Alternative Medicine and the Conventional Practitioner

ULSE PTHE MEDICAL STUDENT SECTION OF JAMA

THE PROMISE AND DIFFICULTY OF INTEGRATING DIFFERENT HEALING TRADITIONS

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PPUULSELSE Evaluating the Alternatives Editors in Chief Jonathan H. Lin, Columbia University College of Physicians and Surgeons Jonathan H. Lin, MA Columbia University College of Physicians and Surgeons The term alternative medicine has been leagues state in their report, engaging Ivan Oransky used interchangeably with comple- in yoga subsequent to open heart sur- New York University mentary medicine, integrative medi- gery can be dangerous. By working to- School of Medicine cine, and unconventional medicine. gether, surgeons and yoga instructors While these names encompass many have modified these exercises to allevi- Senior Editor healing practices outside the realm of ate pressure on the thoracic cavity. Ac- Li-Yu Huang, MHS allopathic medicine, they are not nec- knowledging the prevalence of alterna- Texas A&M University Health Science Center essarily equivalent and are often inac- tive therapies might allow physicians to College of Medicine curate in describing the practice and incorporate those that are beneficial in use of alternative medicine in the the regimen toward complete recovery. Associate Editors United States. Can alternative therapies be inte- Bryan K. Chan For example, not all alternative grated with allopathic practices to pro- Stanford University therapies complement allopathic duce improved patient outcomes? School of Medicine medicine. As Megan Johnson illus- Without rigorous research, it is impos- Scott Gottlieb trates in her essay, homeopaths might sible to identify those therapies that Mount Sinai School of Medicine treat a runny nose by prescribing reproducibly benefit patients’ health. of the City University of New York herbs that enhance the nasal dis- Fortunately, the Office of Alternative Jason A. Konner charge, while allopathic physicians Medicine at the National Institutes of Stanford University School of Medicine would probably provide medications Health is tackling these problems. Af- Heather R. Schroeder-Mullen to suppress the symptoms. Combining ter careful study, some alternative Case Western Reserve University both approaches to restoring health practices may prove to be useful. In- School of Medicine may not work synergistically, and it is deed, experimental evidence already Ronald J. Willy unclear to what degree treatment suggests that surprising benefits can Brown University compatibility exists. Physicians must be found for certain alternative thera- School of Medicine identify the parameters within which pies. For example, gingko biloba ex- Sue Sun Yom, MA alternative practices can be best used. tract has recently been documented to University of Pennsylvania Another term that inadequately slow the progression of dementia in School of Medicine describes alternative medicine is un- some patients.2 The possible benefits JAMA Staff conventional . While most allopathic should be justification enough for physicians may not recommend the continued rational evaluation. Charlene Breedlove Managing Editor use of energy healing to their ill pa- If an accurate, comprehensive defi- Juliana M. Walker tients, they might recommend other nition of alternative medicine remains Assistant Editor practices, such as the use of vitamins. elusive, perhaps a more restrictive Alternative practices may even be es- definition can be applied. From the AMA-MSS Governing Council sential for the total health of the indi- perspective of medical students, alter- Michael W. Bigelow, PhD, Chairperson vidual, given that the training of allo- native medicine consists of those tradi- Cesar Aristeiguieta, Vice Chairperson pathic physicians has traditionally fo- tions and practices of healing not Francine Wiest, Delegate cused on intervention. Perhaps the taught in medical schools.1 Given the Natalie Groce, Alternate Delegate Kristin Cooper, At-Large Officer prevention or palliation of certain prevalence and potential of these Steven Stack, Speaker chronic conditions are areas where practices, it is the responsibility of Jeffrey Towson, Vice Speaker alternative medicine could provide medical students to rectify this situa- Christopher R. Cogle, MD, Past Chairperson effects that are synergistic with allo- tion and educate themselves about the Pulse is prepared by the Pulse editors and JAMA pathic interventions. field. staff and is published monthly from September If alternative practices are not en- References through May. It provides a forum for the ideas, tirely complementary or unconven- opinions, and news that affect medical students 1 1. Eisenberg DM, Kessler RC, Foster C, Norlock FE, and showcases student writing, research, and art- tional, they are undeniably popular. Calkins DR, Delbanco TL. Unconventional medi- work. The articles and viewpoints in Pulse are not Despite their common use, physicians cine in the United States—prevalence, costs, and necessarily the policy of the AMA or JAMA. All patterns of use. N Engl J Med. 1993;328:246-252. submissions must be the original unpublished are often uninformed regarding alter- 2. LeBars PL, Katz MM, Berman N, Itil TM, Freed- work of the author. Work submitted to Pulse is native techniques. In the absence of man AM, Schatzberg AF. A placebo-controlled, subject to review and editing. double-blind, randomized trial of an extract of organized oversight lies the potential gingko biloba for dementia. JAMA. 1997;278: Address submissions and inquiries to for harm. As Mehmet Oz and col- 1327-1332. Pulse Coeditor in Chief Ivan Oransky, 545 First Ave, Apt 1R, New York, NY 10016; phone (212) 696-5553; Cover: Untitled acrylic painting by Patricia Wong, Stanford University School of Medicine e-mail: [email protected]

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Homeopathy: Another Tool in the Bag

Megan A. Johnson, George Washington University School of Medicine

One popular form of alternative medicine is homeopathy, a system of medicine that attempts to stimulate the body to Common Homeopathic Remedies heal itself. Homeopathy is based on two main principles.1 Adapted from Healing With Homeopathy1 The first is that “like cures like”: one should administer therapies that will produce symptoms similar to those the • Hypericum (St John’s wort) patient is already experiencing.2 According to this principle, Suggested uses: Mild to moderate depression, symptoms are seen as the body’s attempt to restore itself to sharp nerve pain resulting from nerve injuries, health. Enhancing these symptoms would then aid the asthma that is worse in damp weather, toothache, body’s normal healing process. For example, one homeo- late menstruation, and headache pathic remedy for a patient with a runny nose is the red on- Notes: A popular remedy that has long been ion extract, called allium, that enhances the runny nose by used as a treatment for depression stimulating the tear glands and mucous membranes of the • Arnica montana (leopard’s bane) upper respiratory tract.1 In contrast, allopathic medications Suggested uses: After traumatic injuries, soreness such as antihistamines would suppress the runniness. and bruises, or when feeling hypersensitive and The second principle of homeopathy is that of “mini- nervous mum dilution”: one should use the lowest concentration of Notes: Often used after labor and delivery, after a substance that still provokes a response.2 This principle is a fall or blow, or for bruising essential to homeopathy’s viability, since some compounds • Arsenicum (arsenic) used in homeopathy can be toxic at high concentrations.1 Suggested uses: Restlessness, chilliness, Homeopathic medications have beneficial effects only at weakness, thirst, burning pains, nervousness, lower dilutions, although how this occurs is unclear. Pub- anxiety lished guidelines state the prescribed concentration for Notes: Often used for colds, flu, pinkeye, vaginal homeopaths to follow when creating remedies.2 infections, gastroenteritis Many factors contribute to the popularity of homeopathy, among which may be allopathic medicine’s ineffective- ness in treating the chronic health complaints of many pa- A second difficulty is the inconsistency in homeopathic tients. This may be especially true for more systemic condi- training. While many programs are offered in the United tions such as backaches, the “blues,” and general malaise. States, no state licenses the practice of homeopathy without In these cases, homeopathic remedies may be useful, since a medical degree. they do not require a specific diagnosis but are based on A third barrier is that most insurance companies do not the symptoms presented by the patient. Rather than sorting reimburse for alternative medical practices, because they out conditions that may not match a specific diagnosis, ho- lack sufficient scientific proof of efficacy. Nonetheless, homeopaths seek to enhance all symptoms through their meopathic remedies are easily purchased over-the-counter therapies. In this sense, part of homeopathy’s popularity and are also relatively affordable. may be due to this patient-centered view of illness, where Despite these obstacles, homeopathic and alternative the key to resolving health issues lies in understanding and medicines present a “significant public health challenge treating all symptoms, not just those that fit the textbook as well as an opportunity.”4 If homeopathy is, in part, a description of a specific disease. reaction to the shortcomings of modern medicine, it is Despite homeopathy’s popularity, several barriers exist to also a force that cannot be ignored. For many patients its broad acceptance in the United States. The uncertain suffering from chronic problems that lack a specific diag- legal and clinical limits that govern the practice of home- nosis, homeopathy may be an important and useful treat- opathy are the most serious problems facing homeopaths. ment option. If used within its limits, homeopathy could Only three states, Arizona, Connecticut, and Nevada, have complement modern medicine as, “another tool in the homeopathic licensing laws that apply specifically to those bag.”2 Perhaps, together with allopathic medicine, a more 3 with medical (MD) or osteopathic (DO) degrees. Within complete therapy can be employed to benefit patients’ these laws no clear directives exist that distinguish between health. circumstances in which homeopathy could be applied and situations in which it would not be beneficial. In practice References though, most homeopathic treatments are aimed at 1. Jonas W, Jacobs J. Healing With Homeopathy. New York, NY: Warner Books;1996. 2. Cant S, Sharma U. Demarcation and transformation within homeopathic chronic illnesses; homeopathy is not generally considered knowledge: a strategy of professionalization. Soc Sci Med. 1996;42:579-588. useful for acute, life-threatening situations. However, the 3. Lebensorger M. Legalities of homeopathic practice and the NCH Directory of Practitioners. Homeopathy Today. 1997;17:2-10. lack of legal and medical guidelines hinders homeopathy’s 4. Marwick C. Complementary medicine congress draws a crowd. JAMA. 1995; widespread use. 274:106-107.

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Alternative Medicine and the Conventional Practitioner

Wayne Jonas, MD, Director, Office of Alternative Medicine, National Institutes of Health

Complementary and alternative medicine (CAM) repre- Promoting safe and effective CAM therapies—Accumu- sents that subset of practices that are not an integral part lating evidence suggests that CAM practices are valuable of the dominant health care system in the United States for the treatment of disease.19-21 Importantly, alternative but are still used by patients to supplement their health products are often less expensive than conventional medi- care.1 Surveys have operationally defined CAM as those cations. For example, studies report that Hypericum (St practices used for the prevention and treatment of disease John’s wort) is not only as effective as conventional anti- that are not taught widely in medical schools nor generally depressants in treating depression but can be obtained at available in hospitals.2 one third the cost.22 Physicians can search the published medical literature and evaluate the applicability of CAM Public and Professional Interest in CAM for specific patients’ problems. One out of every 3 Americans consulted an alternative Partnering with patients about CAM—More than 80% health care practitioner in 1990, constituting over 400 of those who used unconventional practices in 1990 23 million visits. Over $13 billion was paid for these services, combined these practices with conventional medicine. of which $10 billion was not reimbursed.2 In Europe and Patients who use CAM do not harbor antiscientific or Australia, regular use of CAM practices ranges from 20% anticonventional medicine sentiments, nor do they rep- to 70%.3,4 resent a disproportionate number of the uneducated, 24,25 Substantial professional interest exists in CAM practices poor, seriously ill, or neurotic. Yet 70% of patients as well. Over 50% of conventional physicians in the who use CAM practices do not tell their conventional United States use or refer patients for some CAM treat- practitioner about this use. The physician can fill this ments, and most perceive them as having some efficacy.5-7 communication gap by asking patients about their CAM Hospital systems, health maintenance organizations, and use and work with them to ensure that these therapies 12 insurance companies are increasingly providing CAM ser- are used responsibly. vices.8 In addition, mainstream medical journals are be- ginning to call for research papers in complementary, Medical Students and Medical Education in CAM 9 alternative, unconventional, and integrative medicine. Recognizing the increasing importance of CAM in modern health care, more than 80% of medical students The Role of the Conventional Practitioner in CAM would like further training in these areas.26,27 Currently, Often patients will accept anecdotes or sophisticated over 40 medical schools in the United States offer intro- marketing as sufficient grounds to try new therapies. ductory, elective courses in CAM and almost one third of The conventional practitioner can help patients incorpo- family practice residencies provide some type of instruc- rate more scientific evidence in their health care deci- tion about CAM practices.28,29 sions. The following are directives physicians can adopt In June 1996, a panel of experts in medical and nursing when discussing the use of CAM practices with their education assessed the status of CAM education. The patients.10 panel included deans and associate deans for curriculum Protecting patients from the risks of CAM—Given the and education from medical and nursing schools and rep- extensive use of CAM services and the relative paucity of resentatives from the American Medical Association data concerning safety, patients may be putting them- (AMA), American Academy of Family Practice (AAFP), selves at risk by their use of these treatments.11 Only fully Association of American Medical Colleges (AAMC), Fed- competent and licensed practitioners can help patients eration of State Medical Boards, Pew Health Professions avoid such inappropriate use.12 Some CAM products con- Commission, American Medical Student Association tain powerful pharmacologic substances that can be toxic (AMSA), and other organizations. They made the follow- either alone or in combination with other medications.13 ing 3 recommendations regarding the future role of CAM Also, contamination and poor quality control are more in health sciences education.30 likely with CAM products than with conventional drugs, 1. Medical and nursing education should include in- especially when shipped from overseas.14 Physicians can formation about complementary practices. also ensure that patients do not abandon effective care 2. Medical and nursing education about each comple- and alert them to signs of possible fraud or danger.15 mentary and alternative practice should include informa- Permitting use of nonspecific therapies—Some thera- tion about the discipline’s philosophical paradigm, scien- peutic benefits of CAM may be attributed to nonspecific tific foundation, educational preparation, practice, and factors.16,17 Basic science and clinical trials can separate evidence of safety and efficacy. general factors from those components that are specific, 3. National centers of excellence should continue to and unique to the therapy. Practitioners can combine be developed to foster collaboration among complemen- both specific and nonspecific factors to achieve maximum tary practitioners, nurses, and physicians and to promote benefit to the health of their patients.18 synergy among education, research, and clinical practice.

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The OAM Supports the Following For information about CAM research at the NIH, contact the 11 Centers for Research in CAM public information clearinghouse at (888) 644-6226 or the OAM Web site at www.altmed.od.nih.gov. Focus Location For grant information call the OAM at (301) 435-5024; grant Cancer University of Texas applications can be obtained from the Grants Information Office Health Science Center at (301) 435-0714 or by e-mail at [email protected]. Women’s health Columbia University College of Physicians and Surgeons Stroke and Kessler Institute for References neurorehabilitation Rehabilitation 1. Working Group on Definitions and Descriptions of Complementary and Al- HIV and AIDS Bastyr University ternative Medicine. Defining and describing complementary and alternative Pain University of Virginia medicine. Alt Ther Health Med. 1997;3:49-57. School of Nursing 2. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States—prevalence, costs, and pat- University of Maryland terns of use. N Engl J Med. 1993;328:246-252. School of Medicine 3. Fisher P, Ward A. Complementary medicine in Europe. BMJ. 1994;309:107-111. Aging Stanford University 4. MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative Addictions Minneapolis Medical medicine in Australia. Lancet. 1996;347:569-573. 5. Blumberg DL, Grant WD, Hendricks SR, Kamps CA, Dewan MJ. The physi- Research Center cian and unconventional medicine. Alt Ther Health Med. 1995;1:31-35. Internal medicine Beth Israel Hospital, 6. Berman BM, Singh BK, Lao L, Singh BB, Ferentz KS, Hartnoll SM. Physicians’ Harvard Medical School attitudes toward complementary or alternative medicine: a regional survey. Asthma and allergy University of California, Davis J Am Board Fam Pract. 1995;8:361-363. 7. Ernst E. Complementary medicine: what physicians think of it: a meta- Chiropractic Palmer College of Chiropractic analysis. Arch Intern Med. 1995;155:2405-2408. 8. Pelletier KR, Marie A, Krasner M, Haskell WL. Current trends in the integra- tion and reimbursement of complementary and alternative medicine by managed care, insurance carriers, and hospital providers. Am J Health Promot. 1997;12:112-123. By “philosophical paradigm” the panel meant that 9. Fontanarosa PB, Lundberg GD. Complementary, alternative, unconven- students should learn about the different values and tional, and integrative medicine: call for papers for the annual coordinated worldviews on health and disease that are to be found theme issues of the AMA journals. JAMA. 1997;278:2111-2112. 10. Eisenberg DM. Advising patients who seek alternative medical therapies. Arch in a pluralistic society. Currently, organizations such Intern Med. 1997;127:61-69. as the AMA, AAFP, AAMC, and AMSA are discussing 11. Ernst E. Bitter pills of nature: safety issues in complementary medicine. Pain. 1995;60:237-238. strategies for addressing medical education needs in 12. Special Committee on Health Care Fraud. Special report on health care CAM. fraud. Austin, Tex: Federation of State Medical Boards; 1997. 13. De Smet PAGM, Keller K, Ha¨nsel R, Chandler RF. Adverse Effects of Herbal Drugs. Heidelberg, Germany: Springer-Verlag; 1997. CAM Research at the National Institutes of Health (NIH) 14. Bensoussan A, Myers SP. Towards a Safer Choice. Victoria, Australia: University of Western Sydney Macarthur; 1996. The NIH currently invests about $40 million per 15. Barrett S. The public needs protection from so-called “alternatives.” Internist. year in CAM-related research. To address the need 1994;9:10-11. 16. Roberts AH, Kewman DG, Mercier L, Hovell M. The power of nonspecific ef- for research in complementary, alternative, and uncon- fects in healing: implications for psychological and biological treatments. Clin ventional medical practices, Congress created the Office Psychol Rev. 1993;13:375-391. of Alternative Medicine (OAM) at the NIH in 1992. 17. Thomas KB. The placebo in general practice. Lancet. 1994;344:1066-1067. 18. Chaput de Saintonage D, Herxheimer A. Harnessing placebo effects in The OAM works with NIH institutes and centers to iden- health care. Lancet. 1994;344:995-998. tify and support CAM research applications and devel- 19. Kleijnen J, Knipschild P. Gingko biloba for cerebral insufficiency. Br J Clin Pharm. 1992;34:352-358. ops new programs in selected CAM-related areas. It sup- 20. Le Bars PL, Katz MM, Berman N, Itil TM, Freedman AM, Schatzberg AF. A ports 11 centers conducting over 50 projects on CAM placebo-controlled, double-blind, randomized trial of an extract of ginkgo biloba for dementia. JAMA. 1997;278:1327-1332. research at universities around the country. The OAM 21. Neil A, Silagy C. Garlic: its cardio-protective properties. Curr Opin Lipidol. also maintains an organized bibliographic database of 1994;5:6-10. 22. Linde K, Ramirez G, Mulrow CD, Pauls A, Weidenhammer W, Melchart D. St over 90 000 citations. Selections from this database on John’s wort for depression—an overview and meta-analysis of randomised safety and clinical conditions will soon be available on clinical trials. BMJ. 1996;313:253-258. 23. Eisenberg DM. The invisible mainstream. Harvard Med Alum Bull. 1996:20-25. the OAM web site. An OAM supported public informa- 24. Furnham A, Forey J. The attitudes, behaviors and beliefs of patients of conven- tion clearinghouse responds to 2000 inquiries each tional vs. complementary (alternative) medicine. J Clin Psychol. 1994;50:458-469. 25. Vincent C, Furnham A, Willsmore M. The perceived efficacy of complemen- month. tary and orthodox medicine in complementary and general practice patients. Health Educ Theory Pract. 1995;10:395-405. Conclusions 26. Halliday J, Taylor M, Jenkins A, Reilly D. Medical students and complementary medicine. Comp Ther Med. 1993;1:32-33. As the importance of CAM continues to grow, physi- 27. Furnham A, Hanna D, Vincent CA. Medical students’ attitudes to comple- cians will be increasingly expected to address issues re- mentary medical therapies. Comp Ther Med. 1995;3:212-219. 28. Daly D. Alternative medicine courses taught at United States medical schools: lated to these practices. Physicians cannot become knowl- an ongoing list. J Alt Comp Med. 1997;3:405-410. edgeable about all CAM practices, but they can apply the 29. Carlston M, Stuart M, Jonas W. Alternative medicine instruction in medical schools and family medicine residency programs. Fam Med. 1997;29: principles of evidence-based medicine, as in any area of 559-562. health care.31 The OAM can serve as a resource to physi- 30. Panel issues recommendations for incorporating complementary practices into medical/nursing education. Alt Ther Health Med. 1996;2:25. cians in their effort to provide safe, effective, and appro- 31. Rosenberg W, Donald A. Evidence based medicine: an approach to clinical priate health care for the American public. problem-solving. BMJ. 1995;310:1122-1126.

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Complementary Medicine in the Surgical Wards Mehmet C. Oz, MD, Gerard C. Whitworth, RN, CCP, and Eric H. Liu, Columbia University College of Physicians and Surgeons

Since its inception in the late 1950s, the cardiac surgery patient through several steps of progressive relaxation. service at Columbia-Presbyterian Medical Center (CPMC) Although each hypnosis script is specifically designed to has applied innovative approaches to the treatment of meet the particular needs and issues of the individual pa- cardiac disease. This tradition has led to the creation of tient, during a typical session, the hypnotherapist will sug- extensive programs in heart transplantation, mechanical gest that there will very little pain after the surgery or that cardiac assistance, and pediatric cardiac surgery. The the patient’s spirits and attitude will be high and ener- search for improved healing techniques has not been lim- getic. For many patients the experience of the intubation ited to the operating room. The neurologic and psychiat- tube after coming out of anesthesia is traumatizing; hyp- ric changes associated with open heart surgery have also notherapy has been used to ease such anxiety. Hypnosis been defined, and treatment of these changes is now an sessions are recorded on audiotape and patients are en- integral portion of postoperative cardiac surgery care.1 couraged to listen to them before and after surgery. The need to ameliorate these symptoms, including the Nutrition—Most people believe that nutrition is a pillar inability to sleep, increased anxiety, and possible psycho- to recovery of health. Following open heart surgery, we sis, was the driving force behind the creation of the have an opportunity to make dramatic modifications in complementary medicine (CM) program within the car- our patients’ diets (Table). diac surgery department in 1994. Currently, 40% of the Massage and Reflexology—Both of these therapies are nearly 1400 cardiac care patients per year use the services popular among patients in the program, and nearly 60% provided by the CM program at CPMC. of patients entering the CM program use them. Massage The growth of the CM program is primarily patient- therapy has been effective in relaxing patients as well as driven. Many patients requiring cardiac surgery had already their family members during stressful episodes at the hos- explored or used CM treatments and requested that these pital. All massages are performed by licensed massage techniques be somehow integrated into their surgical regi- therapists, using various manipulative techniques that men. In addition, as allopathic clinicians, physicians felt stimulate muscles. For those patients in whom body mas- that the emotional, palliative, and/or preventive care re- sage is contraindicated, reflexology is offered. Reflexol- quested by patients were areas that surgeons were not well ogy is the manual stimulation of the hands and feet. In trained to provide. The CM program could fill this void in traditional Eastern medicine, stimulation of certain the perioperative management of surgical patients. Hence, points on the hands and feet can produce a “reflex” effect a separate CM service was established that would allow indi- in other areas of the internal body. viduals with experience in the areas of prevention and/or Yoga—This program was chosen by 15% of our cardiac health maintenance to interact with patients under the su- care patients. We use a modified yoga routine to prevent pervision of physicians. injury to the sternum or manubrium in recent operated Currently, the CM program at CPMC operates on a upon patients. Patients are led through a series of gentle hospital-subsidized, fee-for-service basis. However, health exercises that allows them to stretch muscles that have care providers and former patients have approached health been unused since the surgery and to focus on breathing insurance organizations and requested reimbursement for techniques that will ease the strain on the thoracic cavity. these therapies. Some companies have been receptive, pro- In addition, yoga can be used to manage the daily stresses viding full or partial reimbursement and demonstrating an in a patient’s life to prevent future recurrence of disease. interest in supporting CM, while others have not. In all Aromatherapy—This therapy uses the sense of smell to cases, health insurers have asked for more data and re- restore the body to health. Aromatic oils, such as lavender search about the efficacy of complementary therapies, a and neroli, have long been believed to have a soothing need that we are addressing. effect on the mind and body. Physiologically, this may be reflected in an increase in parasympathetic nervous sys- Modalities Offered by the CM Program tem activity. By measuring heart rate variability, we hope Music Therapy—This modality uses music’s influence to determine what effects aromatherapy has on the body. on the mind and body to ease the stress patients endure Therapeutic Touch—The most controversial modality when undergoing open heart surgery. Patients listen to is the use of therapeutic touch or energy healing. Practi- specially designed “hemisync,” 5-tonal, or popular music tioners move their hands over patients without physical tapes through headphones while anesthetized during sur- contact in order to effect changes in their chakras, or en- gery. Patients are encouraged to listen to the tapes preop- ergy meridians. With nothing more than a mindful inten- eratively and postoperatively to support the recovery pro- tion to heal, the practitioner attempts to change a per- cess. Of the patients entering the CM program, 80% son’s energy meridians, allowing the body energy to flow chose this modality. evenly and achieve a state of health. In 1997, 10 extremely Hypnotherapy—Hypnosis is used by many of our pa- skeptical patients found therapeutic touch to be remark- tients to help manage anxiety, depression, and, most im- ably helpful and have supported continued research and portantly, pain. In our program, a hypnotherapist leads a use of this treatment.

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Evaluating the Efficacy of CM To meet the need for scientific research in the field of Recommended Diet Following Open Heart Surgery CM, the program at CPMC actively evaluates the efficacy Vegetarian diet and no dairy products of all modalities used by patients. In addition to deliver- Ͻ20% of energy from fat (only 5% saturated) ing the therapies, practitioners and coordinators monitor Limited complex carbohydrates to maintain weight and assess the outcomes of these interventions on the within 20% of ideal overall health of the patients. Emphasis on food groups that include grains, beans, To determine the benefit, if any, of the various comple- fruits, and vegetables mentary modalities, we study their effects using the fol- Ascorbic acid (1000 mg/d) and vitamin E (400 IU/day) lowing 4 health assays: Ubiquinone (30 mg 3 times a day) and carnitine • Autonomic nervous system function is gauged by (500 mg 2 times a day) monitoring heart rate variability frequencies in the inten- Calcium citrate (1 g/d) and magnesium citrate sive care unit setting or on the wards. By measuring heart (800 mg/d) Folic acid (1 mg/d) and vitamin B-complex (50 mg/d) rate, we can determine whether the complementary mo- with supplemental pyridoxine hydrochloride dality has a relaxing or stimulatory effect on the patient. (50 mg/d) after determination of baseline • Cognitive function is studied using word pair selec- homocysteine level tion biases. • Immune function is assessed using energy panels in vivo or using patient serum in vitro. • Quality of life is assessed using a moods’ scale profile. The combination of multidisciplinary researchers, Patients who use CM modalities are followed prior to a well-equipped facility, and a relatively homogenous and after interventions at weekly intervals to assess short- population consisting of cardiac patients will help us to term and long-term benefits. By using a multidisciplinary identify the potential role of CM in the allopathic health approach, incorporating assays of autonomic nervous sys- care system. Our patients are already asking for this tem, cognitive function, immune function, and quality-of- advice. life surveys, we hope to provide a model for investigating complementary modalities and to add substantively to the References literature on this topic. Thus far, we have demonstrated 1. Kornfeld DS, Zimberg S, Malm JR. Psychiatric complications of open-heart surgery. N Engl J Med. 1965;273:1-6. that the use of hypnosis in the perioperative cardiac sur- 2. Ashton RA, Whitworth GC, Seldomridge JA, Shapiro PS, Michler RE, Smith gery setting results in a significant reduction in anxiety as CR, Rose EA, Fisher S, Oz MC. Self-hypnosis reduces anxiety following coronary artery bypass surgery: a prospective, randomized trial. J Cardiovasc well as a decrease in the amount of postoperative pain Surg. 1997;38:69-75. medication required by patients.2,3 Other studies are un- 3. Ashton RA, Whitworth GC, Seldomridge JA, Shapiro PS, Michler RE, Smith CR, Rose EA, Fisher S, Oz MC. The effects of self-hypnosis on quality of life fol- der way to determine the potential therapeutic properties lowing coronary artery bypass surgery: a prospective, randomized trial. J Alt of other complementary modalities. Comp Med. 1995;1:9-14.

Interested in the Alternatives? Here’s Where to Learn More

For those interested in holistic health the following is a Books list of resources: Murray MT. Natural Alternatives to Over-the-Counter and Pre- Organizations scription Drugs. New York, NY: William Morrow & Co; 1994. American Holistic Medical Association Balch JF, Balch P. Prescription for Nutritional Healing. 2nd 6728 Old McLean Village Dr, McLean, VA 22101; ed. Garden City, NY: Avery Publishing Group; 1997. (703) 556-9728/9245 [[email protected]] Internet American Association of Naturopathic Physicians. FDA: http://www.fda.gov 2366 Eastlake Ave East, Ste 322, Seattle, WA 98102; American Holistic Health Association: (206) 323-7610 http://www.healthynet/ahha Herb Research Foundation American Botanical Council: http://www.herbalgram.org 1007 Pearl St, Suite 200, Boulder, CO 80302; Ask Dr. Weil: http://www.drweil.com (303) 449-2265 Periodicals Alternative Therapies in Health and Medicine 1998 Pulse Art Contest PO Box 627, Holmes, PA 19043; (800) 345-8112 Entries for the 1998 Pulse Art Contest must be postmarked by June 1. Winners will be considered for future publication in Herbal Gram (quarterly publication of the American Pulse. For information, please refer to the February 4 issue of Botanical Council and the Herb Research Foundation) Pulse or contact Senior Editor Li-Yu Huang at (254) 899-1993. PO Box 201660, Austin, TX 78720; (512) 331-8868

Downloaded From: https://jamanetwork.com/ on 09/24/2021 held instruments.6 We support that resolution and suggest the actors, famous places, and historical subjects in a style de- following ways to implement this practice in health care set- scended from (and indebted to) such ukiyo-e masters as tings, including outpatient and home care settings. Kitagawa Utamaro (1735-1806). 1. Wipe the bell, diaphragm, and tubing of stethoscopes and The print on the JAMA cover portrays not just a lady but the surface of otoscopes with alcohol swabs between patient a beautiful, elaborately dressed and coiffed geisha, that is, a uses. professional courtesan and male companion trained in the tra- 2. Wash hands thoroughly with soap and running water ditional arts of Japanese dancing, shamisen playing, and the between patient contacts. singing of popular songs. The print bears an inscription indi- 3. Have alcohol swabs readily available (eg, adjacent to cating that it is one in a series of 36 geisha scenes of the plea- sinks, in patient anterooms, and at nursing stations). Swabs sure quarters in Edo’s old Yanagibashi (Willow Bridge) neigh- need to be easily accessible to encourage use. borhood, and bears the label “Yanagibashi, Sakuragawa” 4. Provide a dedicated stethoscope and other handheld in- (Sakura River or river amidst the cherry blossoms). struments (including blood pressure cuffs) for patients who The lady, dressed with an ivy-decorated robe against a red require contact precautions (eg, patients isolated because of hemp-flower background, holds in her elegantly posed left multidrug-resistant microorganisms, such as vancomycin-re- hand a sakazuki (sake cup)—not a tea cup, as the Cover Story sistant enterococcus infection). Because topical cleaning with indicates. In her right hand she clutches what seems to be a alcohol does not reliably remove all bacteria, nondisposable, 3-fold purse. Is she about to leave the teahouse, having a sip of dedicated equipment should be more thoroughly disinfected wine on the way out? Is she in a bit of a rush—a lock of hair has with an approved topical disinfectant between patients. Dis- come loose from her immaculate hairdo—as she gets ready, posable stethoscopes are an acceptable choice. purse in hand, to meet a client at the bridge? 5. Instruct environmental services personnel who perform The print is signed (Kunichika-hitsu) and also bears the routineroomcleaningbetweenpatientsabouttheneedforand head woodblock-carver’s name, the seal of what appears to be techniques of thorough cleaning of items that contact patients, a past owner (thus incorporating the character tatematsuru/ such as blood pressure cuffs. ho¯), and the name of what is most likely the publishing house— Formal evidence-based recommendations await more data Ittsu¯ Yorozuya. I hope the foregoing will clarify essential de- on the clinical significance of contamination of handheld in- tail relating to the artist of this appealing, attractive, and little struments by pathogenic microbes and the effectiveness of reproduced print, while possibly stimulating further research these and other techniques for preventing transmission of by ukiyo-e art experts. these organisms. Judith N. Rabinovitch, PhD Rebecca Wurtz, MD, MPH University of Montana Evanston Hospital and Northwestern University Missoula Medical School 1. Pace BP. The Cover (Yasuo Kuniyoshi, A Woman). JAMA. 1998;279:340. Evanston, Ill Robert Weinstein, MD Cook County Hospital and Rush Medical College Chicago, Ill for the Society for Healthcare Epidemiology of America CORRECTIONS 1. Marinella MA, Pierson C, Chenoweth C. The stethoscope: a potential source of Incorrect Table.—In the Pulse article entitled “Complementary nosocomial infection. Arch Intern Med. 1997;157:786-790. Medicine in the Surgical Wards,” published in the March 4, 1998, issue 2. Breathnach AS, Jenkins DR, Pedler SJ. Stethoscopes as possible vectors of infec- HE OURNAL tion by staphylococci. BMJ. 1992;305:1573-1574. of T J (1998;279:710-711), the Table contained several er- 3. Gerken A, Cavanagh S, Winner HI. Infection hazard from stethoscopes in hospital. rors. The corrected Table is published here. Lancet. 1972;1:1214-1215. 4. Bonten MJ, Hayden MK, Nathan C, et al. Epidemiology of colonization of patients and environment with vancomycin-resistant enterococci. Lancet. 1996;348:1615-1619. 5. Garner JS, and HICPAC. Guidelines for isolation precautions in hospitals. Infect Control Hosp Epidemiol. 1996;17:53-80. Recommended Diet Following Open Heart Surgery 6. American Medical Association House of Delegates. Proceedings of the 50th Interim Meeting. Chicago, Ill: American Medical Association; December 8-11, 1996:398. Vegetarian diet and no dairy products Ͻ20% of energy from fat (only 5% saturated) Cover Story, “Lady”: Correction and Clariﬁcation Limited complex carbohydrates to maintain body weight within 20% of ideal To the Editor.—The Cover Story on the Japanese woodblock Emphasis on food groups that include grains, beans, print titled Lady1 is erroneously attributed to the modern fruits, and vegetables American-style expressionist painter Kuniyoshi Yasuo (1893- Ascorbic acid (1000 mg/d) and vitamin E (400 IU/d) 1953), who emigrated to America at age 13 years. The actual Ubiquinone (30 mg 3 times a day) and carnitine name of the artist who created this print, as recorded on the (500 mg 2 times a day) work itself, is Toyohara Kunichika (1835-1900)—kuni written Calcium citrate (1 g/d) and magnesium citrate (800 mg/d) as in country, chika as in China’s Chou [dynasty]. This error Folic acid (1 mg/d) and vitamin B complex (50 mg/d) apparently was due to a cataloging mistake, owing to the pass- with supplemental pyridoxine hydrochloride ing resemblance of yoshi in the name Kuniyoshi to chika in (50 mg/d) after determination of baseline Kunichika. homocysteine level A native of Edo (the old name for Tokyo), Kunichika lived almost 3 generations before the aforementioned Kuniyoshi. Born Arakaw Yasohachi, Kunichika studied with the woodcut master Toyohara Chikanobu, whose name he later took. He went on to become a disciple of the renowned printmaker Misattributed Artist.—In The Cover story published in the February Utagawa (Tsunoda) Kunisada (1786-1864), also known as 4, 1998, issue of THE JOURNAL (1998;279:340), the cover painting was Toyokuni III. Although a minor artist, Kunichika is regarded misattributed to Kuniyoshi Yasuo. The correct name of the artist is Toyohara Kunichika and the painting is entitled Lady. as the last of the genuinely traditional ukiyo-e (floating-world picture) artists. He created conventional scenes of geisha,

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