21st century ushers in integrative medicine: but many questions remain about how the health care system will react. (Integrative Medicine).

First recognized by the medical and scientific community during the 1990s, integrative medicine today is attracting interest from medical practitioners, administrators, academicians and scientists seeking to incorporate it into their research, practice and teaching.

Consider these developments:

* Health systems, insurers and state and federal governments are investing more deeply and broadly in integrative medicine.

* In recent years, it's estimated that there were more visits by the American public to alternative practitioners than to primary care physicians.

* Use of herbal remedies and dietary supplements is now supported by a $30 billion industry in the U.S.

* Until recently when only limited insurance or tax benefits became available, American consumers paid for most of the costs for these products and services out of pocket.

* It is also estimated that the out-of-pocket amount spent by consumers for alternative care exceeds the out-of-pocket co-payments and deductibles consumers make for health care covered by insurance.

An irony for physicians is that one last bastion of traditional fee-for-service medicine resides among alternative practitioners.

Names and labels

In trying to develop names for these alternative types of care, various labels were advanced such as nontraditional, unconventional, unorthodox, holistic and "wholistic--a revival from the 1960s.

In the midst of the call for greater scientific evidence and objectivity, these labels betrayed cultural values, prejudices and judgments about the validity and appropriateness of such types of care.

The more properly descriptive terminology of alternative and complementary medicine became generally accepted. Alternative came to imply a mutual exclusivity between these types of care and the regular practice of medicine. Complementary was more accurate in describing a compatibility between the utilization and acceptance of these treatments as an adjunct to--not a replacement for--regular medicine.

Institutions such as Thomas Jefferson University Hospital in Philadelphia pioneered use of the term (and the practice of) integrative medicine. Integrative medicine implies an active, conscious effort by the health professions and medical science to seek out and sort out the evidence and application of various complementary types of care for appropriate incorporation into the continuum of health care.

Types of care

Meditation, talk therapies, bioenergetic manipulation, massage, physical manipulation, insertion, ingestion, injection and surgery, are one array.

Alternative/complementary practices are then organized around the use of one or more of these techniques. For example:

* Chinese medicine uses bioenergy ("qi") manipulation (tui na, qi gong), insertion (acupuncture needles) and ingestion (herbs and foods) for medicinal purposes, approximating a more "complete" system of care.

* Chiropractic is traditionally limited to manipulative therapy.

Furthermore, individual practitioners within one system of care may incorporate use of other healing practices from outside that system of care such as the physician or chiropractor who incorporates acupuncture.

Finally, individual techniques practiced in a manner that is removed from the traditional system of care--what may be called "formulary approaches"--are increasingly proven to be effective.

For example, in the traditional practice of Chinese medicine, the client generally seeks the services of a seventh-generation Chinese practitioner who may also wish to incorporate herbs, manipulation and other remedies for the treatment of a medical condition.

Meanwhile, in the U.S., a licensed physician may attend a six-week course in acupuncture in California and become a licensed acupuncturist. Research shows that acupuncture provided by the physician on a "formulary" basis is effective.

Availability

The availability of complementary care is determined by:

* Existence, numbers and locations of practitioners trained (and licensed, where applicable) to provide these services

* Access to these practitioners through clinics, hospitals, academic medical centers, and health care systems and networks.

Individual practices exist and often thrive independent of the mainstream health care system. Given the dimensions of the movement, it is often striking how few "alternative" providers presently exist relative to the mainstream medical workforce.

Manual and manipulative therapies are relatively well represented with approximately 100,000 massage therapists and over 50,000 licensed chiropractors. There are approximately half that number of osteopaths, with perhaps fewer than one-quarter maintaining any practice in manipulative therapy.

Manipulative therapy is also relatively well regulated, with licensure for chiropractic in all 50 states and the District of Columbia and accreditation of graduate schools of chiropractic. Meanwhile, osteopathy has been fully subsumed under the credentialing processes of mainstream medicine.

By contrast, other fields of complementary medicine are sparsely represented:

* There are fewer than 10,000 licensed acupuncturists in the U.S., with licensure available in most states and D.C. About 3,000 are MD-acupuncturists.

* There are approximately 3,000 homeopaths; most are licensed physicians.

* There are about 3,000 naturopaths, with licensure available only in a dozen states, primarily in the northwestern U.S. and New England, and five accredited graduate schools, primarily in the Northwest and Southwest. Naturopaths represent the practice of an eclectic style of medicine and "western herbalism,' drawing from the herbal traditions of other cultures worldwide.

* Perhaps some hundreds of Ayurvedic practitioners exist--many following highly individual practices, with others ascribing to a tightly controlled Maharishi Ayurveda school of practice.

* In another tradition from India, there are thousands of yoga masters who offer somewhat attenuated training in a variety of yoga, primarily designed as a meditative practice intended to influence the physical body (Hatha-Yoga).

* Energy healers now come from several organized schools of energy healing nationwide, while the practice of energy healing is widely incorporated among members of the nursing profession in the U.S. through healing touch and therapeutic touch. A number of physical therapists also include cranio-sacral therapy.

Models of integration

To provide integrated care, the health care system requires licensed health care providers--or training for existing providers--in one or more types of complementary care.

Often the health care system can make capital investments in facilities required to provide integrative care that individual practitioners can't afford to make. Sometimes the success of an integrated care clinic is based upon attracting an individual practitioner's existing client base, with the practitioner gaining new referrals from the health care system.

When complementary medical services are added to existing services, they become a cost center rather than a cost-effective source of savings. In response to consumer demand, some managed care systems offer access to a network of complementary care providers who agree to accept negotiated rates. An innovative approach is available through the WellPower (www.wellpoweronlinecom) network of licensed "holistic" health providers that offers a non-insured rider to employers, unions, and associations for access to practitioners at negotiated rates.

Many academic medical centers initially adopted an "arms-length" relationship to alternative/complementary medicine in the 1990s with isolated efforts at research, teaching or practice. But today, some like Thomas Jefferson University Center for Integrative Medicine (www.JeffersonHospital.org/cim), are developing a model for true academic research and clinical integration.

Integrated care implies that various types of medical care are provided under the supervision of a physician. To the extent that such physician-supervised centers function as full-service primary care facilities, there is a concern that if primary care "gatekeepers" refer patients for complementary care, they may never come back.

For example, the American WholeHealth Network, based upon a successful model in Chicago to provide integrated medical services under physician supervision, was unable to receive adequate physician patient referrals and had to embark on costly direct-to-consumer marketing.

The late William Fair, a leader in integrated care, developed one response to the referral problem. He proposed that a facility for complementary care should not be supervised by a physician. This concept, initially developed as Synergy Health, was first tested in New York City under the name Haelth.

Cost-effectiveness

Thanks to an alternative/complementary medicine research program at the National Institutes of Health, a database is being developed that provides abundant and credible data on the effectiveness of alternative healing.

Utilization research of alternative/complementary care is required to better understand:

* Patient motivation and satisfaction

* Willingness to pay for care

* Preference of one type of care over another

* Willingness to substitute care

* Multidisciplinary guidelines for best practices in disease management

The Agency for Health Care Quality, working with a limited budget, is providing important analyses on effectiveness and cost-effectiveness of various treatments for low back pain including pharmaceuticals, surgery, spinal manual therapy, acupuncture, massage, and other therapies If improved effectiveness and cost savings are to be realized by consumers, the health system and third-party payers, it is incumbent upon integrative medicine to determine what kinds of therapeutic options can be provided to which patients for cost-effective disease management.

Integrative medicine products

Appropriate use of nutrients and herbs is a critical component of many integrative medical practices.

Presently in the U.S., these natural products are widely available, classified and regulated as dietary supplements. As such, they are regulated by the Food and Drug Administration for identity, purity and safety, but not for efficacy.

However, unlike pharmaceuticals, information about the health effects cannot be provided on the product label or with the product. Due to the increasing availability of credible, third-party research on the efficacy of herbal and nutritional ingredients, it is important for practitioners of integrative medicine to maintain a medical standard of information and practice about herbal and nutritional ingredients.

The importance of dietary supplementation for optimal health and for the prevention and management of many medical conditions is also recognized by the medical profession. (1) Part of this requirement is to develop and maintain an appropriate clinic- or hospital-based formulary of high quality sources of herbs and nutrients.

Adding to this quixotic regulatory environment are problems such as:

* The natural products industry does not adhere to medical and scientific standards.

* Many irresponsible marketing claims are made about natural products.

* Medical and scientific professionals are not knowledgeable about the science behind herbal and nutritional medicine.

This volatile mix produces much confusion and misinformation on both sides. Medical professionals are presently on their own trying to understand the proper indications, ingredients and dosages for the appropriate scientific use of herbal and nutritional remedies. And consumers can only look to practitioners for guidance.

The Fair and Accurate Information Reporting Alliance for Integrative Medicine is a new service in Provo, Utah (www.fairalliance.com), designed to help remedy this shortfall by providing interactive CD-ROM technology and Internet links regarding dietary supplement claims, counter-claims and current research.

Medical education

Clearly, there is a need for improved education about integrative medicine at medical schools, and through post-graduate studies and continuing medical education programs. CME programs face the challenge that current practitioners have generally had no exposure in medical school or in post-graduate medical training.

According to surveys conducted by the Center for Research in Medical Education at Thomas Jefferson University, the majority of today's medical students in all graduation years and among all classes want more education in integrative medicine. The proportion is increasing with each graduating year.

Among classes in medical school, the proportion is relatively high in the first year (when entering students carry the culture of the general population), declines somewhat in the second and third years (as students become more professional and generally witness little reinforcement for the teaching of integrative medicine), and rises again in the fourth year (after students have been exposed to the problems and questions of patients).

There is a need for both "basic science," and clinical texts and journals in integrative medicine. Elsevier has developed many tides in complementary medicine, including a series on Medical Guides to Complementary & Alternative Medicine. (2)

Much curriculum development and faculty training remains to be done in this area and the traditional support of state and federal governments for medical education could be well utilized to help provide medical schools with the needed resources.

In the interim, health care providers can help stimulate appropriate CME and in-service training so that practitioners can be knowledgeable and helpful to their patients seeking guidance on the use of integrative medicine.

Public policy

Policy makers at the state and federal levels should also become more knowledgeable about integrative medicine.

The bipartisan Congressional Caucus on Complementary & Alternative Medicine and Dietary Supplements was organized for this purpose and is co-chaired in the Senate by Sens. Tom Harkin (D-Iowa) and Orrin Hatch (R-Utah) and in the House of Representatives by Rep. Dan Burton (R-Indiana).

The Policy Institute for Integrative Medicine and others are working with members of the caucus and other elected representatives to broaden and deepen federal support for appropriate analyses and programs in integrative medicine. However, it is unlikely that the current regulatory legislation governing dietary supplements will be changed. (3)

While funding for the National Center for Complementary and Alternative Medicine increases each year commensurate with the multiyear doubling of the overall NIH budget, it is critical that other federal agencies charged with programs relative to health resources and services, primary care, health professions training and workforce development, consumer education, health services research and other areas be brought to bear on the important challenge and opportunity of integrative medicine.

Public support, together with private innovation, has been the hallmark for medical advancement in the 20th century and should continue to be the case for integrative medicine in the 21st.

References

(1.) Fairfield and others, Journal of the American Medical Association, July 2002.

(2.) Elsevier, www.elsevierhealth.com.

(3.) Dietary Supplement Health and Education Act of 1994, as amended 1998.

Marc S. Micozzi, MD, PhD is director of the Policy Institute for Integrative Medicine at Thomas Jefferson University Hospital in Philadelphia, Pa. He can be reached by phone at [phone] or by e-mail at [e-mail]