Summary: What role will complementary, alternative and integrative practices and practitioners have in primary care of the future? Greg Garcia, ND, LAc here responds to the Integrator call for input to Primary Care 2025, a Kresge-funded project led by futurist Clem Bezold, PhD. Garcia reviews some trend-lines in the recent past before describing ethical and evidence issues that will shape what he believes is a preferred, more integrated future. Garcia is a principal with Natural Medicine Consultants who was for over a decade a member of the faculty at Portland, Oregon-based National College of Natural Medicine.

Primary Care 2025

On April 24, 2011, the Integrator posted an alert on an opportunity to respond to an Institute for Alternative Futures (IAF)-funded project on the future of primary care. The project, Primary Care 2025, led by IAF's Clem Bezold, PhD, is funded through a grant from the Kresge Foundation. Bezold shared with interested parties a set of perspectives developed via an IAF focus group with members of the New York Academy of Medicine. These included this view:

15.  Integrative encounters in primary care - Integrative encounters address all dimensions of health by bringing the knowledge of conventional, unconventional, complementary, alternative, traditional and integrative medicine disciplines to bear across the many different cultural traditions of persons cared for. 

The Future of Primary Care:
A Response to the New York Academy of Medicine Focus Group
on the Question of CAM in the Future

Greg Garcia, MD
Natural Medicine Consultants, LLC

"Most of the feedback to the CAM question I am getting in the focused groups from conventional primary care folks is that they will include use of the modalities as they are proven effective/cost effective. Any forecasts on the evidence on behalf of CAM modalities and/or CAM licensed providers would be welcome."

-- Clem Bezold, PhD, Integrator Blog, April 25, 2011

Greg Garcia, ND, lAc

Complementary and alternative medicine (CAM) appeared to break through several barriers when the New England Journal of Medicine published the study by Eisenberg et al in 1993 on the prevalence of unconventional medicine used by patients who subsequently were not communicating about these behaviors with their primary care (mainstream) doctors. Information regarding the sheer number of patient visits to unconventional practitioners, the amount of out-of-pocket money spent on CAM, and the apparent communication barriers between patients and doctors created an undeniable jolt to the status quo in mainstream medicine.

Funding and research into various CAM techniques and practices became possible through the National Institute of Health. Numerous mainstream medical institutions developed centers of CAM research so that 10 years later it was not uncommon to find continuing education offered at some of the most prestigious medical institutions on subject matters ranging from natural medicine and psychiatry to mind-body medicine. Communication and interpersonal skills in medical education became required subject areas for assessing competency.

"A barrier that has yet to be overcome is revealed in the posted comments on behalf of the Institute for Alternative Futures that question the effectiveness or cost effectiveness of CAM."

A barrier that has yet to be overcome, however, is revealed in the posted comments on behalf of the Institute for Alternative Futures that question the effectiveness or cost effectiveness of CAM. Raising concerns about the effectiveness or other parameters of CAM is certainly not new or surprising. Concerns in the past emphasized safety issues or speculated on ethical problems if CAM modalities with unknown mechanisms of action or effectiveness were incorporated into treatment plans.

What's seems apparent with all of these mentioned concerns about CAM is an underlying assumption that mainstream medicine is in a superior position by virtue of its having a more science-based foundation. Furthermore, if the mainstream medicine is scientific assumption is a priori accepted, then the implication to the public of its safety, effectiveness, and economic worthiness seems to go without question.

The goal of a science-based foundation for medicine is as old as the AMA itself. As recently as 1980, the American Medical Association (AMA) code of ethics included the principle that "A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily associate professionally with anyone who violates this principle."^[i]The emphasis on the scientific basis of conventional medicine was described in 2002 as a reflection of the AMA's "lasting concerns to eradicate quackery and other non-allopathic forms of medicine".^[ii]

	"The emphasis on the scientific basis of conventional medicine was described in 2002 as a reflection of the AMA's "lasting concerns to eradicate quackery and other non-allopathic forms of medicine".

The AMA's current version of this principle, titled Opinion 3.01, continues their organizational emphasis on the scientific basis of medicine. Opinion 3.01 declares "it is unethical to engage in or aid and abet in treatment which has no scientific basis and is dangerous, is calculated to deceive the patient by giving false hope, or which may cause the patient to delay in seeking proper care".^[iii] According to the AMA, the present language sets "ethical parameters on the practice of complementary and alternative medicine".^[iv]

While the prohibition against associating with non-scientific practitioners (widely viewed at the time as a prohibition against associating with chiropractors) was eventually found to be a violation of the Sherman Antitrust Act in 1987, the more profound probing of the ethical and scientific qualities contrasting mainstream medicine and CAM occurred this past decade.

A probable historic turning point between mainstream medicine and CAM was the rising advocacy for pluralism within the medical ethics community that occurred this past decade. Pluralism allowed for accommodation (Kaptchuk and Miller, 2005, and Tilburt and Miller, 2007) by supporting the ethical principle of patient autonomy and freedom of choice in medical options, without compromising the importance or value of scientific evidence for mainstream medicine.^[v],[vi] Though pluralism may seem a near fait accompli in bioethics, the debate over the credibility of CAM as seen through the prism of scientific evidence and cost-effectiveness has been on-going and vociferous.

[Of note: The final appeal to the Supreme Court by the AMA regarding the 1987 court decision against their organization was denied in November, 1990. The national telephone survey conducted by Eisenberg et al as the basis for their 1993 article previously cited was undertaken in the last 3 months of 1990. Interestingly, the genesis of the term ‘evidence based medicine' appeared initially at McMaster University about a year later (1991 or 1992). The now ubiquitous phrase ‘evidence based medicine' is a common standard for justifying efficacy and is widely adopted as a requirement in health related policies and for funding purposes by state and federal agencies.]

"Upon examining components of practice and scientific knowledge, the ethical precept to do no harm, and the need to not waste money, Morreim concludes that holding both sides accountable to these standards may well be more deleterious to mainstream medicine."

Perhaps one of the more astute commentaries on the role of science in medicine (Morreim 2003) held the same standards of scientific evidence and cost-effectiveness to mainstream medicine as critics wish to apply to CAM. Upon examining various components of clinic practice and scientific knowledge, the ethical precept to do no harm, and the need to not waste money, Morreim concludes the outcome of holding both sides accountable to these standards may well be more deleterious to mainstream medicine. With regard to cost-effectiveness, for instance, Morreim cites examples such as arthroscopic debridement and lavage for osteoarthritis of the knee, coronary angiography, and internal mammary artery ligation, where costs were both substantial (totaling over $10 billion annually for the first 2 procedures alone) and the evidence supporting the techniques scientifically questionable.^[vii] Another example Morreim cited, coronary bypass surgery, only has "4 to 13% of patients who now undergo this operation would meet the eligibility criteria for the randomized controlled trials that established its efficacy...and [it's] used significantly more in the United States than in Canada and Europe, with no conclusive justification in terms of patients' illness or infirmity".^[viii]

Others critiqued the use of randomized clinical trials (RCTs) as the gold standard of evidence in mainstream medicine, particularly as they are applied to CAM. Barry (2005) utilized an anthropological perspective on the development (and the rhetoric) of ‘evidence' in medicine. Highlighted in her research are some of the difficulties encountered when measurement standards used in RCTs are applied to CAM practices that result in the removal of context, setting, and other elements inherent in many patient's (and CAM practitioner's) perspectives of what works and is beneficial.^[ix]

The dichotomy between these different ways of knowing leads Keshet to conclude that the boundaries established by biomedical scientists as a method of "distinguishing their field and its practitioners from less authoritative, non-science practitioners" are untenable."

A final commentary with regard to the role of science in CAM and mainstream medicine borrowed techniques from Sociology of Knowledge to explore how both sides attempt to preserve or gain legitimacy. Keshet (2009) initially collected 600 English language international abstracts of and responses to articles published over a 3 year period (ending in 2001) that dealt with the efficacy of CAM in general or with specific CAM techniques such as homeopathy, acupuncture, or spinal manipulation. After narrowing down the number of articles to those specifically addressing how to appropriately evaluate the effects of CAM, Keshet makes some interesting observations about the complexity and diversity of knowledge in mainstream medicine and CAM and with how proponents for each side use that knowledge. The dichotomy between these different ways of knowing leads Keshet to conclude that the boundaries established by biomedical scientists as a method of "distinguishing their field and its practitioners from less authoritative, non-science practitioners" are untenable.^[x]

Even as the role of science in mainstream medicine becomes less opaque than once casually assumed, the concern for patient safety remains a given across all primary care professions. In one of the few legal articles addressing CAM practitioners and patient safety, Doyle (2001) states a finding of malpractice will likely depend on the seriousness of injury as well as misdiagnosis or other cause for delay in [seeking] conventional treatment.^[xi] It's generally been well accepted for licensed professionals to be judged by members of their own profession (unlike someone without a license who would probably be compared to the standard of a medical doctor). Doyle, however, writes of a case, Rosenberg v. Cahill, adjudicated in 1985, where the court allowed a medical doctor to "testify as to the standard of care expected of chiropractors".^[xii]

According to Doyle, the court allowed the medical doctor's testimony because of an overlap of expertise in certain conditions or circumstances. Specifically, the court "found an ‘overlap' of expertise in the professionals" use "of x-rays and diagnosis of certain conditions (emphasis added)."^[xiii] Doyle states "in terms of overlap, the alternative provider is usually held to the heightened standard of care - the standard of the reasonable, competent physician".^[xiv]

	"With the growing need for more primary care physicians in this country already well established, the role of licensed naturopathic physicians and other primary care CAM providers should be expanded rather than restricted or disallowed."

Although the above ethical, philosophical, epistemic, and legal citations are by no means definitive, together they suggest trends that can help shape and optimize the preferred future of licensed CAM providers in the United States. With the growing need for more primary care physicians in this country already well established, the role of licensed naturopathic physicians and other primary care CAM providers should be expanded rather than restricted or disallowed.

Already in Oregon and Arizona, the legend formulary available to naturopathic physicians significantly parallels that of mainstream primary care medical providers. The ‘overlap' and gradual merging of certain portions of clinical practice, already seen in physical examination, laboratory diagnosis, clinical diagnosis, and now the adding of prescriptive rights, will eventually require licensing boards and future policy makers to consider new ideas and methods for addressing public safety.

Perhaps the question of safety is best considered from the patient perspective. Should it make a difference which primary care profession prescribes the legend medication or provides a CAM technique as part of their treatment plan? In other words, can the patient expect the same quality of consideration, understanding, and training whether or not a particular treatment involves an antibiotic or a botanical formula? If not, what steps can be taken now and in the future to strengthen the clinical encounter for patients regardless of their primary care doctor's professional background?

As Eisenberg et al and many others since have demonstrated, patients would like both mainstream medicine and CAM practices available. What has changed since then is the increasing number of CAM practitioners that are or have become primary care, including some with prescriptive rights such as naturopathic physicians. The overlapping of clinical skills and scope of practice between separate professions underscores the need to integrate or combine training opportunities across professions. How else to strengthen the growing complexity of clinical skills and judgment necessary to navigate this shared terrain amongst primary care professions?

"With the advent of ‘overlapping' scopes of practice, the development of common educational experiences and policy guidelines regardless of professional licensure seem necessary."

Purists may rebel against the perceived ethical or philosophical threats to the status quo. The burden imposed by the patient's right to choose, however, has to be shared within our entire health care system and amongst all primary care providers. The principle of patient autonomy, which bestows upon the patient the right to choose their medical options and treatment, should not inadvertently force the patient to bear the burden alone should their primary care doctor's background or disparate professional training opportunities negatively impact the quality of their treatment. While all professions require their members to have a strong sense of their own competencies, the systemic lack of opportunity for all professions to gain access to and learn their given scope of practice cannot be resolved by individual practitioners.

The best and most appropriate response to support the principle of patient autonomy is the obligation we incur as providers to ensure patient safety. With the advent of ‘overlapping' scopes of practice, the development of common educational experiences and policy guidelines regardless of professional licensure seem necessary.

	"If CAM and mainstream medicine keep the perspective and needs of the patient in the forefront, and follow through on developing greater accommodation for all primary care professions, together they will create the primary care experience patients have shown they would like to have."

Medicare will likely have to add more CAM professions and techniques beyond the current chiropractic coverage offered since 1974, improving access for seniors to all primary care options. In addition, the funding of mainstream medical residencies through Medicare and other federal funds will likely have to expand as well to include other primary care professions lest it be found discriminatory.  Expansion of the types of residency funded to include all primary care professions may provide a method and means for integrating training opportunities in the future.

The philosopher Martha Nussbaum once provided a definition of ethics during an interview given on the radio. She stated, "Ethics is about what matters, and how one should behave."^[xv] If CAM and mainstream medicine keep the perspective and needs of the patient in the forefront, and follow through on developing greater accommodation for all primary care professions, together they will create the primary care experience patients have shown they would like to have.

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^[i] Principles of Medical Ethics, Judicial Council, American Medical Association, June 7, 1958. www.ama-assn.org/ama/upload/mm/369/1957_principles.pdf  Site accessed September 17, 2009.
^[ii] Riddick FA, Morin K. Highlights of the Code of Medical Ethics of the American Medical Association. Metro Doctors 2002;Jan-Feb:20-21. [*Riddick was Chair, Council on Ethical and Judicial Affairs - AMA when he authored this article]
^[iii] Ibid.
^[iv] Ibid.
^[v] Kaptchuk TJ, Miller FG. What is the Best and Most Ethical Model for the Relationship Between Mainstream and Alternative Medicine: Opposition, Integration, or Pluralism? Academic Medicine 2005; Vol 80:pp286-290.
^[vi] Tilburt JC, Miller FG. A Principled Ethical Approach. Journal of the American Board of Family Medicine 2007; Vol 20(5):489-494.
^[vii] Morreim EH. A Dose of Our Own Medicine: Alternative Medicine, Conventional Medicine, and the Standards of Science. Journal of Law, Medicine & Ethics 2003; Vol 31:222-235.
^[viii] Ibid.
^[ix] Barry CA. The Role of Evidence in Alternative Medicine: Contrasting Biomedical and Anthropological Approaches. Social Science & Medicine 2006; Vol 62:2649-2657.
^[x] Keshet Y.The Untenable Boundaries of Biomedical Knowledge: Epistemologies and Rhetoric Strategies in the Debate Over Evaluating Complementary and Alternative Medicine. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine
2009. Vol 13(2):131-155.
^[xi] Doyle A, Alternative Medicine and Medical Malpractice Emerging Issues. The Journal of Legal Medicine 2001; 22:533-552.
^[xii] Ibid.
^[xiii] Ibid.
^[xiv] Ibid.
^[xv] Backlar P. (2006). Making Medical Decisions for the Profoundly Mentally Disabled [Review of the book Making Medical Decisions for the Profoundly Mentally Disabled, by Normal L. Cantor]. New England Journal of Medicine, 354;20: 2199-2200.