Essentials of Complementary and Alternative Medicine (June 1999)

ALLOPATHIC MEDICINE'S CRITICISM OF ALTERNATIVE MEDICINE
The first generation of allopathic doctors hardly turned the other cheek to such criticism. They gave as good as they got, putting forward a range of objections to 
alternative medicine. In the orthodox analysis, alternative practitioners were not simply ignoramuses and incompetents; they were zealots, medical cultists obsessed 
with a single theoretical and therapeutic tenet, blind and deaf to the merits of any conflicting belief or practice, and determined to bend every case to their 
fundamentalist faith. The alternative doctor, a Baltimore medico declared, “circumscribes himself and practises a ...  one-idea system only, and is so tied down and 
limited to that ... that he denies the usefulness of all known and honorable means of aiding the sick.” Regular doctors resented the label  allopathy because it was 
implied their medicine was just another -pathy, merely one more sect instead of open-minded science. “The title ‘Allopathy',” it was objected, was an “insignificant 
misno-mer ... applied to us opprobriously ... with sinister motives .... [I]t is both untrue and offensive.” Hence, “when people ask you ‘what school you practise,' you 
may very properly answer that you are simply a PHYSICIAN, that you belong to no sect,” that you, “like the bee, take the honey of truth wherever you find it” (
33
).
Insinuation and derision were a game two could play. Homeopathy, Oliver Wendell Holmes declared, was “a mingled mass of perverse ingenuity, of tinsel erudition, of 
imbecile credulity” (
34
). Another doctor characterized it as “a confused mass of rubbish” (
35
). Other unorthodox schools of practice were accorded comparable 
respect. For example, osteopathy was denounced by an end-of-the-century physician as “a complete system of charlatanism ... and quackery, calculated and 
designed to impose upon the credulous, superstitious, and ignorant” (
36
). Soon after, the editor of JAMA described naturopathy as “a medical cesspool” (
37
). 
Irregulars might protest all they wanted that their methods had empirical foundations, and therefore were scientific. However, allopaths believed that enslavement to 
simplistic “one-idea systems” resulted in biased interpretations of clinical experience. Hence, “this subterfuge cannot avail. Call himself by what name he will, a quack 
is still a quack—and even if the prince of darkness should assume the garb of heavenly innocence, the cloven hoof would still betray the real personage”(
38
).
Cloven-hooved or not, alternative practitioners did see most of their patients return to health. But those successes, mainstream physicians argued, could be 
accounted for entirely by the operations of nature. By the mid-1800s, allopathic philosophy acknowledged that most diseases are self-limited, and will resolve 
themselves under anyone's care. However, that explanation was much more frequently applied to alternative patients than to mainstream ones. Homeopathy in 
particular, with its immaterial doses of drugs, seemed to be explainable in no other way than as “placeboism etherealized” (
39
). Homeopaths, one physician laughed, 
would be just as successful “were the similars left out, and atoms of taffy or sawdust ... substituted, to give their patients room to exercise their faith, and  nature time 
and opportunity to do the work” (
40
).
MEDICAL LICENSING
The mutual hostility between allopathic and alternative practitioners was played out at both the political and the philosophical level. The context for the Thomsonian 
cartoon was that movement's assault on the state medical licensing laws that had been enacted throughout the country in the early 1800s. Although the laws were 
only casually enforced, they did confer the blessing of government on allopathic medicine. Alternative healers regarded this legislation as undemocratic violations of 
both their right to pursue the calling of their choice and the public's right to select whom they wanted as their doctors; they also regarded this legislation as 
transparent attempts by allopaths to corner the medical market. Denouncing the laws as elitist and monopolistic, alternative practitioners (Thomsonians, particularly) 
succeeded in getting virtually every state licensing law wiped from the statute books by mid-century. Licensing provisions for allopaths would be revived, however, in 
the 1880s and 1890s, as the impact of the germ theory renewed public respect for the power of allopathic medicine. Alternative physicians would then campaign for 
the passage of separate licensing laws to govern their systems too, and although they were generally successful in their quest, licensing was obtained only very 
gradually, and painfully, through vicious political struggles waged state by state (
41
). The first osteopathic licensing law, for example, was adopted in Vermont in 
1895; by 1901, 14 other states had followed suit. Chiropractic, by contrast, did not win its first licensure battle until 1913 (Kansas), but then another 31 states passed 
chiropractic laws within a decade. Not until 1973, however, were osteopaths fully licensed in every state, and it was the following year before the same could be said 
of chiropractors. Naturopathic licensing has developed more slowly; presently only 12 states issue ND licenses (
42
, 
43
).
Until winning legislation in their individual states, alternative medicine practitioners were subject to fine or imprisonment for practicing medicine without a license. Not 
even the leaders of the major systems were exempt: Benedict Lust was arrested in 1899, and D. D. Palmer was jailed seven years later (
44
, 
45
). In the early part of 
this century, there was also a good bit of courtroom conflict between osteopaths and chiropractors, the former often succeeding in getting the latter prosecuted for 
practicing osteopathy without a license (
46
). Battles over the adoption or expansion of alternative medical licensing privileges continues to enliven the deliberations of 
state legislatures. Meanwhile, practitioners of therapeutic approaches that have not managed to achieve licensure status deplore (much like the alternative physicians 
of the 1830s did) the infringements on “medical freedom” practiced by the “medical/pharmaceutical complex” (
47
).
THE ISSUE OF CONSULTATION
State legislatures were one battleground, and the sickroom and hospital ward were another. War was declared in that arena in 1847, with the founding of the 
American Medical Association and the Association's adoption of a code of ethics. Although most of the code was taken verbatim from a noted English publication of 
half a century earlier, an innovation was introduced in response to the emergence of alternative medicine during the interim. This consultation clause began by urging 
physicians to call in qualified colleagues when perplexed by a case. But it ended with the stricture that anyone “whose practice is based upon an exclusive 
dogma”—i.e., who is a sectarian, an irregular—could not be accepted as “a fit associate in consultation” (
48
). In other words, it would be unethical, a threat to the 
patient's health and not just the doctor's sense of decorum, for an allopathic physician to consult or agree to be consulted by a homeopath or other alternative 
“dogmatist.” Thus, in one doctor's interpretation, one might ethically consult “with foreign physicians, doctresses [women physicians],” even “colored physicians ... 
provided they are regular practitioners.” But if the would-be consultant were a dogmatist, even a native-born white male one, “justly exclude him as unsuitable for 
fellowship with those who profess to love all truth.” It would be as suitable for “a Jewish rabbi ... to exchange pulpits with Christian ministers” as for allopathic doctors 
to consult with alternative ones (
49
). For the rest of the nineteenth century, the consultation clause would be used to oppose the admission of alternative practitioners 
to local and state medical societies, the staffs of public hospitals and the military medical corps, and the faculties of publicly funded medical schools. The original 
clause was dropped from the AMA code when it was revised in 1903, but the principles adopted in its stead maintained the understanding that ethical practitioners 
would not voluntarily associate with alternative healers; only in 1980 would the Association revise its ethical principles so as to remove all restrictions on consultation 
(
50
, 
51
 and 
52
).
Official disdain for alternative medicine would only be intensified by the grand reformation of medical education that began in the later years of the nineteenth century, 
and culminated with the celebrated Flexner Report of 1910. That survey—rather exposé—of the miserable educational standards that prevailed at nearly all of 
America's medical schools was an acute embarrassment to the allopathic profession. But it catalyzed an educational housecleaning that drove many institutions out of 

business and forced the surviving ones to impose far more rigorous programs of training.
Flexner's report did not have so immediate an impact on alternative schools and practitioners. He did include homeopathic and osteopathic colleges in his survey, and 
had as scathing words for them as for any allopathic schools. The eight osteopathic educational facilities, for example, were condemned as “hopelessly meager,” 
“utterly wretched,” “intolerably foul” (
53
). Even Still's own college, osteopathy's flagship, was dismissed as “absurdly inadequate” (
53
). This ridicule solidified 
mainstream practitioners' conviction of the unscientific (and therefore unworthy) nature of alternative medicine, but it did not result in the wholesale closing of 
alternative medical schools. To be sure, the number of homeopathic colleges dropped precipitously, from a high of 22 in 1900 to only 2 by 1923; however, 
homeopathy was already weakened by internal dissension (
54
). Osteopathy, by contrast, lost only one school in the twenty years following the Flexner Report, and 
the number of chiropractic schools actually grew prolifically (
55
, 
56
). Thus, as late as the mid-1920s, a Philadelphia physician could determine that alternative 
medicine was still flourishing, at least in his region: one third of his patients admitted they had also put themselves under the care of an alternative practitioner of 
some sort within the three months preceding their visit to him (
57
). Eisenberg's 1993 survey found also that one third of Americans rely on unconventional therapies 
(
58
). Public respect for alternative healers was already being undermined, however, by the compelling image of  scientific medicine, the term insisted upon by 
allopathic doctors to distinguish the new medicine derived from the germ theory and the Flexnerian reformation of education.
The scientist-physician in shining lab coat armor confidently predicted endless triumphs over disease with the weapons of modern medical research; to the dazzled 
public, alternative systems appeared static and impotent by comparison. Alternative medicine fell lower in the popular estimation when sulfa drugs appeared in the 
1930s; then the introduction of antibiotics the following decade made good on the promises of scientific medicine and made healing alternatives seem less necessary. 
As early as the 1930s, a survey of America's “healing cults” concluded that “homeopathy is past and gone,” and that chiropractic was approaching its twilight, both 
because they could not compete with scientific medicine (
59
).
Characterization of alternative medicine as cultism continued into the second half of the twentieth century. Osteopathy was identified as “a cult practice of medicine” 
by the AMA until 1961, and “professional associations [with] doctors of osteopathy” were proscribed as “unethical” until that same year (
60
). For that reason, 
osteopaths were prevented from serving as medical officers during World War II; and although Congress authorized the appointment of osteopaths to military 
hospitals in 1956, it was to be a full decade before the first DO would actually be offered a position (
61
, 
62
). Similarly, the AMA long held it unethical to refer patients 
to chiropractors, and staunchly opposed the extension of hospital privileges to DCs. As late as 1966, the Association's House of Delegates adopted a resolution 
designating chiropractic “an unscientific cult.” Chiropractors fought back, in 1976 filing an antitrust suit against the AMA, the American Hospital Association, and 
several other medical organizations. A verdict would not be rendered until 1987, but it went against the defendants, the judge finding the AMA guilty of a “conspiracy 
against chiropractors ... intended to contain and eliminate the entire profession of chiropractic.” The AMA appealed, but the decision was upheld (
63
, 
64
).
Osteopathic physicians were included in the Medicare reimbursement system when that act was passed in 1965, but chiropractors and naturopaths were denied 
participation. Chiropractic and naturopathic professional associations both appealed to Congress for reconsideration, but each was turned down in identical language: 
their “theory and practice are not based upon the body of basic knowledge related to health, disease, and health care which has been widely accepted by the 
scientific community” (
65
). Likewise, their programs of education “do not prepare the practitioner to make an adequate diagnosis and provide appropriate treatment” 
(
65
). Continuing pressure from the chiropractic community succeeded in winning inclusion of their practitioners under Medicare in 1974, but naturopaths remain 
outside as of this writing (
66
).
ELEVATION OF ALTERNATIVE MEDICINE'S STANDARDS
Much of this chapter has been given to discussion of the first century of unconventional medicine precisely because attitudes set during that period continue to shape 
interprofessional relations as the second century of alternative medicine draws to a close. But concomitant with this historical constancy, there have been profound 
changes over the course of the twentieth century, too. In 1900, alternative systems of practice were still bound to crude and speculative theoretical rationales; they 
still claimed panacea-like potency for their therapies; they operated schools with minimal requirements that admitted students of dubious qualifications; they were 
tainted, some more than others, with hucksterism (chiropractic schools, a 1930s survey observed, “fairly reek of commercialism”) (
67
); and they unrealistically aimed 
to overthrow rather than complement allopathic medicine. By midcentury, however, a vigorous bootstrapping effort was underway, which had already raised the level 
of education and ethics in all systems of practice. Theoretical foundations were being strengthened and therapeutic claims modified. Conventional medicine was 
being acknowledged as highly effective in its sphere, and alternative practitioners' longstanding competitive attitude toward allopathic physicians was giving way to a 
goal of cooperation.
For their part, mainstream physicians steadily assumed a more flexible stance too, first, as has been noted, toward osteopathic medicine. During the 1950s and early 
1960s, the AMA gradually recognized that the quality of osteopathic academic training was comparable to that of allopathic. Then, in the mid-1960s, osteopaths were 
admitted into orthodox residency programs, even to membership in the American Medical Association. During that same decade, DOs in California and Washington 
were actually encouraged by those states' medical societies to convert their degrees to MD and join the allopathic ranks. The medical establishment's sudden 
willingness to merge with osteopathy was, of course, assailed by some as an attempt to suppress competition by assimilating it. Ever since, alternative medical 
systems have been riven with angst that the culmination of their struggle for professional respectability might turn out to be absorption into the mainstream and loss of 
their identity and independence (
68
, 
69
 and 
70
).
Therefore, although the trend of professional improvement in alternative medicine has taken an even sharper upward turn since the middle of this century, a gulf of 
distrust and misunderstanding remains between the sides. The aura of sectarianism cast by alternative systems for so long lingers in the memory of many mainstream 
practitioners, distorting their view of complementary medicine and inhibiting them from appreciating the remarkable transformation that has occurred. This blaming of 
complementary healers for the sins of their fathers, moreover, is as ironic as it is unjust, since allopaths' fathers committed all the same sins. Prior to this century, 
orthodox medicine was littered with naive theories, ineffective (sometimes dangerous) therapies, and inferior educational institutions. Whatever skeletons there are 
hidden in alternative medicine's closet are to be found in the allopathic closet as well, and one might reasonably think of the professional evolution of the major 
systems of complementary medicine as a repetition of the pattern of development of the allopathic profession, with a time lag of half a century or so. For the analogy 
to be fully accurate, however, more extensive and concrete evidence of the efficacy of complementary therapies is required. It was for the purpose of filling that need 
that the National Institute of Health's Office of Alternative Medicine was established in 1992.
THE REVIVAL OF ALTERNATIVE MEDICINE
In recent decades, the improvement of professional standards within alternative medicine has been paralleled by increased public interest and patronage. This 
improvement constitutes a striking turnaround from the decline experienced by most alternative systems during the middle years of this century. Although as recently 
as 1969 a federal study concluded “the number of naturopaths ... is rapidly declining” (
71
), unconventional practice experienced an extraordinary revitalization in the 
1970s. Not only did naturopathy, chiropractic, and other nineteenth-century systems regain popularity, but various newer programs of healing appeared on the scene 
as well. When the journal  Alternative Therapies in Health and Medicine began publication in 1995, its editor was able to identify 39 distinct categories of alternative 
practice as topics acceptable for articles, everything from anthroposophy to vitamin treatments (
72
).
This alternative medicine revival was due in significant measure to rising public disaffection with mainstream medical practice. The reasons for dissatisfaction are a 
familiar litany: patient alienation from the impersonal and intimidating style of specialized, technological, hospital-based medicine; the dramatic increase during the 
twentieth century of chronic degenerative diseases, ailments that confound cure but demand caring and cooperative management; awareness of the too-frequent 
iatrogenic effects of prescription pharmaceuticals; the rise of consumerism and concern for patients' rights and autonomy (much like the 1830s' demands of 
Thomsonians for medical freedom); and the rising costs of medical care. However, it should be appreciated that those dissatisfactions had been building for a long 
time. The 1924 survey of Philadelphia patients cited earlier determined that the chief reasons they had sought alternative help were their beliefs that allopaths did not 
give thorough physical examinations and were “too busy to devote the time and attention that the obscurity of the symptoms ... demanded,” and that “the medicine 
ordered made the patient feel worse than before taking it” (
73
). An Illinois contemporary commented on a similar survey of public discontent with physicians that, “We 
have rendered wonderful service in the serious ailments. We have not looked properly after the little things,” recognizing that such chronic “little things” were not little 
matters for patients (
74
). That same year, 1923, an Indiana physician summed the situation up with the observation that, “irregular healers ... would not exist if they 
did not fill a kind of need .... This indicates that the people of this country are demanding of the medical profession something more than shaking up test tubes and 
looking through microscopes” (
75
).
To the allopathic profession's credit, that “something more” has been recognized and energetically pursued by physicians in recent years. The 1970s, in particular, 
were the pivotal decade for a liberalization of mainstream attitudes toward illness and treatment. Family medicine as an area of specialization came into its own in the 
seventies, dedicated to restoring a more personal and empathic touch to physician-patient interactions. By that time also, the understanding of psychosomatic 

medicine was undergoing a transformation that would foster a stronger belief in the power of mind to influence body function. The notion that mind and body are fully 
integrated, and that emotional states affect health, had been part of medical thinking from the time of Hippocrates, and since the 1930s there had in fact been a 
distinct area of investigation identified as psychosomatic medicine. However, in its initial phase of evolution, psychosomatic medicine had been preoccupied with 
relating specific physical ailments (e.g., hypertension) to emotional stress. During the 1960s and 1970s, a more complex interpretation emerged, one that identified 
psychological forces as one element in the multifactorial etiology of all illnesses. The mind was now being viewed as an ever-present participant in physical 
functioning (
76
, 
77
). By the end of the 1970s, both the biopsychosocial model of disease and the discipline of psychoneuroimmunology had been developed within 
allopathic medicine; the former incorporated social pressures into the psychosomatic analysis and the latter clarified neural, endocrine, and immunological pathways 
by which mind could influence health. During the same period, the introduction of biofeedback practices demonstrated the power of the mind to affect the body 
therapeutically, and not just pathologically (
78
). In short, mind/body medicine was becoming a respectable branch of conventional practice.
Nevertheless, the concept of the mind as healer is more fully associated with alternative medicine, constituting not just an integral part of nineteenth- and early 
twentieth-century alternative healing philosophy, but also emerging as a distinctive area of practice unto itself in the last third of the twentieth century. One source of 
this growth has been religion—a significant proportion of Americans have always believed in the power of prayer and have sought spiritual content in their medicine. 
Scientific medicine's determination to reduce vital phenomena to wholly material, mechanical explanations makes it seem spiritually barren to many and has fueled a 
revival of healing through prayer. The Human-Potential Movement, which originated in the early 1960s, has been equally important. This movement involves a search 
for higher and nobler states of consciousness than the base impulses central to Freudian psychology. This quest for self-actualization supposed the existence of 
untapped sources of awareness and psychic energy, including the energy to restore the body. During that same decade, the antimaterialist hippy counterculture 
sparked a fascination with the mystical religious and philosophical traditions of Asian culture, and promoted practices such as transcendental meditation. East and 
West have since been blended through the New Age healing philosophy that aims at reconciling scientific and spiritual ways of looking at the world and health into a 
unified intellectual scheme. In this attempt, acupuncture, Ayurveda, and other ancient healing traditions of the Far East—traditions that have always focused on the 
functional rather than organic disequilibria of the body—have been embraced as particularly powerful ways of comprehending the extraphysical components of health 
and wholeness. Much like the animal magnetism of the mid-nineteenth-century Mesmerists and the Innate Intelligence of turn-of-the-century chiropractors, the  qi, 
prana, and human energy fields of today's holistic healers are conceptualizations of immaterial agents that sustain harmony both within the body and between the 
body and the cosmos (
79
, 
80
 and 
81
).
New Age medical mysticism is representative of a final obstacle in alternative medicine's climb toward scientific respectability. Like every other alternative approach, 
New Age philosophy wraps itself in the banner of holism: in the current climate of healing, one cannot expect to be taken seriously unless one is holistic. The 
rhetorical use of the term as a label of legitimacy has resulted in a promiscuous crowding of therapies under the broad holistic umbrella. Much of allopathic medicine's 
remaining reluctance to give complementary medicine a serious hearing is the side-by-side intermingling of methods that are relatively easy to rationalize scientifically 
(herbs, massage, acupuncture) with therapeutic aromas, personal auras, and mushy empowerment philosophies: “Empathology finds and clears the underlying 
causes of your ... health issues [and] facilitates your personal truth” (1997 coupon advertisement). But even the most extraterrestrial-seeming of today's holistic 
therapies can be appreciated historically as striving to do what alternative approaches to care have always attempted: to assist the body in its effort to heal itself.
The value of supporting nature's healing labor has never been stated more eloquently than by the renowned American journalist Finley Peter Dunne, commenting in 
1901 on the differences between Christian Science and medicine. “If th' Christyan Scientists had some science,” his Irish protagonist Mr. Dooley proposed, “an' th' 
doctors more Christianity, it wudden't make anny diff'rence which ye called in—if ye had a good nurse” (
82
). The nursing profession has been one of the most active 
and effective groups in promoting complementary medicine in our own time, and that has been true from its beginnings as a profession. “Nature alone cures,” 
Florence Nightingale wrote in 1859 as part of her definition of the art and goal of nursing. “What nursing has to do,” she maintained, “is to put the patient in the best 
condition for nature to act upon him” (
83
). This approach has served as the core principle of complementary medical philosophy from the start, since Thomsonian 
doctors began rescuing patients from the slough of disease by pulling them up the steps of common sense. The best medicine, as Mr. Dooley realized, has always 
been good nursing.
The history of alternative medicine has, under various names and approaches, been a competitive dance with the dominant orthodox system of treatment. Alternative 
systems have always risen when the prevailing approaches have become too abstract, too impersonal, too harsh, or too costly for full public support. Alternative 
systems have usually started by relying on empiricism and outcomes reports, and then often either degenerate into dogma or get absorbed into an orthodoxy-like 
professionalism; when this happens, they become more distant from the patient, and this makes room for newer alternative systems to arise. Throughout this process, 
the battle for legitimacy is played out on semantic, regulatory, political, and economic grounds, with each side claiming “nature,” “science,” “holism,” and “healing” on 
its side. To the degree we can understand and learn from the recurring themes that alternative medicine brings, we will be able to better balance the empirical and 
rational elements of medicine for the benefit of the ill.
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HAPTER
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CHAPTER 2. T
HE
 P
HYSICIAN AND
 C
OMPLEMENTARY AND
 A
LTERNATIVE
 M
EDICINE
Essentials of Complementary and Alternative Medicine
CHAPTER 2. T
HE
 P
HYSICIAN AND
 C
OMPLEMENTARY AND
 A
LTERNATIVE
 M
EDICINE
Ronald A. Chez, Wayne B. Jonas, and David Eisenberg
Introduction
Conventional Medicine
Complementary and Alternative Medicine
 
Extent of CAM Use
 
Why Do Patients Use CAM?
 
Content of CAM
 
Common Themes in CAM
Addressing CAM in Practice
 
The Role of the Physician
 
Questioning Patients about CAM Use
 
Working with Patients Who Visit CAM Practitioners
 
Obtaining and Evaluating Information About CAM
 
Obtaining Information on Licensing, Training, and Referral
 
Reimbursement
 
Liability and Regulatory Considerations
Future Prospects for Integrated Medicine
Chapter References
INTRODUCTION
The public's use of complementary and alternative medicine (CAM) is not a peripheral practice, fad, or medical side issue. Rather, it reflects a genuine public health 
care need that will not disappear. What then is the conventional practitioner's responsibility for offering meaningful counsel to a patient who is considering CAM? How 
does a practitioner make informed decisions about a particular CAM modality to determine whether it has a role in the patient's care? In this chapter we provide the 
basic information needed for addressing CAM with patients who may be using or asking about non-mainstream therapies. This information includes several elements:
the extent of CAM use.
why patients use CAM.
clarification of CAM.
the role of the physician in CAM.
questioning patients about CAM use.
obtaining and evaluating information about CAM.
how to provide appropriate follow-up and referral when needed.
a discussion of training, licensing, liability, and reimbursement related to CAM.
CONVENTIONAL MEDICINE
The chief goals of medicine have recently been summarized in a report by the Hastings Institute (
1
). Dominant emphases relate to curing disease, promoting health 
and preventing illness and injury, restoring functional capacity, avoiding premature death, relieving suffering, enhancing quality of life, and caring for those who 
cannot be cured. These goals are the same for all practitioners, regardless of their methods or beliefs.
Critics of conventional medicine argue that these goals are not being fulfilled. Instead, they are being replaced by an approach to patients that is reductionistic, cure 
oriented, organ specific, mechanistic, depersonalized, and subspecialized. A dogmatic attempt to address chronic disease with this approach is infringing on the 
aforementioned goals. Nevertheless, even severe detractors acknowledge the great value of conventional medicine regarding competent care for acute disease and 
trauma, the capacity to expertly apply innovations in both diagnosis and treatment, and the ability to translate basic science discoveries into clinical care.
Most physicians are aware of the finite aspects of their scope of practice. They recognize that it is impossible to be all things to all patients and keep current with 
every aspect of the rapid continuous advance of conventional medicine. Coupled with this knowledge is the diminishing ability of physicians to fulfill their responsibility 
to function as a patient advocate. Medical decision making is increasingly altered because of economic considerations in the provision of health care, which includes 
the actions of hospital boards and administrators, employers, third-party payers, the legal profession, and government regulations.
COMPLEMENTARY AND ALTERNATIVE MEDICINE
Extent of CAM Use
The best data on rates of usage of CAM come from two identical surveys conducted by Eisenberg and colleagues in 1990 and 1996 (
2
, 
3
). These authors 
extrapolated data from a 1990 U.S. telephone survey of approximately 1500 respondents. In 1990, they found that one-third of Americans (representative of all 
sociodemographic groups) used CAM that year. Almost all of these patients were also being cared for by traditional medical doctors. However, approximately 90% 
self-referred to alternative providers, and, importantly, three of four did not tell their physicians about use of the alternative care. A repeat of this survey in 1996 with 
more than 2000 respondents showed a dramatic increase in CAM use—to 42% of the population—and out-of-pocket CAM expenditures equaling the amount spent 
out-of-pocket for conventional medicine (
3
). The rate for women was 49%.
Other surveys have shown that approximately 50% of patients who have cancer (
4
) or human immunodeficiency virus (
5
) will use unconventional practices at some 
point during their illness. The medical records of these patients were incomplete, however, because they did not reflect the use of CAM therapies. Therefore, 
Americans are using CAM in substantial and increasing numbers. Similar and even higher figures are found in Europe (
6
), Australia (
7
), and other countries. This fact 
should stimulate each practicing physician to ask why his or her patients are seeking out these therapies, pay attention to the patients' answers, and decide how the 
practitioner should respond as a health care provider.
Why Do Patients Use CAM?
The predominant conditions for which Americans use CAM are chronic and stress-related conditions such as back problems, arthritis, headaches, digestive problems, 
depression, cancer, hypertension, and autoimmune syndromes—in other words, conditions for which there are no cures and for which inadequate treatment regimens 
sometimes produce adverse side effects.
Patients use alternative practices because these modalities are part of their social network, they are not satisfied with the process or result of conventional care, or 
they are attracted to CAM philosophies and health beliefs (
8
, 
9
). Patients who use CAM do not generally hold anti-science or anti-conventional medicine sentiment, 
nor do they represent a disproportionate number of the uneducated, poor, seriously ill, or neurotic (
8
, 
9
, 
10
 and 
11
). Included in these multiple motivations is the 
patient's wish to obtain faster resolution of illness. Some patients are motivated by the desires to prevent illness or injuries and maintain wellness. Most of these 
patients function as active participants in their own health care (
9
).
T
YPES OF
 CAM M
ODALITIES
 U
SED

Patients who use unconventional medicine are not necessarily unconventional patients. Many interventions used by the patients in the Eisenberg studies (
2
, 
3
) 
straddle or are part of current conventional medical practice. This can result in confusion as to the definition of CAM. For instance, the more frequently used 
interventions included exercise, relaxation techniques, and massage; all of these are part of treatment programs prescribed by medical doctors. Other approaches 
included imagery, prayer, and spiritual healing. Medical doctors usually do not interfere with the use of these modalities.
Chiropractic manipulation was also a frequently used intervention (
2
, 
3
). Although there has been resistance by organized medicine to chiropractic, this modality has 
been demonstrated to be equally effective as other treatments that can be offered for acute lower back pain of nonorganic etiology. It has even been recommended as 
such by the United States Public Health Service (
12
).
The list of the more frequently used CAM modalities in the Eisenberg study also included herbal medicines and megavitamins. Herbal medicine is a difficult area for 
most medical doctors because most lack formal training in it, many of the medicaments are unfamiliar, and only recently has there been an authoritative source, such 
as the Physicians Desk Reference for prescription items (
12a
). Also, there is little required Food and Drug Administration overview and labeling of herbal products 
sold in the United States, although other countries (such as Germany and Australia) have established guidelines and oversight procedures. These same factors apply 
to the difficulty that physicians find in sanctioning the use of megadose vitamins. As a result, physicians cite generalized concerns about safety and efficacy if these 
products are used by their patients.
Content of CAM
CAM is defined as that subset of medical and health care practices that is not an integral part of conventional (Western) medicine. Many practices overlap with 
conventional medicine, and some eventually become part of it (
13
).
More than 350 modalities can be listed under the broad category of CAM. The United States NIH classification divided the modalities into seven major categories 
(
Table 2.1
) (
14
). These categories are not equivalent in terms of understanding or acceptance by conventional medicine, and there is no consensus on definitions or 
classification schemes.
Table 2.1. NIH Model for CAM Classification
For instance, mind-body interventions include biofeedback, meditation, relaxation techniques, support groups, guided imagery, and yoga. Biofeedback is now 
integrated in conventional medicine for treating urinary and fecal incontinence, swallowing disorders, and chronic pain relief, including headaches. The category of 
manual healing methods includes physical therapy and massage as well as chiropractic manipulations. Again, elements of these are included in conventional 
medicine. For the bioelectromagnetic application category, both the electroencephalogram and electrocardiogram use the body's endogenous electromagnetic 
elements. Diathermy, laser, and radiofrequency surgery are part of the low-frequency thermal aspects of this category. The diet and nutrition category presently 
includes prescribed physician regimens of specific food elimination diets and lifestyle programs that have successfully treated patients who have cardiovascular 
disease.
In contrast, Western medicine has difficulty accepting and understanding the place for other alternative medical systems, such as Ayurveda, homeopathy, and 
traditional Chinese medicine. Similarly, the biofield approaches, such as therapeutic touch, Reiki, polarity therapy, and reflexology, all deal with life forces and subtle 
energy fields, concepts that are not part of the usual thought processes of Western medical doctors.
Conventional medical pharmacotherapy was founded on the use of plants as sources of medicines, but the present pharmacological manufacturing system focuses on 
synthetic compounds that may be costly and, in some cases, cause severe side effects. Currently, several herbs have been studied in prospective randomized 
controlled trials from which data have been published in peer-reviewed journals. The possibility that herbal medicines may achieve the same or better outcomes as 
prescription medicines, but at less cost and with fewer side effects, must be considered and examined. One difficulty is how to define the proper dosing for these 
products, because too frequently a disparity exists between one brand and another, caused by lack of manufacturing standardization. Phytomedicines and 
ethnobotany will become more prominent as a source of conventional pharmacological and biological treatment. As an example, the estrogen-like isoflavins in soy 
protein may have value for the perimenopausal and postmenopausal patient. In contrast, the acceptance of blood-processed products, apitherapy, and many folk 
medicine products remains doubtful.
Common Themes in CAM
Common themes are promulgated in the CAM literature that traverse the seven large categories shown in 
Table 2.1
. However, as previously stated, these categories 
are not all equivalent, neither in acceptance nor in understanding by conventional medicine. Some familiar themes focus on the enhancement of wellness and 
prevention of disease, whereas others emphasize self-healing and the use of recuperative powers. These themes are also espoused in conventional medicine. Other 
themes, such as an orientation toward mind–body–spirit relationships and the restoration of balance and subtle energy fields or life force, are difficult to comprehend 
for medical doctors trained in the classical sciences of physics and biochemistry. The introduction to Part I of this book provides a framework for conceptualizing the 
diverse themes that cut across both conventional and complementary medicines.
What can be readily applied to the everyday medical care of all patients is the distinction between disease and illness, curing and healing, and pain and suffering. 
Specifically, if disease is the diagnosis that derives from the patient's presenting signs, symptoms, and laboratory tests, then illness is the human experience of the 
disease that takes place in the context of an individual person's singular set of beliefs, fears, expectations, and meaning. If cure is an externally applied medical 
intervention that removes all evidence of the diagnosed disease, then healing is the internal process of recovery that takes place on a physical, emotional, mental, 
and spiritual level. People can heal when they believe that it is not only possible to be well, but also that they are worthy of being well (a spiritual or psychological 
element). Finally, because we as human beings have bodies and minds, pain as part of our existence is inevitable. Because suffering is the person's response to 
pain, it is not inevitable that suffering be extreme or negative, and in that sense suffering is a focus of interventions aimed at healing (
15
).
ADDRESSING CAM IN PRACTICE
The Role of the Physician
Patient advocacy encompasses promoting patients' well-being, protecting them from harmful practices, facilitating informed choice, honoring their values and decision 
making, and promoting dialogue and partnership. It also includes the purposeful identification of the physicians' own medical experience and knowledge within the 
limits of their training, which results in the responsibility to seek appropriate consultation and referral. The interplay of patient advocacy, the difficulty in achieving the 
goals of medicine, the perceived and real limits of conventional medicine, and the reality of today's practice environment serves as the motivation to 1) learn why 
patients are seeking and using complementary and alternative practices for their health needs; and 2) help define the significant role physicians play in these areas. 

We recommend that physicians follow the framework of “Protect, permit, promote, and partner” when approaching CAM in their clinical practices (
16
):
Protect patients against dangerous practices.
Permit practices that are harmless and may assist in comfort or palliation.
Promote and use those practices that are proven safe and effective.
Partner with patients by communicating with them about the use of specific CAM therapies and products.
P
ROTECTING
 P
ATIENTS FROM
 CAM R
ISKS
Given the extensive public use of CAM products and practices, the poor communication between patients and physicians about this use, and the paucity of knowledge 
about the safety and efficacy of most CAM treatments, a situation exists for harm from these treatments (
17
). Many CAM practices, such as acupuncture, homeopathy, 
and meditation, are inherently low-risk modalities, but if they are used by unskilled practitioners or in place of more effective treatments, adverse consequences may 
result. Only fully competent and licensed practitioners are qualified to help patients avoid such inappropriate use (
18
). Also, some alternative medicine products, such 
as herbal preparations, contain powerful pharmacological substances that can produce direct toxicity and herb–drug interactions (
19
). Contamination and poor quality 
control are also more likely with these products than with conventional drugs, especially if they are shipped from overseas (
20
).
Patients need to be especially cautious about products and practices that can produce direct adverse effects from toxicity. The conventional physician can help 
patients distinguish between CAM practices with little direct toxicity potential (e.g., homeopathy, acupuncture) versus those with potential for such toxicity (e.g., 
megavitamins and herbal supplements). In addition, physicians can work with patients to be sure they do not abandon effective care, are alert to signs of possible 
fraud or abuse, and are aware of unintended effects from interactions between conventional medicine practices and alternative therapies. Practices that rely on  secret
 formulas, promise cures for multiple unrelated conditions, use either slick advertising for mail order products or pyramid marketing schemes, and recommend 
abandoning conventional medicine for their practice should be suspect (
21
).
P
ERMITTING
 P
RACTICES THAT ARE
 H
ARMLESS AND
 M
AY
 A
SSIST IN
 C
OMFORT
 
OR
 P
ALLIATION
Clinical improvement due to nonspecific factors that arise from the doctor-patient interaction, spontaneous healing, statistical regression to the mean, expectation, and 
placebo effects account for much of the benefit seen in medical practice (
22
, 
23
). Science is concerned with separating these factors from those thought to be 
attributable to specific and isolatable aspects of a therapy. Practitioners, however, are mainly concerned with how to achieve maximum benefit for individual patients 
with little harm (
24
). Many CAM systems attempt to enhance these nonspecific factors by emphasizing high-touch, personalized, self-care approaches that may be 
useful in symptom reduction and palliation in chronic disease. The physician can help patients optimize chances for recovery by permitting the use of beliefs and 
treatment approaches that increase hope, bolster expectation, reduce symptoms, and enhance well-being if these beliefs and approaches are neither harmful nor 
expensive.
P
ROMOTING
 S
AFE AND
 E
FFECTIVE
 CAM T
HERAPIES
There is accumulating evidence that CAM practices have value for the way physicians treat, manage, and understand health and disease. Botanic medicine research 
has shown the benefit of herbal products such as  Ginkgo biloba for improving dementia due to circulation problems and possibly Alzheimer's (
25
, 
26
); saw palmetto 
and other herbal preparations for treating benign prostatic hypertrophy (
27
); and garlic for the prevention of heart disease (
28
). Several randomized, 
placebo-controlled trials report that  Hypericum (St. John's Wort) is effective in the treatment of depression. Additional studies have compared its effects with those of 
conventional antidepressants. These studies report that  Hypericum is not only as effective as conventional antidepressants, but produces one tenth the side effects 
and represents one third the cost (
29
).
In addition, when controlled trials demonstrate that a widely used CAM therapy is not effective (such as acupuncture for smoking cessation or for the treatment of 
obesity), the physician can recommend against its use even though it may produce little harm (
30
).
As research provides credible information on the less-explored areas, expanded options for managing clinical conditions will arise. For example, studies on arthritis 
suggest improvements using homeopathy (
31
), acupuncture (
32
), vitamin and nutritional supplements (
33
), herbal products (
34
, 
35
), diet therapies (
36
), mind-body 
approaches (
37
), and manipulation (
38
). Similar collections of usually small studies exist for many other common conditions, such as heart disease, depression, 
asthma, and addictions. The physician can play a central role in assisting the patient to determine the value of evidence for his or her condition and situation. 
Searching the published medical literature and evaluating its applicability for specific problems is a service conventional physicians can provide. When no good 
research exists, this information can also be useful for many patients (
39
). 
Chapter 5
 outlines a step-by-step and time-efficient approach for using research evidence 
to assist in decision making about using CAM practices.
P
ARTNERING WITH
 P
ATIENTS
 R
EGARDING
 CAM
There is a major communication gap between physicians and the public about CAM (
2
, 
3
). The physician has a responsibility to help fill this communication gap by 
asking patients about their CAM use and working with them to assure that it be done responsibly (
40
). The physician can become familiar with the basic concepts of 
CAM modalities, distinguishing the features and research bases of the main unconventional practices. In addition, conventional physicians can identify responsible 
CAM practitioners (including other physicians) who provide specific services. Learning about CAM practices will become an increasingly important aspect of both 
medical school education and medical practice in the future.
Questioning Patients about CAM Use
How does the physician answer when the patient asks if there is an alternative caregiver in the area to whom the physician would refer him or her, or asks about a 
specific alternative medicine about which he or she has been reading? For many medical doctors, this is, first, an issue of safety. It is dangerous for the public to 
believe that the term natural is synonymous with the terms safe, benign, or effective.
It is necessary to recognize that there are both direct and indirect adverse effects from some CAM interventions and treatments. The chapters in Part II of this book, 
“The Safety of CAM Products and Practices,” deal with these issues in detail. It is pertinent that there is little federal supervision of most CAM products derived from 
plants, including herbs sold over the counter. Also, it is disconcerting that there is a paucity of authoritative licensing and certification bodies for CAM providers 
equivalent to those extant in conventional medicine. These oversight and supervisory structures are gradually being developed both inside and outside the CAM and 
conventional communities.
How then does the physician become more knowledgeable about CAM? Each individual physician will have to consider how well informed he or she wants to be about 
CAM—in terms of both general and specific aspects. The American Medical Association Council on Scientific Affairs and the Federation of State Medical Boards 
recently recommended that physicians routinely inquire about the use of CAM by their patients, educate themselves and their patients about the state of scientific 
knowledge regarding CAM, and educate their patients who choose CAM about the potential hazards of stopping conventional treatment (
18
).
Asking the patient during the intake interview whether he or she has been using or considering other kinds of treatments, medications, supplements, or seeing 
nonphysician therapists for relief of symptoms is a valuable source of information. If the answer is “Yes,” then the physician can follow with questions similar to those 
presented in 
Table 2.2
.

Table 2.2. Doctor-to-Patient Questions Related to CAM Use
According to the responses, the physician may be able to inform the patient that: 1) a conventional treatment is available; 2) the patient may not need the particular 
CAM intervention; 3) the CAM practice is unnecessarily high in cost and low in value; or 4) the practice may be useful and can be continued. It may also become clear 
that the patient turned to CAM because conventional medicine was failing him or her, or that the patient in fact distrusted or was afraid of conventional medicine.
The physician has an obligation to warn, discourage, or monitor the patient when a potentially dangerous CAM intervention is being considered or used. Some 
examples include the use of intravenous products of unknown quality or toxicity (e.g., hydrogen peroxide, herbs), colonics, and high doses of vitamins or 
pharmacological agents of unknown risk or value. The physician need not automatically interdict all CAM interventions on the assumption that there is a real or 
potential danger. Appropriate questions regarding the safety of a particular CAM treatment relate to whether it prevents or precludes needed conventional care, and if 
it can be continued in conjunction with conventional treatment without harm to the patient. When the patient uses interventions associated with few adverse effects, 
such as acupuncture, biofeedback, or homeopathy, there may be no contraindication to its continued use. If the physician acknowledges this, it may benefit the patient 
with little risk and help the physician gain a better understanding of the particular practice.
In all cases, the physician will want to pursue the patient dialogue in such a way that the patient will continue to seek medical care and receive appropriate 
conventional care. This is facilitated if the patient understands that his or her best interests are being explored with a purposeful focus on safety and efficacy. By 
focusing on the four goals outlined earlier in this chapter (protect, permit, promote, partner), a more integrated practice that appropriately addresses CAM with 
conventional medicine can be developed. These goals are organized into a series of operational questions that the physician can self-query as patients describe their 
use or interest in CAM practices and products (
Table 2.3
).
Table 2.3. Evaluating CAM Use with Patients
Working with Patients Who Visit CAM Practitioners
Table 2.2
 outlines questions that the physician can ask of the patient, and 
Table 2.3
 outlines questions physicians can ask of themselves when confronted with CAM 
practices. Because there are more visits to CAM practitioners than to conventional primary care physicians in any one year, however, the physician may frequently be 
faced with managing patients who visit CAM practitioners on a regular basis. How can the physician work with patients who are already visiting CAM practitioners and 
address the safety and management issues involved? Eisenberg has outlined a series of steps for this type of situation. In addition to the safety and screening 
questions previously discussed, the physician can ask the patient to begin a symptom diary and provide a set of questions for the alternative provider; for example, 
“What previous experience have you had with the condition?” “What will be the number of treatments and expected time table for a ‘fair' trial?” and “Are you willing to 
communicate with my conventional physician?” (
Table 2.4
). After CAM therapy has been provided for a “fair” amount of time, the physician should review the results 
with the patient, including a symptom diary, and discuss continuation or discontinuation of the therapy and other treatment options (
40
). Contact with the CAM 
provider is encouraged early during treatment, as is thorough documentation of the process. Documentation should include advice to the patient, symptom diaries, 
safety issues, discussions with the CAM provider, outcomes, and conventional options tried or refused. If effective conventional care is available and is refused by the 
patient, termination of further management or, at the minimum, detailed documentation of the physician's recommendations may be necessary (
40
).
Table 2.4. Questions for the Patient to Ask the CAM Provider
Obtaining and Evaluating Information About CAM
Traditionally, once medical doctors complete their formal education, they continue to expand their medical knowledge base through self-study. When the physician 
decides how much detail about CAM he or she might want to provide, there are an increasing number of information sources available. This book and its companion, 
Textbook of Complementary and Alternative Medicine, are two sources of basic information about alternative practices, their safety, their main uses, and their 
organizational status. In addition, many peer-reviewed medical journals now contain clinical research articles related to CAM. There are also several peer-review 
journals published with a specific focus on CAM. Examples are  Complementary Therapies in Medicine, Alternative Therapies in Health and Medicine, Integrative 
Medicine, The Journal of Alternative and Complementary Medicine, Forschung Komplementarmedizin, The Scientific Review of Alternative Medicine, Focus on 
Alternative and Complementary Medicine, Advances, and others. Another efficient way to become informed about current CAM therapies is through newsletters such 

as Self Healing, Complementary Medicine for the Physician, and Alternative Medicine Alert.
Herbal medicines are one of the more confusing areas for physicians. The American Botanical Council is an excellent informational resource, with its publication of 
the translation of the German Commission E monographs, its own journal called  HerbalGram, and therapeutic monographs describing dosage, safety, and use of 
individual herbs. Verro Tyler, former professor of pharmacognosy at the University of Indiana, has written several excellent books ( The Honest Herbal, Herbs of 
Choice). Other books included Healing Power of Herbs by Michael Murray, Out of the Earth by Simon Mills, and Herbal Drugs and Pharmaceuticals by Norman Disset 
(editor). For information about safety, see