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Te Principles and Challenges O Inte Gra Ive * 'W Medicine More Than a Combination of Traditional and Alternative Therapies

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Te Principles and Challenges O Inte Gra Ive * 'W Medicine More Than a Combination of Traditional and Alternative Therapies Te principles and challenges o inte gra ive * 'w medicine More than a combination of traditional and alternative therapies Victoria Maizes Integrative medicine is a new term that sometimes is used Integrative medicine focuses on prevention as a means Opher Caspi interchangeably with complementary and alternative of enhancing health and well-being. Five areas of pre- Program of Integrative medicine, and at other times refers to treatments that vention are addressed: physical activity, nutrition, screen- Medicine combine conventional medicine stress management, Department of and alternative modali- ing, and spirituality. The first three Medicine ties.1 We define the fundamental principles of integra- are commonly stressed by traditional physicians, but College ofMedicine tive medicine differently. often without specific recommendations.2 For example, University ofArizona Central to our definition ofintegrative medicine is the the relationship between diet and certain chronic diseases body's innate ability to heal. Healing is believed to origi- is often not addressed. Physicians who practice integra- Correspondence to: natewithin the patient rather than the physician. For exam- tive medicine are encouraged to inquire about patients' [email protected]. edu ple, a patient presents with pneumococcal pneumonia and sources of stress and coping strategies. Regular practice an antibiotic is prescribed. The patient recovers. Has the of relaxation such as t'ai chi or meditation are recom- doctor cured thepatient, the antibiotic eradicated the pneu- mended to patients, as are breathing exercises and self- monia, or the patient's immune system, assisted by the hypnosis. Physicians inquire about the patient's spiritual antibiotic's reduction ofbacterial load, led to the patient's life, because they consider understanding this aspect of recovery? Integrative medicine asserts the latter. patients' lives as critical to promoting health. Integrative medicine requires a shift from the "fix- Complementary and alternative medicine serves an ing" paradigm that has been central to biomedicine. important role in integrative medicine, yet the two are When pathology is emphasized, the individual's experi- not synonymous. The former opens new paradigms for ence of being ill and the social context of disease are many conventionally trained physicians; for example, neglected. Instead, an integrative medicine physician explaining the Chinese medical system's use ofmoxibus- helps the patient consider the meaning of the illness for tion to turn a breech baby.3 The latter is committed to that patient, which can serve as a powerful agent for the practice ofgood medicine whether its origins are con- change and for healing. Language is used to support this ventional or alternative4; for example, offering adaptogens natural tendency toward healing. Awoman with metasta- for replenishing the qi, mind-body, as well as nutritional tic lung cancer writes to her integrative medicine physi- recommendations to patients with "fatigue," when the cian, "My body is falling apart...my spirit soars." Despite lack of a clear diagnosis may not lead an allopathic physi- a low likelihood of cure, this woman articulates a heal- cian to offer treatment. Complementary and alternative ing process and sense ofwholeness. medicine assists the practitioner of integrative medicine Sir William Osler's famous words-"It is much more in taking a holistic approach. important to knowwhat sort ofpatient has a disease than Although centers of integrative medicine have what sort ofdisease a patient has"-express another prin- opened in many cities, little has been written about ciple of integrative medicine. Integrative medicine how complementary and alternative medicine and allo- focuses on the needs of each individual human being, pathic providers collaborate to provide care.5 Getting asking the questions, "What do you love? What gives you to know patients takes time; in the old general prac- strength in times of trouble? What gives your life pur- tice model, physicians had a lifetime in which to get pose or meaning?" Although not typical questions asked to know their patients. Today's mobile society, as well during a physician visit, these questions are essential in as economic incentives in our current healthcare sys- integrative medicine, because they allow providers to tems, do not support this time investment. Finally, it understand their patients' values and the context in is unclear how evidence-based medicine should be which they live. It is then possible to design a unique applied to integrative medicine, when the field stress- treatment plan. es individual treatments and is willing at times of low The principles of integrative medicine maintain that risk to use unproven treatments. the experience of a therapeutic relationship facilitates Integrative medicine shifts the paradigm from sick- the healing process. The physician emphasizes the ness to health, keeps the patient in the central focus of patient's participation and responsibility and recognizes care, and multiplies the number of strategies available the patient's preferences and self-knowledge when to the patient. It is a new kind of medicine that shifts designing a treatment plan. the experience for both patient and provider. 148 wJm Volume 171 September 1999 References 3 Cardini F, Weixin H. Moxibustion for correction ofbreech 1 Oumeish OY. The philosophical, cultural, and historical aspects of presentation. JAMA 1998;280:1580-1584. complementary, alternative, unconventional, and integrative medicine 4 Gaudet TW. Integrative medicine: the evolution ofa new approach to in the Old World. Arch Derm 1998;134:1373-1386. medicine and to medical education. Int Med 1998;1:67-73. 2 Donohoe MT Comparing generalist and specialty care: discrepancies, 5 Anderson R A case study in integrative medicine: alternative theories deficiencies and excesses. Arch Intern Med 1998;1 58:1596-1608. and the language ofbiomedicine. J Alt Comp Med 1999;5:165-173. Complementary and alternative medicine needs an evidence base before regulation Why train practitioners in therapies that do not work? Complementary and alternative medicine is practiced by sincere people, dedicated to helping patients. Yet cyn- Edzard Ernst both physicians and nonphysicians-by far more non- ics would probably point out that sincerity renders a Department of in Complementary doctors thanphysicians most countries. Physicians may quack only more dangerous to the public. A large pro- Medicine employacupuncture, hypnosis, biofeedback, or anyofthe portion ofthese practitioners subscribe to holisticworld- School ofPostgraduate other modalities ofcomplementary and alternative med- views and have relatively little regard for or knowledge Medicine and Health icine. Osteopathic doctors in the United States learn of science.3 Most earn only a modest income.4 Sciences 25 Victoria Park Road spinal manipulation in their training, although manylater Practitioners tend to work in small, often single-hand- Exeter FX2 4NT choose to make little use of it in routine practice.! ed practices, and their referral rates to physicians are United Kingdom Chiropractors are licensed in every state of the United low.5 They spend long periods oftime with patients and [email protected] States, acupuncturists licensed or certified in 32 states there is evidence (albeit inconclusive) to suggest that and the District of Columbia, massage therapists in they often develop better therapeutic relationships with Adriane Fugh-Berman 25 states, and naturopaths in 11 states. Homeopathy their patients than do physicians.6 In the United Department ofHealth Care Sciences is separately licensed only in Arizona, Nevada, and Kingdom, most practitioners of complementary and George Washington Connecticut, although other states may include home- alternative medicine say theywould like to practice more University School of opathy in the scope of practice of naturopaths, chiro- extensively within the regular health services7 but, due Medicine practors, or oriental medicine practitioners. Herbalism to their relativelylong consultation times andhence high 2150 Pennsylvania Avenue #2B417 is not separately licensed or certified, but it is consid- costs per patient, it is doubtful whether their services will Washington, DC ered within the scope of practice of naturopaths, prove to be affordable.8 Complementary and alterna- 20037 acupuncturists, or chiropractors in some states. There tive medicine might therefore continue to be mostly are no separate licensing or certification standards for private medicine. Correspondence to: other complementary and alternative medicine practices. Practitioners' training in complementary and alter- Dr. Fugh-Berman In the United Kingdom, complementary and alter- native medicine is highly variable. Most have benefited [email protected] native medicine (with the exception ofhomeopathy) is from some formal training,8 but many physicians still almost entirely in the hands of therapists without med- worry about their medical competence. The degree of ical qualifications. The number ofthese therapists is now competence required to guarantee patients' safety varies estimated to equal that ofprimary care physicians. Since for obvious reasons. It is necessarily high when thera- it was established in 1948, the British National Health pies associated with potentially serious adverse effects System has incorporated homeopathy; it still operates are being administered, such as spinal manipulation, five homeopathic
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