to predominate However, there is evidence that other therapeutic modalities, with different conceptual frameworks, are beginning to compete with this dominant model Eisenberg, et al, 1993; Eisenberg, et al, 1998; Eisenberg, et al, 2001 A number of trends suggest that conventional medicine may yield in the 21st century to an inTHE FUTURE OF CAM IN creasingly pluralistic health-care system, in which different models WESTERN MEDICINE of care may co-exist Barrett, 2003 A recent trend analysis provides the following forecast for However, the mere coexistence of different healing mothe future of CAM: dalities does not produce an integrative system of care Indeed, CAM therapies will become major tools for health within the
current health care system, patients and providers expepromotion and disease prevention; rience problems when multiple–but uncoordinated–healing ap CAM will be integrated into conventional medical proaches are used Markman, 2002 A commonly cited example is protocols; the potential for adverse herb-drug interactions that may occur as Some CAM providers will become recognized as pripatients mix herbal and pharmaceutical treatments without the mary care providers; awareness or guidance of health care providers Ang-Lee, Moss, Conventional providers will increase the use of Wuan, 2001; Piscitelli, 2000; Piscitelli, Burstein, Chaitt, 2002 alternative therapies; Other problems include poor communication between providers Providers that take a role in creating healthy comand patients, issues about credentials, training, and licensure of munities will gain a competitive edge providers and excessive costs of multiple, uncoordinated treatments Bezold, 2001 Cohen Eisenberg,
2002

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COMPLEMENTARY AND ALTERNATIVE DEFINING TERMS
In 1991, the Office of Alternative Therapies of the National Institutes of Health was created to investigate the increasing use of alternative therapies in the US In 1997, this office was designated a Center, with an enlarged research budget The National Center for Complementary and Alternative Medicine NCCAM defines CAM as a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine These range from highly specialized methods eg, biofeedback and ancient practices eg, meditation; to comprehensive traditional healing systems eg, Ayurveda NCCAM categorizes these widely varied alternative therapeutic
modalities into five broad areas: Alternative medical systems Traditional Chinese Medicine, Ayurveda, homeopathy, naturopathy Mind-body interventions biofeedback, hypnosis, mindfulness meditation, yoga, guided imagery Biologically based therapies diet, supplements, herbals, vitamins, detoxification, elimination Manipulation and body-based methods massage, chiropractic, osteopathy, Feldenkrais, Alexander Technique Energy therapies acupuncture, Reiki, magnets, therapeutic touch While somewhat arbitrary, these categories provide a structure for considering the scope and methods of alternative and complementary approaches Some therapies fit into more than one category wwwnccamnihgov

Increasingly, the term integrated or integrative describes medical practices that, while retaining many of the characteristics and strengths of biomedicine, also embrace the more holistic concepts and methods of complementary and alternative practices Rakel Weil, 2003 A healthy, effective system of
integrative care will require a conscious, thoughtful approach to combining different healing modalities Just what new models of care will emerge and how quickly they will evolve is unclear Barrett, 2003

CAM use in the united states
A major trend over the last four decades has been the steady increase in US consumers use of complementary and alternative therapies, including acupuncture, chiropractic, energy healing, herbal medicine, homeopathy, and massage Eisenberg, et al, 1993; Eisenberg, et al, 1998; Druss Rosenheck, 1999; Barnes, et al, 2004 This trend is likely to continue Kessler, et al, 2001 From 1990 to 1997, annual visits to alternative practitioners grew from 470 million to 629 million Eisenberg, et al, 1998 Those estimated 629 million visits to complementary care providers far exceeded the 386 million visits made to all US primary-care physicians that year, and out-of-pocket expenditures for CAM therapies were an estimated 27 billion, comparable to those of all US primary
care providers

Significantly, complementary and alternative modalities are often used in addition to, and not as replacements for, conventional care Eisenberg, et al, 1993; Eisenberg, et al, 1998 One can argue that the impetus for new, integrated models of care comes from consumers themselves, who are using both forms of care, often for the same condition Singer, 2001 One national survey of the use of CAM Eisenberg, et al, 1998 found that the highest use was for back problems, allergies, fatigue, and arthritis; other conditions included headaches, neck problems, hypertension, sprains or muscle strains, insomnia, pulmonary problems, dermatological disorders, digestive disorders, depression and anxiety see Table 1 on page 3 Another survey found frequent CAM use for psychological problems, pain, back problems, musculoskeletal disorders, chronic illness, anxiety, headaches, and smoking cessation Astin, 1998 According to the Eisenberg, et al, 1998 survey, the most frequently used therapies
were relaxation techniques 16 percent, herbal medicine 12 percent, massage 11 percent, and chiroPROGRAM ON INTEGRATIVE MEDICINE
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practic 11 percent Less commonly used were folk remedies, energy healing, homeopathy, hypnosis, biofeedback and acupuncture This survey also found that CAM use was higher among women 49 percent than men 38 percent; less common among African Americans 33 percent than other racial groups 45 percent; and highest among the 35-49 year age group 50 percent compared with older 39 percent or younger 42 percent age groups Greater use was reported among those with college educations 51 percent than with no college education 36 percent; and with annual incomes above 50,000 48 percent than with lower incomes 42 percent

consumer
rationale for CAM use
The growing numbers of CAM users tell only part of the story of change in the health care system Consumers motives for seeking alternative care reveal a great deal about why the numbers are growing and suggest the consumer priorities that are likely to influence the shape of future health care models Many cultural and individual factors influence choice of health care services, including gender, age, geography, education, and race Bair, et al, 2002 Also important are the health conditions for which consumers seek care Research indicates that those suffering from chronic, non-life-threatening health problems tend to be the heaviest users of CAM Bausell, Lee, Berman,

TABLE 1 USE OF CAM FOR PRINCIPAL MEDICAL CONDITIONS BY US ADULTS, 1997
PERCENT WHO USED CAM FOR CONDITION IN PAST 12 MONTHS PERCENT WHO SAW CAM PROVIDER FOR CONDITION IN PAST 12 MONTHS PERCENT WHO SAW MD AND USED CAM THERAPY FOR CONDITION IN PAST 12 MONTHS PERCENT WHO SAW MD AND CAM PROVIDER FOR
CONDITION IN PAST 12 MONTHS

CONDITION

PERCENT WHO REPORTED CONDITION

MOST COMMONLY USED THERAPIES FOR THE CONDITION

Back Problems Allergies Fatigue Arthritis Headaches Neck Problems High Blood Pressure Sprains or Strains Insomnia Lung Problems Skin Problems Digestive Problems Severe Depression Anxiety Attacks WEIGHTED AVERAGE

240 207 167 166 129 121 109 108 93 87 86 82 56 55

476 166 279 267 322 570 117 236 264 132 67 273 409 427 282

301 42 63 100 133 375 09 103 76 25 22 97 156 116 114

588 280 516 385 420 666 119 294 484 176 68 341 409 427 318

391 64 131 159 200 475 11 159 133 34 00 107 269 210 137

Chiropractic; massage Herbal; relaxation Relaxation; massage Relaxation; chiropractic Relaxation; chiropractic Chiropractic; massage Megavitamins; relaxation Chiropractic; relaxation Relaxation; herbal Relaxation; spiritual healing; herbal Imagery; energy healing Relaxation; herbal Relaxation; spiritual healing Relaxation; spiritual healing

adapted from Eisenberg et al,
1998
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includes provider and self-treatment

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PRINCIPLES OF HEALING EMPHASIZED IN MANY COMPLEMENTARY AND ALTERNATIVE THERAPIES
While a disparate array of alternative therapies and healing systems fall under the umbrella term CAM, what they typically have in common are fundamental principles of health and healing These principles are not unique to CAM conventional medicine subscribes to some, nor do all CAM therapies embrace them equally Taken together, however, they provide a framework for understanding CAM approaches to healing that contrast with the biomedical model of care Many CAM therapeutic systems emphasize some or all of the following principles to a greater degree than conventional medicine Effective integration of CAM and conventional
care must rest on acknowledgment, appreciation, and application of these principles in a patient-centered context PROMOTE THE BODY S SELF -HEALING ABILITIES This is perhaps the most important principle, influencing all others EMPHASIZE EFFECTIVE COMMUNICATION BETWEEN P ATIENT AND HEALER , which builds trust and promotes integration EMPHASIZE SELF-C A R E and empowerment of the patient in the healing process RECOGNIZE MIND, BODY, AND SPIRIT as interactive and inseparable ADDRESS UNDERLYING CAUSES OF ILLNESS —including emotional, environmental, and spiritual factors–rather than just its clinical manifestations PREVENT I L L HEALTH by remaining in balance and harmony with the psychosocial and physical environment ENHANCE WELLNESS with optimal diet, exercise, and a reducedstress lifestyle INDIVIDUALIZE TREATMENT to the particular patient, rather than focusing on the disease condition

2001 Many reports conclude that the majority of CAM users employ CAM as an adjunct to
mainstream medicine for prevention rather than treatment of illness Druss Rosenheck, 1999; Ernst, 2001 Additionally, research investigating the motives of CAM users suggests that, while many consumers still value and rely on conventional care, they also appreciate many of the characteristics and qualities of CAM care that are not typically found in mainstream medicine– including a holistic approach to healing, personal attention, cultural sensitivity, lower cost, and fewer negative side effects Astin, 1998 These characteristics or principles include beliefs and practices shared by many complementary and alternative modalities see box, left

provider rationale for cam use
Like their patients, mainstream health care practitioners are exploring non-conventional health and healing options in greater numbers A primary motivation is desire to communicate more effectively and be more knowledgeable in interactions with their patients who are coming to them with questions about complementary
and alternative therapies A second motivation is perceived limitations of conventional health care Starfield, 2000; Astin, Ariane, Pelletier, Hansen, Haskell, 1998; White, Resch, Ernst, 1997; Crock, Jarjouja, Polen, Rutecki, 1999 Some cite dissatisfaction with the fast pace and pharmaceutical focus of conventional care as a reason for exploring CAM The dramatic statistics on medical errors and pharmaceutical risks have alerted providers to the need for concern about the safety of conventional medical practices Lazarou, Pomeranz, Corey, 1998 Deaths from medical errors in 1997 exceeded those from motor vehicle accidents, breast cancer, AIDS, or workplace injuries Institute of Medicine, 1999 Another strong motivator is the search for effective treatments for diseases that do not respond well to conventional care For example, a growing list of systemic disorders such as fibromyalgia and lifestyle-related health problems frequently fail to respond to the treatment approaches of
conventional medical practice Yunus, Bennett, Romano, et al, 1997; DeBacquer, et al, 2004
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EMPHASIZE THE USE OF NATURAL NON-PHARMACEUTICAL SUBSTANCES

or non-surgical techniques in the care of the patient

APPRECIATE THE ELECTROMAGNETIC AND ENERGETIC NATURE OF THE HUM A N ORGANISM and the importance of vitality in healing A P P R E C I A T E THE IMPORTANCE OF INTUITIVE A W A R E N E S S

and the individuals unique experiences in determining pathways to healing ACKNOWLEDGE THE HEALING JOURNEY and that the return to wholeness can be a gentle and gradual, developmental process adapted from Gaylord Coeytaux, 2002

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Positive personal experiences with CAM, positive feedback from their patients about CAM, and reports of
exemplary health-care programs that have incorporated CAM compel some practitioners to learn more about these therapies The increased interest in preventive approaches is also a compelling rationale for attraction to CAM therapies Ernst, 2001 Whatever the motivation, increasing numbers of conventional clinicians are learning about and exploring CAM therapies for personal and professional use Some of them are contemplating or actively integrating complementary and conventional methods, in both small and more comprehensive ways Barnes, Abbot, Harkness, Ernst, 1999; Barrett, 2003; Veenstra, 2000; Moore, 1997 Health insurers and managed care organizations that have incorporated CAM into their policies state that their primary motivation is market demand Therapies such as nutritional counseling, biofeedback, acupuncture, preventive medicine, and chiropractic are increasingly covered under many health plans Pelletier, Astin, Haskell, 1999

integrative medicine: definitions and
methodologies
As the name attests, integrative medicine brings together diagnostic and healing methods from mainstream medicine and alternative healing systems Ideally, integrative medicine draws on the formidable strengths of biomedicine and benefits of holistic and natural healing modalities in an individualized, patient-centered approach that seeks to enhance and utilize self-healing capacity Bell, et al, 2002 The vision for integrative medicine is under debate Of particular concern is the possibility that integrative medicine will be perceived–and therefore practiced–as combination medicine Adding alternative therapies to a practice grounded in conventional medical beliefs may appear to be integrative and may be a critical first step towards integration, but it is not integrative medicine Integrative mediWHAT IS INTEGRATIVE cine must be defined by a new philosophical context that embraces MEDICINE? healing the whole person and utilizing principles commonly emphaAccording to the
National Institutes of Health, Center sized in CAM see box, page 4 Examples of concepts fundamental to for Complementary and Alternative Medicine NCCAM, integrative health care planning include: detoxifying the physical, sointegration combines mainstream medical therapies cial, and psychological environment; nourishing and supporting the and CAM therapies for which there is some high-quality body, mind, and spirit; and stimulating the patients self-healing abiliscientific evidence of safety and effectiveness ties The cases on pages 6 and 7 provide examples of the application wwwnccamnihgov/health/whatiscam/3 Pracof these principles in an integrative medicine consult service tically speaking, integrative medicine involves the application of medical diagnostic and therapeutic techniques from both conventional and alternative traditions However, It is not merely the addition of nonconventional therapies and techniques to conventional practice A new model of healing is called for–one that
goes beyond treatment of disease to embrace a The integration of CAM practices, therapies, and beliefs with conholistic approach to health and healing as addressed ventional health-care practices offers considerable potential for an by Snyderman Weil 2002 and many others improved health care system, such as expanded treatment options, improved patient and provider satisfaction, and improved therapeu-

moving towards integrative health care: benefits challenges

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CASE 1: ADULT OUTPATIENT ONCOLOGY CONSULT: MR J
THE PROBLEM: A UNC oncologist referred a 56-year-old white male with a recent diagnosis of pancreatic carcinoma to the UNC Integrative Medicine IM Consult Team This patient, Mr J, was experiencing abdominal pain, weight loss, and
diarrhea A 4-cm mass had been found in the head of the pancreas, with three small metastatic lesions in the liver He had been given a grave prognosis at another institution, and was justifiably anxious Mr J was seeking support and guidance for exploring complementary treatment options He was particularly interested in nutritional therapies PRE-EXISTING TREATMENTS: Mr J had been on a regimen of chemotherapy for a week and continued a course of standard oncology care thereafter IM TEAM INVESTIGATION: Initially, the IM Consult Team, consisting of a neurologist, pharmacist, and psychologist, met with Mr J and discussed some complementary options in the areas of mind-body therapies, nutrition, body-work and energetic therapies, mindful exercise, social support, and spiritual perspectives Mr J struggled with conflicting beliefs about his potential for survival based on pessimistic comments from his former oncologist, on data on median survival time of people with his diagnosis, and awareness
of other patients who had survived this condition in spite of very similar lesions IM TEAM RECOMMENDATION: The IM Team recommended dietary modifications such as: to eliminate high glycemic index foods, caffeine, red meats, and fatty foods; and to increase water intake They also recommended a number of supplements as follows: vitamins–C, B- complex, B-12, E, D, A, Co Q-10, Alpha lipoic acid; selenium, calcium, and magnesium; probiotics, modified citrus pectin, fish oil, and pancreatic enzymes The herb milk thistle also was recommended Mr J was encouraged to maintain his support network, which included members of his church–a central feature of his life An array of mindbody skills were offered to Mr J as well OUTCOMES: Mr J complained about the extreme change in diet, yet he readily complied The Team worked with him using hypnosis and guided imagery, to gain insight about his beliefs and to modify them Training to optimize heart-rate variability was helpful in recognizing and
maintaining the still point in the present moment, where calm and insight could easily occur Mr J participated in regular meetings with the IM Team for 15 months At this time, Mr J is still working regularly, with stable weight and stable primary tumor size, good energy, sleep, and appetite He remains uncertain about the course of his illness, but admits that his survival is impressive LESSONS: A key concern of Mr J was the lack of communication and difference in perspectives between the Consult Team and his conventional oncologist A turning point in care for all was a meeting with Mr J, a family member, and all of his caregivers to discuss his progress and to develop a comprehensive plan This meeting represented, for him, truly integrative care

tic outcomes White Ernst, 2000 With these benefits, there are also many challenges If conventional and non-conventional practices are to come together successfully, practitioners will confront a number of important issues, including
differences in practice cultures, credentials and training, quality assurance, funding and research In addition to enhancing the strengths of conventional medicine, integrative care may be able to better balance its deficiencies Caspi, et al, 2003 These include potential negative side effects of individual pharmacological agents and polypharmacy, high costs and depersonalizing nature of technological interventions, and suppression of symptoms without promoting overall healing

infusion of a fresh perspective on healing

The goal of medicine is not merely to treat disease, but to relieve suffering, and suffering is experienced not only at a biological level but by the complex social and psychological entity that is the human being The intense pace of modern medicine sometimes overlooks the needs of the whole person, resulting in medical intervention that, though technically adequate, fails to meet these needs Cassell, 1982 As the principles of CAM merge with conventional care, they
could infuse the practice of medicine with the bio-psycho-sociospiritual goal of healing the whole person

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expanded options for patient care
By its nature, an integrative clinical practice provides an expanded array of health-care options While conventional therapies such as prescription drugs may effectively address a particular condition, not every individual will respond well to a given protocol For instance, use of the triptans has revolutionized the acute treatment of migraine However, over 25 percent of patients

CASE 2: PEDIATRIC INPATIENT CONSULT
THE PROBLEM: The UNC Integrative Medicine Consult Team was contacted by hospital staff due to a conflict between attending physicians and the parents of a 13-year-old
female with extensive inflammatory bowel disease who was experiencing continued weight loss and bleeding into the bowel The attending physicians and house staff reported that the patient had recently relapsed while under their care after initially doing better The attending physicians believed that the deterioration was related to the use of non-conventional substances administered to the patient by her parents The house staff indicated that the conflict was generating stress in the patient and believed that the stress was contributing to the deterioration THE TREATMENTS: The parents had been giving the patient a powdered mixture containing licorice, germanium, comfrey, fish oil, lactobacillus, calcium, iron and an unknown herb The patient had been successfully treated 18 months earlier for this same condition by a naturopathic physician using this remedy, and perhaps others Following this treatment, which took place in another state prior to the patients family moving to North
Carolina, the patient had remained symptom-free until eight weeks prior to this admission, when she again began experiencing bloody diarrhea, abdominal pain, and weight loss The attending physicians had pursued a course of treatment that consisted of total parenteral nutrition TPN intermittently, Cipro, floxocin, Flagyl, prednisone, and Asacol IM TEAM INVESTIGATION: The IM Consult Team, consisting of a physician, psychologist, and pharmacist, met separately with the physicians and house staff, and with the parents The teams appreciation of CAM therapies helped gain the familys trust and participation in resolving the conflict The team undertook a literature search to determine possible side effects and interactions of the treatment protocols Comfrey and germanium were discovered to be potentially toxic to the liver and capable of interfering with clotting The team further determined that Cipro was probably unnecessary IM TEAM RECOMMENDATION: The IM Consult Team recommended to the
parents that they follow the advice of putting the bowel at rest, and limiting the administration of any oral substances The Team also recommended the use of self-hypnosis, guided imagery, and biofeedback Although the parents were not convinced that the naturopathic treatment was responsible for the bleeding, they and the attending physicians agreed that putting the bowel at rest along with other complementary approaches would be worth a try A plan was developed that consisted of restricted oral intake, a very few oral medications, and a self-hypnosis routine including guided imagery addressing pain control and healing of the bowel OUTCOMES: The family participated in the self-hypnosis instruction and practiced it with the patient The patient also was trained in heart rate variability control Because her sympathetic nervous system was very active, she was taught a routine for balancing the sympathetic and parasympathetic systems The approach, in effect empowered the patient to
de-stress CAM principle of self-care and empowerment By the end of the first week, the patient experienced a marked reduction in pain and bleeding At the end of the second week, she tolerated the re-introduction of food Patient, family and staff satisfaction with the care improved dramatically, as did communication between family and hospital staff LESSONS: Upon discharge, the patient was pleased with self-hypnosis and considering biofeedback The family agreed to consultation with a local naturopathic physician to oversee use of herbs, probiotics, and dietary management Integration of conventional and complementary therapies was achieved Application of mind-body therapies was an effective component of the treatment program Both the conventional providers and family members gained new awareness and insights for the management of this condition

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do not respond at all to triptans, and in those who do, effective treatment occurs in only 75 percent of headaches Matchar, 2003 Incorporating complementary therapies for acute headache–such as self-hypnosis, aromatherapy, and acupressure–provides patients with effective options that lead to pain control and lower cost Holroyd Mauskop, 2003 Other examples include: Blood pressure management through a combination of hypnosis, diet modifications, and medication Kirsch, Montgomery, Saperstein, 1995;

Migraine reduction by combined use of feverfew and a beta blocker; Holroyd Mauskop, 2003; Smoking cessation with buproprion and hypnosis Richmond Zwar, 2003; Marlow Stoller, 2003; Chemotherapy side-effect reduction with acupuncture and anti-emetics Josefson Kreuter, 2003; Low-back pain management with opiates and acupuncture Grant, Bishop-Miller, Winchester, Anderson,
Faulkner, 1999

enhanced patient and provider satisfaction
CAM practices, while varied, tend to share a holistic approach to healing, one that emphasizes an individualized approach to diagnosis and treatment While many good health practitioners spend ample time with patients and provide a multifactorial assessment, it is often the disease, rather than the person, that guides the approach to treatment Anecdotal evidence suggests that many CAM and integrative-care providers spend more time getting to know the patients individual needs and desires, providing a patient-centered approach to diagnosis and treatment that may improve both patient and caregiver satisfaction Snyderman Weil, 2002 Integration can improve a patients personal decision-making and enhance physical and emotional well being by improving communication with all providers and by increasing their knowledge of health-promoting practices Furnham, 1996 Furthermore, integration of complementary treatments such as mind-body
therapies may increase patients conscious participation in the healing process and feelings of empowerment Health-care providers may experience greater satisfaction through learning about new treatment strategies and developing skill in implementing them For example, a randomized trial training generalist physicians to give manual therapy for acute low-back pain produced moderate benefit for patients; the most substantial finding was the increased self-efficacy and satisfaction of the doctors in managing low-back pain Curtis, Evans, Rowane, Carey, Jackman, 1997

decreased dependency on medication
Increased use–and misuse–of pharmaceuticals provides motivation for integrating CAM and conventional medicine The conventional clinician-patient dyad is often content to passively employ multiple medications in the name of symptom reduction, efficiency, and convenience With the proliferation of medical specialties, each with its own cadre of medicines, polypharmacy and adverse drug
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erly and those with chronic illnesses Beyth Shorr, 1999; Bretherton, Day, Lewis, 2003; Colley Lucas, 1993 Substituting non-pharmacologic therapies may reduce potential iatrogenic effects of multiple medications, including the potential for drug dependency and negative side effects, and could lower costs while maintaining positive health outcomes For example, in a comparison outcome study of patients with major depression who underwent an aerobic exercise regimen, treatment with sertraline, or a combination of exercise and sertraline, all three groups showed equivalent improvement after four months Interestingly, those who exercised
showed a marked reduction in relapse rate, compared with the sertraline-alone group Babyak, et al, 2000

ORGANIZATIONS SUPPORTING INTEGRATIVE HEALTH CARE
Organizations providing education or support and certification for integrative medicine skills American Academy of Environmental Medicine: wwwaaemcom, 7701 East Kellogg, Suite 625, Wichita, KS 67207, 316 684-5500 American Academy of Medical Acupuncture: wwwmedicalacupunctureorg, 4929 Wilshire Boulevard, Suite 428, Los Angeles, CA 90010, 323 937-5514 American Association of Orthopaedic Medicine: wwwaaomedorg, PO Box 4997, Buena Vista, CO 81211, Tel 800 992-2063, Fax 719 395-5615 American College of Advancement in Medicine chelation therapy: wwwacamorg, 23121 Verdugo Drive, Suite 204, Laguna Hills, CA 92653, 800 532-3688 American College of Preventive Medicine: wwwacpmorg, 1307 New York Avenue, NW, Suite 200, Washington, DC 20005, Tel 202 466-2044, Fax 202 466-2662 American Holistic Medical Association: wwwholisticmedicineorg,
12101 Menaul Boulevard, NE, Suite C, Albuquerque, NM 87112, 505 292-7788 American Holistic Nurses Association , http://wwwahnaorg/, PO Box 2130, Flagstaff, AZ 86003-2130, 800 278-2462 Anthroposophical Society in America: http:// wwwanthroposophyorg/, 1923 Geddes Ave, Ann Arbor MI 48104, Tel 734 662-9355, Fax 734 662-1727 Foundation for the Advancement of Innovative Medicine: http:// wwwfaimorg/, Two Executive Blvd; Suite 206; Suffern, NY 10901, 877 634 3246 toll free International Medical and Dental Hypnotherapy Association: wwwinfinityinstcom/imdhahtml, 4110 Edgeland, Suite 800, Royal Oak, MI 48073, 800 257-5467 248 549-5594 International Society for Orthomolecular Medicine: http:// wwworthomedorg/, 16 Florence Avenue; Toronto, Ontario, Canada M2N 1E9, Tel 416 733-2117, Fax 416 733-2352

enhanced health-care outcomes

There is evidence that a combination of conventional and complementary treatments often produces better outcomes than conventional therapies alone, particularly
when outcomes include reduction of negative side effects of treatment The synergy of integrative care in many clinical situations offers a variety of benefits, including accelerated recovery from surgery, decreased reliance on medications, and reduction of side effects Enqvist Fischer, 1997; Somri, et al, 2001 Another study Davidson, Abraham, Connor, McLoed, 2003 demonstrated marked improvement of features of atypical depression by the addition of chromium to standard treatment In addition, a study by Shults, et al 2002 found significantly slower progression of Parkinsons disease with the addition of coenzyme Q10 to existing treatment regimens in a dose-dependent fashion CAM therapies can provide healing options when conventional treatment has failed or is not available For example, it is difficult to treat tardive dyskinesia TD, and there are few treatment options However, use of vitamin E in moderate to high doses protects against deterioration in TD patients Soares McGrath,
2001

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added emphasis on disease prevention and wellness
In medical school training, there is relatively little emphasis on preventive care, compared to disease management Garr, Lackland, Wilson, 2000 At the University of North Carolina School of Medicine, for instance, only 3 of 29 courses in the first two years have segments specifically devoted to issues of prevention Many complementary therapies may be usefully applied in primary prevention as well as integrated in secondary and tertiary efforts Examples include dietary management, exercise, stress reduction, biofeedback, and the use of supplements Some specialty treatment guidelines now include complementary therapies as part of recommended treatment paths, such as the American
Headache Societys recommendation for use of magnesium and riboflavin supplements for the prevention of migraine, which is based on the highest quality clinical study of magnesium and migraine Peikert, Wilimzig, Kohne-Volland, 1996

the challenge of change
Despite considerable interest on the part of the health-care consumer and many practitioners, CAM integration with mainstream medicine is occurring relatively slowly Kessler, et al, 2001 Reasons include simple inertia, financial disincentives, differences in beliefs about healing, lack of access to education about CAM, and limited information on clinical outcomes about complementary and alternative therapies Faass, 2001 These are not small barriers to change, nor will the momentum of consumer and practitioner interest be sufficient to create an integrative model of care Until these issues are addressed successfully, conventional and CAM modalities will most likely continue their largely independent coexistence, with the atttendant
problems The challenge to health care practitioners is to understand and address the key issues that are raised as conventional, complementary, and alternative healing systems interact and perhaps converge

consumer-driven health care
For the conventional practitioner, the most compelling factor in the movement toward integrative health care is the growing use of complementary and alternative medicine by their patients Kessler, et al, 2001 Although there are positive aspects of patient-driven health care, there are also downsides: as patients FACTORS SUPPORTING reach out for information and guidance from multiple sources– INTEGRATIVE HEALTH CARE many of which are incomplete or ill informed–they risk making choices that may be dangerous, inefficient, or unnecessary Since the Patient use of and desire for CAM and IM vast majority of patients who use CAM also use conventional care, it Expanding choices of CAM therapeutic mobecomes the responsibility of the conventional provider to
become dalities in the US at least minimally knowledgeable about CAM Although most paHealth professionals increased awareness of, tients do not discuss CAM with their conventional providers, others interest in, and education about CAM and IM seek validation or clarity about CAM therapies, or request referrals Increased communication among convento alternative caregivers, requiring even further expertise tional and CAM providers In the age of information overload, keeping abreast of Documentation of success of integrative pracadvances in ones own profession is a daunting task for all care protices viders Becoming well-informed and staying current about a wide
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array of healing modalities outside ones specialty
may seem impossible Yet, in the name of professionalism, one needs to be able to respond to patient questions about alternative therapies, to understand that a much wider range of options is now available, and to be aware of the risks, benefits, and costs of these options

FACTORS IMPEDING INTEGRATION
Inertia of the status quo Differences in clinical vocabularies and ideologies Boundary issues among CAM and conventional providers Lack of health-care provider motivation and educational opportunities Perceived lack of CAM research validation Financial disincentives Lack of certification and licensure of CAM providers and fear of legal risk

system resistance
usual and customary care

Perhaps no greater barrier exists to change than the status quo There is a general perception in Western culture that conven tional medicine is a known entity, imbued with good intentions and excellent methods It is perceived by some as a comfortable, workable, and profitable system that answers the
health care needs of most people most of the time, despite significant treatment side effects and interactions, sub-optimal evidence of effectiveness, and accelerating costs Beyth and Shorr, 1999; Bretherton, et al, 2003; Colley Lucas, 1993; Poynard, et al, 2002; Starfield, 2000 In particular, usual and customary care may be used by the insurance and pharmaceutical industries to place economic barriers that impede change and use of alternatives Integrating CAM into this system is therefore difficult and, in some instances, integration of specific complementary therapies requires greater evidence of efficacy and safety than required of conventional treatments Bower, 1998

institutional competition
In addition, the status quo is more than the practice habits of health care providers It embraces all the social, political, and economic institutions, policies, and laws that make up the conventional health care system Legal statutes, regulations, curricular policy, and professional culture
all have a significant effect on the practitioners ability to provide integrated services The market economy of health care, including reliance on expensive procedures and short office visits, combined with the powerful influence of the pharmaceutical industry on the health-care prescribing habits of physicians, is a tremendous deterrent to institutional change Relman Angell, 2002

a clash of clinical cultures
The lack of a common conceptual framework and corresponding clinical vocabulary can significantly impede integration by making communication challenging among different healthcare cultures For example, the term chi is meaningful in the practice of acupuncture but has no direct functional counterpart in the vocabulary or belief system of western medicine Likewise, the phrase magnetic resonance spectroscopy may mean very little to a practitioner of Ayurvedic medicine

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educational needs
pre-doctoral education
There is widespread agreement that health profession schools, particularly medical and nursing schools, should include information about complementary and alternative medicine Berman, 2001; Frenkel Ben Arye, 2001; Sampson, 2001; Weil, 2000; White House Commission on CAM Policy, 2002 By 1997, two-thirds of medical schools offered elective courses in CAM or included such information in required courses Wetzel, Eisenberg, Kaptchuk, 1998 The National Institutes of Health has awarded grants to develop and evaluate educational approaches to integrating CAM into health professions education http://nccamnihgov Nonetheless, CAM education– whether training in specific CAM techniques or the introduction of fundamental principles–is still a relatively small part of conventional medical education White
House Commission on CAM Policy, 2002

post-graduate and continuing education
Although a few residencies have begun to offer and even require rotations in CAM Kemper, et al, 2000; Muscat, 2000, and curriculum guidelines and course evaluations are beginning to be published Kemper, et al, 2000; Kligler, Gordon, Stuart, Sierpina, 2000 most conventional residencies have not integrated CAM information into their curricula Few opportunities exist for conventional practitioners to acquire sufficient education or training in CAM to feel confident and competent in complementary medicine Those opportunities that are available require significant time and personal commitment White House Commission on CAM Policy, 2002, with the practitioner often resorting to the development of his or her own individualized curriculum While reliable and timely publications about CAM and integrative health care are becoming more common, they are still not widely accessible For example, journals carrying the bulk of
new information about CAM are non-mainstream and may be under-subscribed by medical libraries Moreover, with few colleagues or mentors available, the conventional practitioner may lack guidance in choosing sources and weighing the quality of CAM evidence Educational opportunities are increasing, however, and the increasing demand for education or training in CAM is giving rise to such innovative programs as the Integrative Medicine fellowship associated with the University of Arizona, started by Dr Andrew Weil White House Commission on CAM Policy, 2002

research validation: perceptions and needs
For many conventional practitioners, the chief impediment to implementation of integrated health care is a perceived lack of quality research in complementary/alternative medicine A non-validating study result for a specific modality or a single-case report of adverse events associated with CAM treatments can rapidly dampen enthusiasm for integration Despite the paucity of well-designed
studies, conventional practitioners rely heavily on research reports since personal experience and success or failure in use of CAM with patients is often lacking Many conventional-care providers are discouraged by the lack of readily available evidence supporting the value of integration in their routinely read literature Specifically, they want–but often
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cannot find–evidence related to outcomes for specific therapies conditions Other factors that provide a negative impression of complementary care include:

Conventional care advocates have often emphasized negative studies and side effects of complementary medicine eg, the few reported cases of cervical complications of chiropractic There is evidence of a
significant publishing bias in favor of studies of conventional medical treatment as compared to studies of complementary therapies For example, a randomized blinded trial of peer review of two manuscripts that were identical except for the nature of the intervention one being an orthodox and the other an unconventional treatment for obesity, found a 3:1 rating in favor of publishing the orthodox treatment study Resch, Ernst, Garrow, 2000 Funding devoted to the study of complementary and integrative approaches has been sparse but is now increasing The total amount of funding for integrative medicine [research] in the United States in the past decade is less than the average cost for developing 1 drug in conventional medicine Shang, 2001, 613 Few CAM therapies are patentable, and thus the financial payoff from research is low, relative to pharmaceutical products This limited funding and lack of financial incentives has contributed to the lower quality and scarcity of CAM research
Clinical studies in complementary care are often of questionable quality in terms of hypothesis, design, statistical analysis, or conclusions; expectations of bottom line answers about the value or merits of many CAM therapies is unrealistic in a field that so recently gained the attention of mainstream research institutions Much of the research is published in CAM-related publications and other non-standard journals with an undefined quality of peer review, although increasingly, mainstream health-care journals are devoting space to CAM therapies Individual CAM therapies or holistic treatment approaches challenge the application of standard research methods for assessing efficacy For example, in designing a randomized double-blind controlled clinical trial, it may be impossible to blind the practitioners to the nature of the treatment There is a need for skillful application and appreciation of other research designs In addition, there is an urgent need to familiarize researchers with
issues involved in developing meaningful CAM research

With growing national research support and an increasingly broad spectrum of conventional medical journals publishing CAM research, the basis for these criticisms is diminishing somewhat, but is likely to remain a concern for many years

financial disincentives
There are numerous financial disincentives to integration–from the personal costs of time and education, to staff and insurance expenses–but chief among them is the lack of third-party reimbursements for many complementary therapies Venture capital was available in the early-to mid1990s for start up of integrative clinics, but, with limited reimbursements, profit margins were slim

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PERSPECTIVES ON INTEGRATIVE HEALTH
CARE
Consumers, practitioners, and society all bring different perspectives, needs, and challenges in the process of integration

patient
From a patients perspective, integrative health care represents, foremost, a wider range of valid, safe health and healing options than currently available through conventional medicine alone, participating at the center of health-care decision making, and working in true partnership with providers Weiger, et al, 2002 Patients should be fully informed of the risks and benefits of treatments under consideration and take personal responsibility for health recovery and maintenance Astin, 1998 Open communication between patient and all providers is essential to realize these benefits In many integrative settings, consumers are encouraged to recognize and use their intrinsic self-healing abilities and are assisted in creating a personal definition of health that is operational, practical, cost-efficient, and appealing Giordano, Boatwright, Stapleton,
Huff, 2002 Understanding that body, mind, and spirit are fully integrated in both health and disease is fundamental to developing a personal program of integrated medical care

health care providers
For health care practitioners, successful integration requires specific knowledge of the patients medical and psychosocial history, physical, mental, emotional, and spiritual state, and an understanding of the breadth of treatment options available For conventional providers, knowledge of CAM therapies and approaches need not be accompanied by specific skills in the application of those treatments Integration can occur by way of referral to CAM practitioners as long as there is adequate documentation of therapies, an open attitude toward collaborating with other health-care providers, and effective communication among practitioners In addition, for conventional health-care providers to succeed in integrating complementary medicine, certain basic attitudes, beliefs and behaviors are
essential: Intentional consideration and use of both CAM and conventional resources in promoting health, preventing disease, and guiding treatment choices; An attitude of openness toward alternative models of health and healing based on evidence of efficacy, personal experience, and positive outcomes for patients; A willingness to explore the health-related goals of both patient and caregiver in an open atmosphere of balanced partnership; Professionalism and respect for other health-care providers participating in patient care; A significant effort in optimizing communications among colleagues; Acknowledgement of improved standards of training for all modalities practiced; Adopting a scientific approach to healing practices; Demonstrating self-care strategies that blend conventional and complementary practices

health care system
From societys perspective, integrative health care raises issues related to basic beliefs about the nature of health and healing, resource allocation,
and clinical outcomes Kessler, et al, 2001 Integrating health care requires the recognition and resolution of a number of politically sensitive issues, including consumer access to care, control of provider credentialing, scientific credibility, funding, and the structure of third-party coverage As noted by Cohen, these factors are fully interactive such that health care providers, consumers, regulatory agencies, and legislators are constantly reshaping the process of integration Cohen, 2002

to non-existent and the funding dried up rapidly Faass, 2001 Change in this area will require new policies and practices on the part of insurers, medical professionals and national and state legislative bodies In order for these changes to occur, more high-quality studies must be published demonstrating positive outcomes of CAM therapies, and insurers negative biases or lack of knowlPROGRAM ON INTEGRATIVE MEDICINE
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edge concerning CAM must be addressed Pelletier, et al, 1999 Complementary approaches are often held to a higher standard of evidence than is afforded conventional practices For example, the efficacy of hypnotherapy and biofeedback is well established, yet many major health insurance programs do not cover these therapies

licensing and legal risk
A particularly thorny set of issues for conventional practitioners and for health-care consumers relates to licensure, regulation, certification, and privileging of CAM providers in the conventional medicine context Relatively well-defined training and certification programs govern some CAM practitioners, such as chiropractic physicians For others, such as professional homeopaths or aromatherapy practitioners, training and certification standards are more uneven
Licensure, as well as licensure requirements, for most CAM practices varies from state to state White House Commission on CAM Policy, 2002 For example, while most states license the practice of acupuncture by non-physicians, some states require MD supervision or referral White House Commission on CAM Policy, 2002 For some consumers, a lack of such standards or licensure may imply a lack of societal approval or legitimacy As a result, patients may be afraid to disclose their use of those therapies to their conventional providers Similarly, conventional care providers may equate lack of licensure with incompetence In an excellent summary report, Cohen 2002 encourages conventional practitioners to become familiar with the laws in their state regarding complementary care, since it is at the state level that such laws are enacted and enforced Cohen also advises that law in this area is changing rapidly, and regular review of recent changes is important in limiting liability Legal risks are
greatest for the conventional practitioner attempting to practice integrative care in the following circumstances:

When patients are referred to a CAM provider without informed consent or adequate education about the type of therapy provided; When the condition is fully treatable by conventional means and non-standard therapy is used with a resulting delay in treatment or diagnosis; When patients are referred to a complementary practitioner who is known to be incompetent; When a patient is jointly treated by a conventional provider and a CAM practitioner known to be incompetent; and When a condition known to be treatable with a complementary approach is not so treated, especially in the face of failure of other therapies Cohen, 2002

approaches to integrative health care
Many models of integrated care delivery are possible For the conventional practitioner, integration may involve acquiring specific knowledge and skills of one or more complementary/alternative modalities
sufficient to practice at some level, networking with CAM providers, or simply feeling comfortable talking to patients about their use of CAM modalities At the other end of the specPROGRAM ON INTEGRATIVE MEDICINE
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HOLISTIC FAMILY PRACTICE
James Dykes, MD, was well ahead of the CAM curve when he opened his practice, Integrative Health Care, in the mid-1980s, after graduating from Duke Medical School and earning board certification in family practice After completing his second year in medical school, he took a three-year break to become an organic farmer Farming, he says, led to the discovery that nature heals itself To enhance the health of the soil, a good farmer needs to carefully study and replicate what he sees happening spontaneously in nature A good farmer does as
little as possible beyond this In farming, I drew the parallel with medicine Because he values the holistic approach with his patients, Dr Dykes places great emphasis on listening and understanding of many aspects of a patients life, and typically sees only eight or nine patients a day He has refrained from participation with insurance programs of any kind, in the belief that current plans and programs are a barrier to practicing humane and effective medicine Dr Dykes explores conventional and CAM options on behalf of his patients After 17 years of practice, he feels tremendous gratitude toward his patients who have made his practice so rewarding

trum are more complex models such as multidisciplinary practices, where a mix of complementary and conventional practitioners share space, and interdisciplinary practices, which involve various levels of integrated patient management through a partnered arrangement

One type of practice does not necessarily evolve into other, more elaborate,
arrangements The initial form and subsequent development depend on practitioner interests, resources, experience with integration, motivation, skills, and the ability to adapt within the culture of integration On the following pages are descriptions of seven different approaches to integration The Appendix–Models of Integrative Care–on pages 34-35, provides a brief, comparative review of this information While these seven models describe general approaches to integration, each integrated practice also reflects a unique and personal professional journey for those involved The practitioners who choose the path to integration do so for many reasons that ultimately shape the new practices final design There are some areas of the country, such as New Mexico, where CAM practices have a long history In central North Carolina which includes the cities of Raleigh, Durham, and Chapel Hill, the decade of the 1990s saw increasing interest in alternative and complementary medicine, with an influx
of CAM practitioners and a growing interest among local practitioners in gaining CAM skills and experience Many of the integrated care models described above can be found here Brief descriptions of a number of the integrated practices are included in sidebars on the next several pages We are grateful to the practitioners involved for sharing their histories and philosophies Their stories offer valuable lessons about the process of creating an integrated medical practice, as well as a glimpse of some of the options and considerations involved in charting a new path in health care practice

model 1: the informed clinician
In this simplest type of integrative practice, a conventional provider becomes knowledgeable about one or more complementary therapies, and is therefore better able to communicate and accurately inform patients about their use An example of such an approach is a family-medicine physician who becomes knowledgeable about herbal/supplement therapies and mind-body therapies
for conditions commonly seen in the clinic The physician regularly asks patients about their use of CAM and is open to their responses Although communication and information sharing is the primary goal in this model, the health professional may recommend certain CAM approaches, such as a particular nutritional supplement, mind-body, or body-work therapy, as part of a care plan,
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based on patients openness, research findings and optimizing outcomes Gordon, 1996 For each complementary/alternative therapy studied and incorporated into the practice, the clinician must understand:

EXPANDED PHARMACY SERVICES
Tom Jones Drug Health Wellness Center in Garner, NC, and Central Pharmacy/ Central Compounding Center in Durham, NC,
are representative of a number of pharmacies in the Triangle offering certain clinical services and testing, along with wellness counseling, and emphasizing patient education programs, especially in the areas of diabetes, cardiovascular health, and respiratory illnesses Tom Jones, RPh, in Garner and Bill Burch, RPh, Jennifer Burch, PharmD, and Sloan Barber, PharmD, in Durham work closely with national organizations that provide testing and other resources, including diagnostic work by naturopathic physicians, for clients that they counsel in their pharmacies They have a special clinical interest in bio-identical hormone replacement therapy, for both women and men These pharmacists emphasize the importance of their role in the triad that includes physician, patient, and pharmacist Patients physicians must sanction this clinical work before it begins Dr Burch has regular hours within several medical practices where she counsels patients–especially diabetics and patients with heart
disease–on the proper use of medications and issues related to nutrition and proper exercise

The basic assumptions inherent in the complementary modality relating to health and healing; The principal decision-making strategies for that therapy; The typical scope of the discipline, including specific exclusions; Methods for applying the treatment; Any inherent side effects;

Any known adverse interactions with conventional treatments

Initial benefits of this approach are improved patient communication, improved ability to provide information to patients on safety and efficacy of CAM therapies, and, to a limited degree, ability to make informed suggestions about patients use of complementary practices The conventional provider may also benefit personally through CAM-directed self-care This model has limitations The provider may not be knowledgeable about subtle distinctions that guide CAM therapy choices; there is no mechanism for feedback from CAM community providers other
than patients reporting of their experiences; and it may be difficult to track outcomes specifically related to integrated therapies Often, practitioners initially adopt this approach to satisfy patients inquiries about CAM in their areas of practice or to provide guidelines for use of herbals and supplements, including their interactions with conventional drug therapies As practitioners gain experience through listening to patients and reading the literature on CAM, they may be inspired to begin a limited use of CAM therapies within their practice Motivation may include increased breadth of therapeutic choices, improved rapport with patients, and improved symptom management Education may be largely self-study While no credentials are necessary, study is likely to require several hours of reading a week and two conferences/workshops a year Costs–for books, an on-line herbal information service, and conferences–are moderate Risks to practitioner reputation and patients are low This
approach usually requires more time for education per patient visit Ultimately, the benefits are likely to be improved patient care and, perhaps, enhanced physician satisfaction and improved reputation with patients Ideally, this model of integrated practice would evolve to directly contacting and visiting local CAM providers such as massage therapists, nutritionists, or pharmacies, so as to provide a more accurate referral source for patients The practitioner may also provide educational materials and train staff to educate their patients; provide on-line access to an herbal information service;
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begin using herbals/supplements in self-care, or develop a local resource list of mind-body therapies Feedback in the evaluation of this
approach comes primarily from patients and personal and clinical experience with CAM therapies and outcomes

model 2: the informed, networking clinician
This type of integrated practice builds on the first model, adding informal referral networks with CAM practitioners to the providers growing breadth and depth of knowledge of complementary therapies Building a referral base depends on exploration of local resources, patients and colleagues referrals, and personal experience Visiting the CAM practice environment and meeting with each provider face to face is important, as is discussion of needs for communication and documentation Mutual understanding and trust develop with multiple interactions over time The conventional practitioner may choose the number and types of referrals made and the degree of interaction with each complementary practitioner, with continued interactions being contingent on outcomes, patient feedback, and ongoing communication Autonomy of each practitioner is
maintained An example of this approach is found in the University of North Carolina Headache Clinic, in Chapel Hill Here, a neurologist integrates the skills and services of local CAM practitioners as he refers his patients with migraine and other forms of head and neck pain These complementary therapies include acupuncture on- and off-site, herbal medicine, naturopathy, hypnosis, Traditional Chinese Medicine, craniosacral therapy, homeopathy, and neurolinguistic programming NLP A major advantage of this model over Model 1 is that it offers a broader range of treatment options for patients, including use of established community referral patterns when institutional policies limit complementary practitioner credentialing for on-site therapy Patients may feel empowered by visiting CAM practitioners and providing feedback to the conventional provider, thus furthering the development of attitudes of self-care for the patient Limitations include lack of control of documentation; lack of
face-to-face time between practitioners for discussion of cases; difficulty in tracking patient follow-through and outcomes; inconvenience to patients who must travel to different sites to follow through with treatments; uneven credentialling of CAM BOARD CERTIFIED IN UROLOG Y providers; and lack of third-party coverage for AND HOLISTIC MEDICINE complementary services Risks to patients and reputation are small when referral networks are Mark McClure, MD, FACS, trained in Indiana as a conventional physician and created and maintained responsibly There is a completed a residency in urology at the University of Pennsylvania He practiced slight increase in overall legal risk if the conin a conventional urologic group until 1997, when his increasing interest in CAM ventional practitioner attempts to control the modalities inspired him to partner with a member of the Amercan Holistic Nurses scope of therapy provided by the CAM practiAssociation, Cheri Elliott, to establish Landmark Urology
and Complementary tioner to which he/she referred the patient In Medicine Dr McClure was the first urologist to become board certified by the this case, if there is a negative outcome in a American Board of Holistic Medicine in 2000 He lectures frequently and has patient interaction with the CAM practitioner, written textbook chapters, journal articles, and a book about conventional and the patient may attempt to hold the conventional complementary therapies for urologic problems Cheri Elliott graduated from the UNC-Chapel Hill Adult Nurse Practitioner Program in 2004 Together they provider liable for the alleged failings of the offer their patients a holistic approach to urologic health CAM practitioner Although additional credentials are not
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BRINGING EAST AND WEST TOGETHER IN A COLLABORATIVE CLINIC
After 27 years of practice in a university medical school setting–both as physician and administrator–pediatrician Michael Sharp took the first steps to a different kind of practice: training as an acupuncturist and Chinese herbalist The training and exposure to a different perspective on healing led him to create Plum Spring Clinic–a small integrated medical clinic in Chapel Hill, NC, that draws on a variety of healing modalities in a collaborative practice model Our goal, says Dr Sharp, is to integrate western medical practices with a wide range of scientifically based complementary and alternative medical therapies We have found these combinations can dramatically improve our patients health and well-being He notes that the practice specializes in the care of people with conditions that are unresponsive to conventional treatment, such as chronic pain, fibromyalgia, low-back pain, chronic sinus
infection, tension and migraine headaches, and stress Plum Spring staff includes: a physiatrist who aslo practices acupunture; a holistic womens health nurse practitioner who utilizes bio-identical hormone replacement therapy; a physical therapist; a doctor of oriental medicine; massage therapists; a nurse trained in manual lymphatic drainage therapy; and a movement therapist The clinic offers individual consultations and treatment as well as classes in yoga, tai chi, qigong, and topics in alternative medicine Dr Sharp describes the clinics approach as a collaborative process: We refer to each other, hold weekly staff meetings, visit other practitioners in the community, talk over coffee/tea, share magazine articles, discuss what distinguishes us and what is similar about us We are energized by the belief that we are exploring unexplored treatment combinations We have immense respect for our differences and our capacity to see together what we cant see individually This works, he says,
because we all believe none of us has the answer but that by early next week we will have discovered it by some act of synergistic alchemy As one of two licensed MDs in the practice, Dr Sharp sees most new patients first, then offers them options and asks how they would like to proceed He sees the patients in follow-up if not involved as one of the primary treating practitioners, and works with them to reassess progress and consider further options

required for the conventional practitioner, additional resources are needed beyond that of Model 1 These include time for initial visits and follow-up communications with CAM providers and costs of personal education about CAM, including books, on-line CAM services, seminars, and professional meetings It may also require more time per patient visit to educate patients about the reasons for CAM referral, to describe the nature of the treatment to be administered by the CAM practitioner and to arrange for follow-up The path for Model 2 begins
with Model 1, and includes increased research and experience in the use of specific CAM therapies for specific conditions, development of clinical pathways that include CAM therapies, and networking and personal experience with local CAM providers Careful documentation of outcomes is essential to measuring success in this model Feedback for evaluation comes from patients, CAM practitioners and other caregivers, and personal experience

model 3: the informed, CAM-trained clinician
In this next model, the conventional practitioner, who may or may not have already developed referral networks, adds specific training in CAM therapies to a basic knowledge of CAM An example of this model is an established, conventionally trained MD in general practice who bePROGRAM ON INTEGRATIVE MEDICINE
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MEDICAL ACUPUNCTURIST COLLABORATES WITH CAM PROVIDERS IN PAIN CLINIC
José Armstrong, MD, trained in his native Puerto Rico where he completed his internal medicine residency Upon moving to North Carolina, he became a staff physician with Blue Ridge Clinical Associates in Raleigh Dr Armstrong opened Carolina Healthcare Providers in Raleigh as a model CAM practice devoted principally to pain relief and pain management Participating providers include Chinese medical doctors with expertise in neuropsychiatry and acupuncture; a chiropractor; naturopathic physician; massage therapists; certified craniosacral therapists, and specialists of other modalities such as aquatic therapy and bodywork First contact with the practice can be with and through any one of these practitioners Dr Armstrong trained in the rigorous program in medical acupuncture at the University of California at Los Angeles Medical School, and has served as an instructor there in medical acupuncture since
1995

comes a licensed acupuncturist by taking a course with certification provided by a nationally recognized training organization, and then becoming licensed in the state A principal advantage of this approach is that the documentation of indications and outcomes are under the immediate control of the clinician Another advantage is that the practitioner accumulates personal experience in applying a complementary therapy This approach requires documentation of training or credentialing, and liability insurance covering the newly acquired skills Cohen, 2002 Feedback for evaluation of this approach comes from patients, other providers, personal experience, and HMOs

Among the motivating factors for pursuing this model is a desire to expand professional skills, treatment options, and to add billable procedures to the practice mix Credentials are desirable for legal purposes as well as for providing the patient with some reassurance of adequate training in the given modality There is an
investment of time and other costs For example, acupuncture training may involve three to four weeks away from practice, plus several hours per week for video viewing and reading The investment in books, travel, tuition, equipment, and time away from work is substantial The gains are in practitioner satisfaction, enhanced patient care, improved reputation, and billable procedures This approach involves relatively little risk to reputation or patients, although the addition of services not typically covered by insurers may increase the complexity and cost of practice management Further, working providers will have limited time to devote to in-depth training in a CAM therapy or system in the continuing education context ie, brief course sessions, at-home study Emersion in CAM training typically requires time off from clinical practice Thus, the service offered based on CE study would be qualitatively different from that of a specialist in that therapy or system The path to Model 3 may be
directly from Model 1, but may include Model 2 The practitioners path may lead further to a career shift, involving a major emphasis in a CAM modality, training in other complementary modalities, and collaborating with additional complementary practitioners

model 4: multidisciplinary integrative group practice
In this model, practitioners provide both conventional and complementary therapies in a partnership, often focused on specific clinical issues A distinctive feature of this model is that while practitioners work collaboratively in the same office setting, patients see different providers in the clinic, although cross-referrals happen regularly Theoretically, the case manager could be any one
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of the
care-providers, and the choice should be in the hands of the patient in most instances For example, the patient may initially enter the clinic to see the non-physician acupuncturist for back pain, and then the acupuncturist may refer the patient to the internist for further evaluation An example of this approach is The Texas Back Institute, in Plano, Texas This group specializes in the treatment and management of back pain and includes an orthopedist, an osteopath, a family practitioner, a massage therapist, and a biofeedback therapist working collaboratively in the same facility Triano, Rashbaum, Hansen, Raley, 2001; Coile, 1995; Pristave, Becker, McCarthy, 1995 A major advantage of this model is its ability to focus on specific clinical areas, such as family medicine, womens health, pain, geriatrics, or rheumatological disorders Lower overhead is also possible due to shared office space and support personnel Among the major limitations are the risks of greater financial
vulnerability due to variability in productivity among staff and possibly legal risks to the practice if key personnel do not have adequate credentials Cohen 2002 A key motivating factor here is the desire to focus on a specific health problem in a collaborative, integrative fashion Although this model requires no additional training in each associates modality, additional education is required for each associate to become adequately familiar with the others discipline Costs are incurred in the start-up phase and for space, staff, and development of a business plan Attention must be paid to the mix of personnel, including appropriate training and credentials for each practitioner A factor to consider is the significant differences in beliefs, training, and practice styles of the partners This can lead to confusion about the role that each plays in decision making and care of a given patient Clearly identifying the primary case manager for each patient is important in this setting to
improve communication between practitioners, to direct care plans, and to avoid conflicts over patient care In this model, there may be challenges in working out financial arrangements and risk/reward assignments because of the uneven reimbursements by insurers Up-front payments for some but not all services may create confusion for clients The benefits can be considerable Early detection of non-response to conventional care can result in earlier integration of CAM therapies The practice design permits
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INDIVIDUAL PRACTICES WITH FOCUS ON ALTERNA TIVE TREATMENTS FOR CHRONIC HEALTH PROBLEMS
Two physicians in the NC Triangle area, John Pittman, MD, and Dennis Fera, MD, practice separately in non-conventional ways that are described as functional medicine Dr Pittman, trained at the masters level in biochemistry, earned his medical degree in Georgia and completed the pediatric residency program at NC Baptist Hospital in North Carolina He established the
Carolina Center for Integrative Medicine in Raleigh in 1994 It serves patients with a wide range of health needs, including a variety of chronic disorders Says Dr Pittman, Our approach is to view the body in the most complete way possible, especially function on the cellular nutrient level and restoration of normal digestive function Therapies employed include chelation, IV vitamin and mineral therapies, natural hormone therapy, nutritional supplementation, colon hydrotherapy and nutritional detoxification, massage therapy and energy work, and lifestyle and nutritional counseling Notes Dr Pittman, These complementary therapies create an environment where cellular vitality and wellness are efficiently restored An interest in treating pain led Dr Fera to CAM therapies He opened his practice, Holistic Health Medicine, in Hillsborough Dr Fera completed a residency in rehabilitation medicine at New York University Medical Center in 1987, and began his exploration of alternative therapies
shortly thereafter when he realized my formal training often fell short of relieving my patients pain and disease, and simply did not fit my own mind-body-spirit approach to healing Like Dr Pittman, Dr Fera sees many patients with long-term chronic problems who have exhausted their conventional medical options He offers a variety of integrative treatments to his patients, including chelation, oxidation, ultraviolet light, prolotherapy, neural therapy, natural hormone therapies, nutritional medicine, and stomach and intestinal screening and treatments Both doctors offer Meridian Stress Assessment evaluation within their practices

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highly focused efforts as well as the clear definition of treatment protocols and outcomes Further, the openness to considering and applying
reasonable treatment strategies may enhance practitioners reputations among patients and referral sources, as well as increase patients satisfaction There is the potential for cross-fertilization of ideas and synergy of therapeutics in this model because of the practitioners proximity each other and familiarity with approaches to care The evolution of this model may include expanding staff to include other CAM providers herbalist, Reiki healer, etc and expanding treatment focus to other conditions/age groups Other developments, such as the inclusion of group therapy, may help empower patients with support and information Feedback for this approach comes from group members, patients, other caregivers, and HMOs Of all the models presented here, this one may provide the optimal mix of ease of implementation, efficient delivery of patient care and enhanced caregiver growth

model 5: interdisciplinary integrative group practice
A further level of integration takes place in this model, in
which care providers in multiple disciplines see patients together as a team As in Model 4, the focus is often on a special area, such as chronic pain or womens health The team leader is often a physician, although other team leaders are also feasible The case manager may be the physician or another health-care professional In one version of this model, each conventional care provider has some training in a CAM discipline For example, team members in the UNC Integrative Medicine Clinic, which focuses on the treatment of chronic pain, include a physiatrist with expertise in Traditional Chinese Medicine, a neurologist with expertise in hypnosis and neurolinguistic programming, a pharmacist with expertise in herbal and nutritional therapies, a clinical psychologist with expertise in mind-body therapies, and a physical therapist with expertise in body-work therapies In addition to a core team that sees each patient, auxiliary team members, such as a homeopath or Feldenkrais practitioner
may be asked by the team leader to address the need of a specific patient Larger group practices may include multiple primary and auxiliary teams For example, the East-West Health Centers in Denver, CO, includes nine conventional providers four family practice physicians, two internists, one osteopath, one dermatologist, MULTI-DISCIPLINARY PAIN MANAGEMENT and one physiatrist as well as six CAM proCENTER IN NORTH CAROLINA viders herbal medicine, chiropractic, naturAlan Spanos, MD, is among the small group of conventional practitioners in the opathy, acupuncture, hypnosis, NLP, and hoTriangle who turned to CAM before the 1990s Trained at Oxford, Duke, and UNC meopathy who come together as teams to Schools of Medicine, Dr Spanos is board-certified in family medicine and trained in see individual patients Herre Faass, 2001 internal medicine and anesthesiology As a clinical associate, he teaches pain manAn advantage of this model over the agement at the UNC School of Medicine Dr Spanos is
known as a doctor who will preceding one is that patients obtain an interexplore any reasonable option on behalf of his patients Adding acupuncture to disciplinary perspective on their illness as well my practice has been the most refreshing and invigorating thing I have done in as a comprehensive treatment plan, with folyears, he once noted His practice, Blue Ridge Clinical Associates in Chapel Hill, low-up that may address multiple issues–in NC, is a multi-disciplinary pain management center Patients who come to the essence, one-stop care for many patients In center are required to have a primary care physician as the first-line doctor in case addition, this model, even more than the premanagement who will work with Dr Spanos and his colleagues ceding one, encourages expanded educational
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opportunities for practitioners, as their daily interactions stimulate continual cross-disciplinary learning and discussion Success depends on the openness and communication skills of group members Depending on arrangements, this model may offer financial cross-coverage as well as an improved negotiating position with respect to HMOs and other insurers Disadvantages may include difficulty arriving at consensus regarding overall goals or resolving financial inequities among the various participants Potential difficulties include working through different operating assumptions about the nature of healing

A COLLABORATIVE HEALING ENVIRONMENT
Health Space, as described by its founder and principal clinician, chiropractor Brett Hightower, is a multi-dimensional health practice in Raleigh, NC Practitioners include Dr Hightower, who is also an acupuncturist; a massage/bodywork therapist, a naturopath and
exercise physiologist, and a certified hypnotherapist Collectively, they provide a range of complementary and alternative healing services, including chiropractic, acupuncture, physical therapy, oriental wellness, tai chi, yoga, hypnotherapy, massage, personal training, aromatherapy, and reflexology At the heart of the practice, however, is a collaborative journey to health program While it is possible to sample Health Space offerings in a selective way– simply taking tai chi classes or seeking pain relief, for example–most clients enter a partnership with the team of clinicians on a highly individualized journey to health Notes Dr Hightower: They rapidly come to understand the inter-relatedness of mind, body, emotional, and spiritual aspects of the healing process The journey to health program emphasizes the process of healing and attaining wellness Each client first completes an extensive Personal Wellness Profile, which forms the basis for an individually designed health plan,
supported by various clinicians at Health Space

Motivation for the development of this model typically involves a desire to address medical problems comprehensively yet efficiently However, additional time outside of direct patient care is required for discussion of patients and organizational issues A case manager may be required to screen patients for the clinic and organize the clinic visits Although little additional training is required of the individual practitioners, knowledge and skills grow with team interaction and with individuals continuing education There are some additional costs and legal risks–an evolving system of this size needs flexibility in space allocation and additional overhead in the form of support staff This practice model evolves with the expansion of staff to include other complementary providers and sub-specialization as practitioners discover areas of particular expertise and success Evaluation of this approach comes from patients, group members,
insurers and local referral sources

model 6: hospital-based integration
This approach integrates conventional and CAM services under the auspices of a hospital or major medical center This model has two key goals: to improve patient and family experiences of health care in an inpatient setting; and to honor a commitment to provide integrated care Pioneers in integrative health care include the Sloan Kettering Cancer Center Zappa, 2001, the Institute for Health and Healing at California Pacific Medical Center Stewart Faass, 2001, Hennepin County Medical Center Canfield, 2001, and a number of hospitals that are affiliates of the Planetree Network http://wwwplanetreeorg Such examples provide insight into the logistics, efficacy, and value of combining complementary and conventional care Faass, 2001 Although each approaches integrative health care in a unique way, all seek to expand patient care options; to improve communications and patient-caregiver relationships; to reduce dependency
on pharmaceutical and technological interventions in favor of more natural treatments; and to provide a

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AN INTEGRATIVE PRACTICE AT A TEACHING HOSPIT AL
Launched in October 2002, the Integrative Medicine Clinic at the University of North Carolina Chapel Hill offers an interdisciplinary consultation and treatment service for those patients with chronic pain and other conditions who wish to integrate conventional and complementary approaches The Clinic team includes a physiatrist, neurologist, clinical pharmacist, psychologist, physical therapist, nurse, and administrative coordinator–all with integrative medicine skills–who participate with patients in a comprehensive review of physical, emotional, mental, and social aspects of their
condition Medical students and residents often participate in the clinic as learners Following an initial evaluation, team members see patients for up to six months for interdisciplinary assessment, individualized care planning, implementation of care, and collaboration with a primary caregiver for ongoing management Patients actively participate in developing and carrying out the treatment plan and make a minimum commitment of 12 weeks to the program Recommendations for therapies such as acupuncture, massage, hypnosis, biofeedback, mindfulness training, herbal medicine, and nutritional counseling are applied in an individualized, culturally respectful, values-oriented manner The goals of the program are to improve quality of life and increase function A guiding principle is promotion of the bodys self-healing abilities Emphasis is on non-pharmacological options, with medications modified after consulting with the patients and their primary physicians Patients are encouraged to let go
of old, maladaptive patterns of thought and behavior that may prevent seeing each situation as unique and full of potential, and to view and experience the process as a journey towards wholeness

greater attention to wellness, disease prevention, and self-care, which should lead to improved outcomes for their patients Costs associated with implementation at this level include time and personnel dedicated for planning and staff education, consultation fees in the start-up process, and renovation costs Credentialing is required for complementary/alternative care providers working in the hospital settings, but licensure may not be necessary if administrative permissions are granted The only significant risks are those to the hospital/medical centers reputation if community perceptions of complementary medical practices are negative

As with the other models of group practice, there may be difficulty in achieving agreement by participants, and there are potential financial problems related
to compensation and reimbursement The benefits of the model include improved patient care and satisfaction and enhanced reputation Other potential benefits are the retention of nursing and service staffs and an increased competitive edge for the hospital regionally Additionally, there may be opportunities for volunteers to participate in programs supporting patient-centered care, such as healing arts and animal-assisted therapies There must be acceptance and leadership by hospital administrators who are likely to judge the program based on patient satisfaction surveys and costs Physicians and other staff members should be included in planning and implementation Utilization of hospital resources usually depends on competitive allocation, based on perceived needs and the potential for attracting patients Hospital-based integrated practice evolves from concept to pilot projects to expanded implementation in multiple parts of the institution Feedback to evaluate this approach comes from
patients, staff members, hospital/center administrators, and outside agencies that evaluate patient satisfaction, such as Press-Ganey Associates

model 7: integrative medicine in an academic medical center
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tives The University of North Carolina Program on Integrative Medicine is an example of this approach This program and the Universitys Departments of Family Medicine, Neurology, Physical Medicine and Rehabilitation, and Obstetrics
and Gynecology have cooperated to develop and sustain a teaching program in complementary medicine that involves students, resident physicians, faculty, and community practitioners Clinical services developed through this effort include a CAM consultation service and an integrative medicine clinic that provide teaching opportunities and additional resources to the community Major limitations include difficulty in credentialing CAM providers within the Health Center for provision of clinical and educational services, and the high cost of providing services in an educational setting Academic health professionals, who typically combine clinical care with teaching and research, are drawn into the integrative medicine arena through the needs of their patients or research initiatives Administrative costs and staff support may be funded by research grants or by public or private endowments Educational risks to the reputation of the institution are minimized by emphasizing an evidence-based
approach, as well as by demographic statistics describing patients increasing use of CAM and the responsibility of the academic medical community to provide education about CAM therapies Well-designed research projects raise awareness of CAM therapies in a safe and supportive environment, with the potential stigma of undertaking nonmainstream research offset by the validation of receiving external funding, such as NIH grants Employing credentialed CAM providers for clinical services can minimize legal risks Impediments to this model include the heavy reliance on MDs to practice CAM and the need to operate under multiple administrative umbrellas with their associated political and financial pressures The issue of CAM provider credentialing is also a challenge, as is the likelihood of multiple interest groups competing for limited resources The benefits of the academic model include improved patient care and exposure of students, residents, and faculty to CAM, as well as multiple
opportunities for both basic and clinical research This model may evolve on many levels: expansion into the medical center departments and divisions in the areas of teaching and clinical care; expansion of integrative patient care through consultation and research; and through outsourcing CAM therapies to the community when health center policies cannot accommodate complementary medicine providers Feedback for evaluation of this approach comes from patients, students, residents, faculty, administrators, press, public, and HMOs Carlston, Stuart Jonas, 1997

steps towards integrating CAM with conventional practice
A complex mixture of options and barriers influences conventional practitioners toward or away from integration These factors are shaped by individual and interpersonal experiences as well as personal beliefs, institutional policies, and societal forces They include caregiver openness, healthcare administrative support, community resources, availability of educational and
training opportunities, and concern for patients safety and care quality Control over these many factors varies considerably For example, while decisions regarding personal education may be largely under personal control, more difficult to influence are institutional and societal barriers such as limited third-party reimbursement for CAM services
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The models of integration described above are merely examples of many possible variations; the form that develops is unique to each situation Also unique are individual providers paths toward integration, which may initially be triggered by diverse events–a colleagues or patients report, a research article, or a personal experience of illness The resulting steps toward integrative practice are
likewise individualized, often gradual and circuitous, with auspicious coincidences along the way Nevertheless, it is possible to outline a structured, formalized process for moving towards integrated practice, beginning with a few initial steps that are crucial for success These first steps to integration are simple, relatively low-cost activities that set the stage for the development of an integrated practice They include assessing beliefs, acquiring knowledge, and adopting new attitudes and behaviors

assessing beliefs
The process begins with a critical first step–an inventory of personal beliefs about illness and healing Practitioners may never have completed such an inventory, even during medical training From this honest appraisal there may come a renewal of motivation and compassion in the service of others, along with a desire to acquire new skills and knowledge for enhancing care giving Reflection on the principles of complementary care see box on page 4 in terms of ones
personal beliefs and care practices should aid in this process These principles include an emphasis on patient/healer communication and self-care that form the foundation for integrated practice

accessing and acquiring knowledge
Next comes an honest self-assessment of ones personal knowledge base of complementary and alternative practices Reviewing a textbook on CAM or integrative medicine may provide an initial basis for this assessment One starting point is to become knowledgeable about at least one CAM therapy, including evidence that supports its use and possible adverse effects THE PATH TO CHANGE Ideally, one should survey the breadth of The move to a new, integrative model of care requires: CAM therapies and systems of healing, including their principles and assumptions re Assessing beliefs about healing, and appreciating the value of principles of complementary/alternative care garding illness causation and management Identifying reliable sources of information about CAM and
beginning to acSelected CAM topics can then be explored in quire knowledge further depth, depending on interest and area Developing and maintaining methods for keeping up-to-date on CAM and of desired specialization integrative medicine research Excellent continuing education Appreciating the political and economic factors shaping medical practice and courses and self-study materials are available, public health policy including good-quality research reports in Communicating with patients about CAM peer-reviewed journals See the UNC Pro Documenting clinical experiences gram on Integrative Medicines Information Developing quality relationships among CAM and conventional caregivers, Sources for Complementary Alternative Theraand supporting those exploring new models of care pies as well as other publications in this se-

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ries, listed in the front of this publication Conferences provide opportunities for training as well as networking Training in one or more CAM modalities is another option Observation, personal experience, and/or instruction in specific applications of complementary/alternative methods with local practitioners can be valuable learning strategies Further, it is important to develop and maintain methods for keeping up-to-date with reports on CAM-related basic research, clinical outcomes, and complications arising from integrative approaches Examples include subscribing to key journals or initiating a journal club Moreover, becoming knowledgeable about CAM requires being well informed about various contextual issues that affect integrated practice, including the political and economic factors influencing medical practice and public health policy

communicating with patients/
clients
Skillful communication with those who hold diverse belief systems is essential for professionalism in health care To assess skills in this area, consider the following questions: Does history-taking routinely probe the details of CAM use? Do conventional providers listen to their patients experience with alternative-care providers, and their sources of information? Are these therapeutic approaches investigated? The basis for effective communications is an attitude or belief in a partnership with patients, with shared responsibility in therapeutic planning and implementation This partnership is, in essence, an opportunity to communicate and learn from each other To insure success, both patients and caregivers must abandon paternalistic expectations and attitudes in communication and care

communicating with CAM providers
Success also depends on practitioners connections with individual CAM providers and integrative practices Personal contact with these providers–through
referrals, visits, or colleagial gatherings–is critically important It is particularly helpful to visit the community practice settings of CAM providers, who may include chiropractic physicians, herbalists, massage therapists or shamen Where feasible, it would be worthwhile to gain personal experience in the therapy Developing a friendly professional relationship with these providers may offer the basis for effective collaborative patient care

buillding on clinical experience
Conventional health professionals may be relieved to find that that they can build on previously learned skills and experience in shifting to integrative health care New skills, abilities, and knowledge may be incorporated with conventional clinical skills, diagnostic abilities, and knowledge under a new conceptual framework As with any clinical care, it remains important to record clinical observations about negative and positive outcomes, including patient satisfaction with both complementary/alternative and
conventional therapies This information can provide a base of experience that will guide future interventions and referral choices and perhaps lead to the development of ideas for research projects

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developing professional networks
Professional development will benefit from the support of like-minded colleagues, both locally and through national professional organizations These support systems should include interdisciplinary networks Such affiliations provide opportunities to share experience, address common issues and seek additional education and training They may also lead to increased appreciation of the broader societal issues that accompany the integration of CAM with conventional care, including the need for political, regulatory
and organizational changes

additional resources needed
Adequate resources are an obvious requirement for successfully integrating a practice Investments of time and money vary widely, depending on the model of integration and the types of education, training, personnel, facilities, or equipment desired The required education may require significant amounts of time and money, and some models of integration involve increased costs for facilities or equipment, such as massage tables or herbal-information databases These investments may often be made feasible by incorporating them at a pace suitable to the provider

conclusion
Integrative medicine is a visionary concept taking form in a number of directions around the United States As many sectors of society patients, providers, third party payers, government seek answers to the problems of modern western medicine cost, efficacy, safety, access, cultural limits leaders in integrative medicine have led the way and continue to emerge Many
of these innovators have had to take considerable risks, often standing alone on their professional reputations Recent seekers of integrative health care have more tools and support at their disposal than ever Attitudes are changing and experience with CAM therapies is growing along with opportunities for research The extent to which licensed providers can offer new services to patients will depend on the legal, regulatory and political environment Despite challenges, many creative solutions are being tested by integrative providers attending to the business of clinic administration and the pursuit of accessible, affordable health care for a broad array of potential patients There are many sound arguments for moving toward integrative health care, and the human heart will always lead the way

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references
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participants American Journal of Public Health, 92:1832-1840 Barnes, J, Abbot, N C, Harkness, E F, Ernst, E 1999 Articles on complementary medicine in the mainstream medical literature Archives of Internal Medicine, 159:1721-1725 Barnes, P M, Powell-Griner, E, McFann, K, Nahin, RL 2004, May 27 Complementary and alternative medicine use among adults: United States, 2002 Advance data from vital and health statistics, 343, 1-19 Hyattsville, Maryland: National Center for Health Statistics Barrett, B 2003 Alternative, complementary, and conventional medicine: is integration upon us? The Journal of Alternative and Complementary Medicine, 9:417-427 Bausel, R B, Lee, W-L, Berman, B M 2001 Demographic and health-related correlates of visits to complementary and alternative medical providers Medical Care, 392:190-196 Bell, I, Caspi, O, Schwartz, G, Grant, K, Gaudet, T, Rychener, D, et al 2002 Integrative medicine and systemic outcomes research Issue in the emergence of a new model for
primary health care Archives of Internal Medicine, 162:133-140 Berman, B M 2001 Complementary medicine and medical education British Medical Journal, 3227279:121-2 Beyth, R J, Shorr, R I 1999 Epidemiology of adverse drug reactions in the elderly by drug class Drugs and Aging 3:231-9 Bezold, C 2001 Envisioning the future In: N Faass Ed, Integrating complementary medicine into health systems pp 708-718 Gaithersburg, MD: Aspen Publications Bower, H 1998 Double standards exist in judging traditional and alternative medicine British Medical Journal, 316:1694-5 Bretherton, A, Day, L, Lewis, G 2003 Polypharmacy and older people Nursing Times 17:545 Canfield, D 2001 An Integrative Medicine Clinic in a Teaching Hospital In: N Faass Ed, Integrating complementary medicine into health systems pp 391-397 Gaithersburg, MD: Aspen Publications Carlston, M, Stuart, M R, Jonas, W B 1997 Alternative medicine instruction in medical schools and family practice residency programs Family Medicine,
29:559-562
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Caspi, O L, Sechrest, L, Pitluk, H C, Marshall, C L, Bell, I R, Nichter, M 2003 On the definition of complementary, alternative and integrative medicine: societal mega-stereotypes vs the patients perspective Alternative Therapies in Health and Medicine, 9:58-62 Cassell, E J 1982 The nature of suffering and the goals of medicine New England Journal of Medicine, 306:639-645 Cohen, M H 2002 Legal issues in complementary and integrative medicine: A guide for the clinician Medical Clinics of North America, 86:185-196 Cohen, M H, Eisenberg, D M 2002 Potential Physician Malpractice Liability Associated with Complementary and Integrative Medical Therapies Annals of Internal Medicine, 1368:596603 Colley, C A, Lucas, L M 1993
Polypharmacy: the cure becomes the disease Journal of General Internal Medicine 5:278-83 Coile, R C 1995 Chiropractic treatment: An alternative medicine becomes mainstream health care Health Trends, 7:1-8 Crock, R D, Jarjoura, D, Polen, A, Rutecki, G W 1999 Confronting the communication gap between conventional and alternative medicine: a survey of physicians attitudes Alternative Therapies in Health and Medicine, 52:61-6 Curtis, P, Evans, P, Rowane, M, Carey, T, Jackman, A 1997 Training Generalist Physicians in Manual Therapy for Low Back Pain: Development of a Continuing Education Method The Journal of Continuing Education in the Health Professions, 17:148-158 Davidson, J R T, Abraham, K, Connor, K M, McLoed, M N 2003 Effectiveness of chromium in atypical depression: a placebo-controlled trial Biological Psychiatry, 53:261-264 DeBacquer, D G, DeBacquer, G, Cokkines, D, Keil, U, Montaye, M, Ostor, E, et al 2004 Overweight and obesity in patients with established coronary heart
disease: Are we meeting the challenge? European Heart Journal, 25:121-128 Druss, B G, Rosenheck, R A 1999 Association between use of unconventional therapies and conventional medical services Journal of the American Medical Association, 2827:651-656 Eisenberg, D M, Davis, R B, Ettner, S L, Appel, S, Wilkey, S, Van Rompay, M, et al 1998 Trends in alternative medicine use in the United States, 1990-1997: results of a follow up national survey Journal of the American Medical Association, 280:1569-75 Eisenberg, D M, Kessler, R C, Foster, C, Norlock, F E, Calkins, D R, Delbanco, T L 1993 Unconventional Medicine in the United States–Prevalence, costs, and patterns of use New England Journal of Medicine, 328:246-252 Eisenberg, D M, Kessler, R C, Van Rompay, M I, Kaptchuk, TJ, Wilkey, S A, Appel, S, et al 2001 Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey Annals of Internal Medicine, 1355:344-51
Enqvist, B, Fischer, K 1997 Preoperative hypnotic techniques reduce consumption of analgesics after surgical removal of third mandibular molars International Journal of Clinical and Experimental Hypnosis, 452:102-8 Ernst, E 2001 The desktop guide to complementary and alternative medicine: An evidence-based approach Edinburgh: Mosby Faass, N Ed 2001 Integrating complementary medicine into health systems Gaithersburg, MD: Aspen Publications
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Frenkel, M, Ben Arye, E 2001 The growing need to teach about complementary and alternative medicine: questions and challenges Academic Medicine, 763:251-4 Furnham, A 1996 Why do people choose and use complementary therapies? In E Ernst Ed, Complementary medicine: An objective
appraisal pp 71-88 Oxford: Butterworth-Heinemann Garr, D R, Lackland, D T, Wilson, D B 2000 Prevention education and evaluation in US medical schools: a status report Academic Medicine 75:S14-S21 Gaylord, S, Coeytaux, R 2002 Complementary and Alternative Therapies in Family Practice In Sloane, P D, Slatt, L M, Ebell, MH, Jacques, LB Eds, Essentials of Family Practice pp97-113 Philadelphia: Lippincott Williams Wilkins Giordano, J, Boatwright, D, Stapleton, S, Huff, L 2002 Blending the boundaries: Steps toward an integration of complementary and alternative medicine in to mainstream practice Journal of Alternative and Complementary Medicine, 8:897-906 Gordon, J 1996 Alternative medicine and the family physician American Family Physician, 54:22052212 Grant, D J, Bishop-Miller, J, Winchester, D M, Anderson, M, Faulkner, S 1999 A randomized comparative trial of acupuncture versus transcutaneous electrical nerve stimulation for chronic back pain in the elderly Pain, 82:9-13 Herre, H P,
Faass, N 2001 A multi-specialty group practice: East-West health centers In: N Faass Ed, Integrating complementary medicine into health systems pp 385-390 Gaithersburg, MD: Aspen Publications Holroyd, K A, Mauskop, A 2003 Complementary and alternative treatments Neurology, 60, Supplement 2, S58-S62 Institute of Medicine 1999 To Err is Human: Building A Safer Health System Washington DC: National Academy Press Josefson, A, Kreuter, M 2003 Acupuncture to reduce nausea during chemotherapy treatment of rheumatic diseases Rheumatology Oxford 4210:1149-54 Kemper, KJ, Sarah, R, Silver-Highfield, E, Xiarhos, E, Barnes, L, Berde, C 2000 On pins and needles? Pediatric pain patients experience with acupuncture Pediatrics, 105:941947 Kessler, R C, Davis, R B, Foster, D F, Van Rompay, M, Walters, E, Wilkey, S, et al 2001 Long-term trends in the use of complementary and alternative medical therapies in the United States Annals of Internal Medicine, 136:262-268 Kirsch, I, Montgomery, G,
Sapirstein, G 1995 Hypnosis as an adjunct to cognitive behavioural psychotherapy: A meta-analysis Journal of Consultative and Clinical Psychology, 63:214-220 Kligler, B, Gordon, A, Stuart, M, Sierpina,V 2000 Suggested curriculum guidelines on complementary and alternative medicine: recommendations of the Society of Teachers of Family Medicine Group on Alternative Medicine Family Medicine, 321:30-3 Lazarou, J, Pomeranz, B H, Corey, P N 1998 Incidence of adverse drug reactions in hospitalized patients Journal of the American Medical Association, 279:1200-1205 Markman, M 2002 Safety issues in using complementary and alternative medicine Journal of Clinical Oncology, 20:39s-41s Marlow, S P, Stoller, J K 2003 Smoking Cessation Respiratory Care, 4812:1238-54

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UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL

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THE CONVER GENCE OF COMPLEMENT ARY, AL
TERNATIVE

CONVENTIONAL HEAL TH CARE

Matchar, D B 2003 Acute management of migraine: Highlights of the US Headache Consortium Neurology, 60, Supplement 2, S21-S23 Moore, N G 1997 King County natural medicine clinic: Public funding for integrated medicine Alternative Therapies in Health and Medicine, 3:32-33 Muscat, M 2000 Beth Israels Center for Health and Healing: realizing the goal of fully integrative care Alternative Therapies in Health and Medicine, 65:100-1 Peikert, A, Wilimzig, C, Kohne-Volland, R 1996 Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double blind randomized study Cephalalgia, 15:257-263 Pelletier, K R, Astin, J A, Haskell, W L 1999 Current trends in the integration and reimbursement of complementary and alternative medicine by managed care organizations and insurance providers: 1998 update and cohort analysis American Journal of Health, 14:125-133 Piscitelli, S 2000 Preventing dangerous drug
interactions Journal American Pharmacy Association, 405 suppl 1:S44-45 Piscitelli, S C, Burstein, A H, Chaitt, D 2002 Endinavir concentrations and St Johns Wort Lancet, 255:547-550 Poynard, T, Munteanu, M, Ratziu, V, Benhamou, Y, Dimartino, V, Taleb, J, et al 2002 Truth survival in clinical research: an evidence-based requiem Annals of Internal Medicine, 136:888-895 Pristave, R J, Becker, S, McCarthy, L I 1995 Development of provider networks for specific diseases Health Care Innovations, Sept-Oct, 9-3 Rakel, D Weil, A 2003 Philosophy of integrative medicine In D Rakel Ed, Integrative Medicine pp 3-10 Philadelphia: Saunders Relman, A S, Angell, M 2002 Americas other drug problem: how the drug industry distorts medicine and politics New Republic, 22725:27-41 Resch, KI, Ernst E, and Garrow, J 2000 A randomized controlled study of reviewer bias against an unconventional therapy Journal of the Royal Society of Medicine 93:164-167 Richmond, R, Zwar, N 2003 Review of bupropion for
smoking cessation Drug and Alcohol Review, 222:203-20 Sampson, W 2001 The need for educational reform in teaching about alternative therapies Academic Medicine, 763:248-250 Shang, C 2001 The future of integrative medicine Archives of Internal Medicine, 161:613-614 Shults, C W, Oakes, D, Kieburtz, K, Beal, M F, Haas, R, Plumb, S, et al 2002 Effects of coenzyme Q10 in early Parkinson disease: evidence of slowing of the functional decline Archives of Neurology, 59:1541-1550 Sierpina, V 2001 Integrative Health Care p17 Philadelphia: F A Davis Singer, A J 2001 Alternative medicine–why should we care? Academy of Emergency Medicine, 1:65-7 Snyderman, R Weil, A 2002 Integrative medicine Archives of Internal Medicine 162:395-397 Soares, K V S, McGrath, J J 2001 Vitamin E for neuroleptic-induced tardive dyskinesia Cochrane Review In: The Cochrane Library, Issue 2, 2004 Chichester, UK: John Wiley Sons, Ltd
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DEPARTMENT OF PHY SICAL MEDICINE

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UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL

2004

I N T E G R A T I N G COMPLEMENTAR Y

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Somri, M S, Vaida, S J, Sabo, E, Yassain, G, Gankin, I, Gaitini, L, A 2001 Acupuncture versus ondansetron in the prevention of post-operative vomiting A study of children undergoing dental surgery Anaesthesia, 56:927-932 Starfield, B 2000 Is US health really the best in the world? Journal of the American Medical Association, 284:483-485 Stewart, W B, Faass, N 2001 Hospital-based integrative medicine: The Institute for Health and Healing In: N Faass Ed, Integrating complementary medicine into health systems pp 406-412 Gaithersburg, MD: Aspen Publications Triano, J J, Rashbaum, R F, Hansen, D T, Raley, B 2001 The integrative multidisciplinary spine center: The Texas Back Institute In: N Faass Ed, Integrating complementary medicine into health systems pp 398-405 Gaithersburg, MD: Aspen Publications
Veenstra, J 2000 Harvard Medical School establishes integrative medicine division Herbalgram, 50 Weiger, W, Smith, M, Boon, H, Richardson, M, Kaptchuk, T, Eisenberg, D 2002 Annals of Internal Medicine, 137:889-903 Weil, A 2000 The significance of integrative medicine for the future of medical education American Journal of Medicine, 108:441-443 Wetzel, M S, Eisenberg, D M, Kaptchuk, T J 1998 Courses Involving Complementary and Alternative Medicine at US Medical Schools Journal of the American Medical Association, 280:784787 White, A R, Ernst, E 2000 Economic analysis of complementary medicine A systematic review Complementary Therapies in Medicine, 8:111-118 White, A R, Resch, K-L, Ernst, E 1997 Complementary medicine: use and attitudes among GPs Family Practice, 14:302-306 White House Commission on Complementary and Alternative Medicine Policy Final Report Health and Human Services, August 11, 2002 http://wwwwhccamphhsgov/finalreporthtml Yunus, M, Bennett, R, Romano, T J, et al 1997
Fibromyalgia consensus report: Additional comments Journal of Clinical Rheumatology, 3:324–327 Zappa, S B 2001 Integrative medicine at Memorial Sloan-Kettering Cancer Center In: N Faass Ed, Integrating complementary medicine into health systems pp 429-434 Gaithersburg, MD: Aspen Publications

PROGRAM ON INTEGRATIVE MEDICINE

DEPARTMENT OF PHY SICAL MEDICINE

REHABILITATION

SCHOOL OF MEDICINE

UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL

2004

THE CONVER GENCE OF COMPLEMENT ARY, AL TERNATIVE

CONVENTIONAL HEAL TH CARE

APPENDIX: MODELS OF INTEGRATIVE CARE
THE INFORMED CLINICIAN
EXAMPLES Family medicine physi c i a n becomes knowledgeabout herbal/supplement therapies and acupuncture for most common problems encountered: arthritis, headache, and heart disease Refers patients to herbalist for consultation but may retain decision-making for herbal choices Refers patients for acupuncture for pain syndromes when conventional therapy is sub-optimal

THE INFORMED
NETWORKING CLINICIAN
University of North Carolina Headache Clinic, Chapel Hill: Neurologist integrates skills and services of local CAM practitioners for patients with migraine and chronic daily headache Policies of conventional institution limit CAM practitioner credentialing for on-site treatment

THE INFORMED CAM-TRAINED CLINICIAN
Established, conventionally trained MD in general practice becomes trained in acupuncture, taking sixmonth course with certification provided by nationally recognized training organization

MULTIDISCIPLINARY INTEGRATIVE GROUP PRACTICE
The Texas Back Institute, P l a n o , T X : Group consists of an orthopedist, an osteopath, family practitioner, massage therapist, and biofeedback therapist in same facility for back pain management

INTERDISCIPLINARY INTEGRATIVE GROUP PRACTICE
East-West Health Centers, Denver, CO: Nine conventional providers 4 family practitioners, 2 internists, 1 osteopath, 1 dermatologist, and 1 physiatrist; and 6 CAM providers 1
herbalist, 1 chiropractor, 1 naturopath, 1 acupuncist, 1 MSW with hypnosis and NLP skills, and 1 homeopath

HOSPITAL-BASED INTEGRATION
Planetree Programs Institute for Health H e a l i n g , California Pacific Medical Center, San Francisco Sloan-Kettering Cancer Center, New York Zappa, 2001

INTEGRATIVE MEDICINE IN AN ACADEMIC MEDICAL CENTER
UNC Program on Integrative Medicine cooperates with Family Medicine Neurology, Physical Medicine Rehabilitation, ObGyn to develop teaching program in CAM involving students, residents, faculty, and community practitioners CAM consultation service develops from this effort providing CAM educational and service resources to wider medical community

MAJOR ADVANTAGES

Improved patient education; broader choice of therapies; informed referrals to CAM providers; possibility of CAM-directed self-care for the provider

Broader range of treatment options; autonomy of each member of integrative team; choice of level of interaction with each practitioner;
continued interactions contingent on outcomes

Integration of CAM treatment by caregiver trained in conventional care; outcomes and documentation under control of caregiver for that treatment; development of experience in treatment applications

High focus if chosen, eg, womens health, pain, geriatrics Lower overhead possible

More than one focus of CAM Improved patient experience Opportunities for research in integrated care; mindImproved staff working and teaching body approaches; body conditions work; herbals and supplements; expanded educational opportunities for practitioners; one-stop care for patients; financial crosscoverage depending on arrangements; reputation enhancement; community outreach programs by multiple staff members; improved negotiating position with insurers

MAJOR LIMITATIONS

Provider may not be aware of subtle distinctions guiding CAM choices, limited feedback from CAM providers; difficulty tracking outcomes specifically related to integrated therapies

Limited
control of documentation; possible legal risks associated with referrals

Need for some documenta- Financial vulnerability; tion of training or creden- credibility to referral sources tialing; legal risks may increase

Group consensus on goals and timelines may be hard to achieve; financial inequities may create conflict

Acceptance by medical, Difficulty credentialing CAM nursing, or support staffs providers; high overload often one or more are opposed on principle or for other reasons; difficulty credentialing CAM providers within hospital guidelines

MOTIVATION

To satisfy patient inquiry in major areas of practice

Improved patient health practices through specific CAM therapies

Expanded treatment options; Group seeks to focus on billable procedure; interest chronic pain, especially in in energy work the elderly

Care provided for general medical problems with slight emphasis on musculoskeletal problems

Improve patient and family Integrative approach to experience of health care
in patient care, teaching and inpatient setting; provide research integrated care

TIME REQUIRED

Personal education; meeting CAM practitioners; developing referral agreements– extra 2-6 hrs/week

Personal education; 3 full weeks away from service plus videotape, reading reviews–10 hrs/week

No additional time, since No additional time, since Planning and convincing associates bring their train- each brings his/her training staff ing to the table to the table

No additional time, since caregivers and staff have compelling interest that serves their academic goals

PROGRAM ON INTEGRATIVE MEDICINE

DEPARTMENT OF PHY SICAL MEDICINE

REHABILITATION F SCHOOL OF MEDICINE

UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL

2004

I N T E G R A T I N G COMPLEMENTAR Y

A LT E R N ATIVE T H E R A P I E S W I T H CONVENTIONA L CARE

APPENDIX: MODELS OF INTEGRATIVE CARE
THE INFORMED
CLINICIAN
COST Books; on-line herbal information service; conferences–2,000

THE INFORMED NETWORKING CLINICIAN
Books; on-line CAM services; seminars; professional meetings –4,000

THE INFORMED CAM-TRAINED CLINICIAN
Books; travel; equipment; time away from work– 10,000

MULTIDISCIPLINARY INTEGRATIVE GROUP PRACTICE
Start-up; locate space; hire staff; develop business plan; increased malpractice insurance

INTERDISCIPLINARY INTEGRATIVE GROUP PRACTICE
Evolving system of this size needs flexibility in space allocation and additional overhead for support staff

HOSPITAL-BASED INTEGRATION
Modest consultation fees; larger but still modest renovation costs; staff training

INTEGRATIVE MEDICINE IN AN ACADEMIC MEDICAL CENTER
Training and staff support costs; justifications required

CREDENTIALS REQUIRED

None

Desirable

Yes, by all at some point

Yes, by all at some point as available

Yes for CAM providers, but may be independent of licensure issues if administration and medical staffs
agree

Yes, by all, prior to joining staff

RISKS

Small to reputation and patients

Small to reputation and patients; overall legal risk slightly increased

Some financial and legal

Some financial, but less than a smaller group; increased legal

Reputation of the entire organization depending on community perception

Financial, legal, administrative time, reputation within the medical center

LIMITING FACTORS

More time needed per patient visit for education

More time needed per patient visit for education about reasons for CAM referral, reassurances, follow-up Extensive documentation of outcomes required

Time, money, reimbursement, legal risks More extensive documentation of outcomes needed

Assumptions about healing may differ between group members Uncertain role each plays in caregiving Financial arragements and risk/reward assignment Uneven reimbursement by insurers

Assumptions about healing may differ
considerably Uneven reimbursement by insurers

Difficulty in reaching agreement among participants; financial issues

Heavy reliance on MDs to practice CAM, multiple administrative umbrellas with associated policies; CAM provider credentialing: multiple interest groups competing for limited resources

BENEFITS

Improved patient care; physician reputation with patients may increase

Improved patient care through patient empowerment and developing attitudes of self-healing

Improved patient care; caregiver reputations may be enhanced; research; increased referrals

Early detection of nonImproved patient care; responders to conventional reputation enhancement care results in earlier inte- if successful gration of CAM therapies; reputation enhancement; highly focused effort with treatment protocols and outcome definition possible

Improved patient care; reputation ehancement if successful; retention of nursing and service staffs; increased competitive edge

Improved patient care; exposure
of students and residents to CAM; multiple opportunities for basic and clinical research

EVOLUTION

Obtain further training; contact local CAM providers; develop educational materials for patients; train staff to educate patients; provide patients on-line access to herbal information; use herbals/ supplements in self-care

Pursue further training; provide on-line access to CAM information services for patients; begin research in CAM; begin to use CAM in self-care; streamline referral protocols clinical pathways

Expand indications for CAM therapies with time and experience; career shift to include CAM training; training in other CAM modalities; partnering with others for additional CAM treatments

Expand staff to include other CAM providers herbalist, Reiki healer, etc; expand treatment focus to other conditions/ age groups; develop options eg, group therapy to empower patients by support and shared information

Expand staff to include other CAM providers; discover areas of particular
expertise and success

Growth of the concept; pilot projects, followed by expanded implementation to multiple parts of institution

Expansion to medical center departments and divisions in areas of teaching and patient care through consultation and research; outsourcing CAM therapies to community when center bylaws cannot accommodate CAM providers

FEEDBACK

Patients, other caregivers, personal experience

Patients, other caregivers, Patients, other caregivers, personal experience, HMOs HMOs

Patients, other caregivers, HMOs

Patients, staff, other hospitals, HMOs

Patients, students, residents, faculty, administrators, press, public, HMOs

PROGRAM ON INTEGRATIVE MEDICINE

DEPARTMENT OF PHY SICAL MEDICINE

REHABILITATION

SCHOOL OF MEDICINE

UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL

2004

Integrating Complementary Alternative Therapies with Conventional Care
The Program on Integrative Medicine Department of Physical
Medicine Rehabilitation of the School of Medicine University of North Carolina at Chapel Hill

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