Essentials of Complementary and Alternative Medicine (June 1999)

Part II
 of this book, “The Safety of CAM Products and Practices”; McGuffin, Hobbs, Upton, and Goldberg's book  Botanical 
Safety Handbook; or Newell, Clarkson, and Phillipson's  Herbal Medicine for the Healthcare Professional. This last book has tables of indications, contraindications, 
and potential drug–herb interactions and is especially helpful for identifying possible adverse interactions of herbs with conventional medicines. Finally, the 
Physician's Desk Reference has recently published a PDR for herbs.
The Internet also is an important source of information. Several citation databases are dedicated to CAM. In addition, the National Library of Medicine's electronic 
database, MEDLINE, is currently revising its keyword headings to better capture CAM citations. Also, several medical organizations and CAM professional 
organizations have Web pages. The search engine, Yahoo, has more than 300 sites related to CAM and is a frequent source used by the public. 
Table 2.5
 lists some 
Internet sites that the physician and health care professional may find particularly useful.
Table 2.5. Selected Internet Sources of CAM Information
General CAM
altmed.od.nih.gov/NCCAM
 (contains the CCI and links to NCCAM–supported research centers around the United States) 
gn.apc.org/rccm
 (e-mail address for Research Council for Complementary Medicine, United Kingdom) 
cpmcnet.columbia.edu/dept/rosenthal
 (Columbia University, New York, NY) 
pitt.edu/~axcbw/altm.html
 (University of Pittsburgh, PA) 
gen.emory.edu/medweb/medweb.altmed.html
 (Emory University, Atlanta, GA) 
chprd.sph.uth.tmc.edu/utcam
 (University of Texas CAM Cancer Center) 
cgi.pathfinder.com/drweil
 (Andrew Weil's home page) 
probe.nalusda.gov
 (United States Department of Agriculture) 
healthy.net
 (commercial health information source) 
teleport.com/~axmattlmt
 (directory of CAM practitioners) 
quackwatch.com
 (focuses on fraud, quackery, and CAM abuse) 
General Medicine 
medline.nlm.nih.gov
 (Medline and PubMed) 
cochrane.co.uk
 (systematic reviews and randomized controlled trials) 
biomednet.com
 (access to full text publications in biology and medicine) 
webcom.com/mjljweb/jrnlclb/index.html
 (selected articles from Annals of Internal Medicine and New England Journal of Medicine) 
oncolink.upenn.edu
 (University of Pennsylvania cancer information) 
Acupuncture 
acupuncture.com
 (United States site for acupuncture) 
medicalacupuncture.org
 (American Academy of Medical Acupuncture) 
users.aol.com/acubmas/bmas.html
 (British Medical Acupuncture Society) 
acuall.org
 (U.S. National Acupuncture and Oriental Alliance) 
Manipulation 
amtamassage.org
 (American Massage Therapy Association) 
osteopathy.org.uk
 (British Osteopathic Information Service) 
amerchiro.org/index.html
 (American Chiropractic Association) 
Homeopathy 
homeopathic.com
 (Homeopathic Educational Services) 
antenna.nl./homeoweb
 (a site for discussion and news) 
homeopathic.org
 (National Center for Homeopathy, United States) 
Herbal Medicine 
herbalgram.org
 (American Botanical Council) 
herbs.org
 (Herb Research Foundation) 
pharm.usyd.edu.au
 (University of Sydney, Australia herbal site) 
Evaluating the validity and applicability of CAM research literature is one of the primary responsibilities of the physician. Most patients cannot use evidence-based 
principles and research information, so they often come to the physician for this type of information. Because the physician cannot become knowledgeable and skilled 
in all CAM therapies, it is important that he or she become skilled in using an evidence-based evaluation approach to CAM. Quality systematic reviews and 
randomized controlled trials are the best source of valid information for determining safety and efficacy. The Cochrane Library, which is available online and on 
CD-ROM (see 
Table 2.5
) is a rich source of this type of information for all of health care; with its CAM Field Group, it is an increasingly important source of quality 
CAM information. The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) also mounts a listing of 
MEDLINE–derived information on its website (called the CAM Citation Index, or CCI) that is searchable by condition, CAM modality, or study type.
One result of this type of continuing medical education is acquiring knowledge of CAM treatments that may be useful for patient care. In cases when conventional 
medicine is not succeeding, the physician can recommend a proven treatment if it will serve the patient's needs, despite its categorization as CAM or conventional.
Obtaining Information on Licensing, Training, and Referral
The physician may have difficulty responding when asked by the patient for a referral to a CAM provider. Physician-to-physician referral is facilitated by state 
licensure requirements, knowledge of the center where formal medical education was acquired, and specialty board certification. The formal components of medical 
doctor licensure are not always required of various CAM providers. These components include the content and length of time of training, testing, and certification; a 
defined scope of practice; review and audit; and professional liability with regulatory protection and statutory authorization complete with codified disciplinary action 

(
41
).
All 50 states do provide licensure requirements for chiropractic, but only approximately half do so for acupuncture and massage therapy, and fewer do so for 
homeopathy and naturopathy. Only Connecticut and the state of Washington license all five of these provider types. 
Table 2.6
 lists licensure status for the top CAM 
professions in the United States as of 1998. In England, only physicians are licensed to practice medicine, but other practitioners and patients can engage in other 
therapies without legal restraint. Special classifications of alternative medical practitioners also exist in Germany, France, Australia, and other countries. In many 
Asian countries, full licensure and regulation of traditional practitioners occurs. In many developing countries, no regulation of such healers exists. Because the 
situation is constantly changing and varies from country to country and state to state, physicians should contact their own country or state licensing authorities for 
current information.
Table 2.6. Licensing Status of CAM Professions by United States and Its Jurisdictions
Many CAM organizations have requirements for membership that include some aspects of formal training, defined tutoring or mentoring internships, and testing. 
Although not equivalent to medical doctor licensure and board certification, these requirements represent an attempt to set standards, set scope of practice, and 
identify more credible and competent practitioners.
Therefore, the establishment of a CAM referral network may be more subjective than that for conventional medical referrals. In addition to informal discussion with 
physician–colleagues, other patients may be a helpful source of information. When a referral is made, direct follow-up with the patient to assess clinical outcomes will 
provide additional information. As with physician referral, it is appropriate to expect a direct follow-up report from the CAM provider with details as to plan of care, 
defined goals of treatment, and a time line for results (
42
).
Reimbursement
In some countries (e.g., England and China), many CAM products and some practices are included under the national health insurance systems. In other countries 
(e.g., Germany), a combination of government health benefits and private insurance covers CAM benefits under conditions of special patient evaluation and follow-up.
In the United States, an increasing number of third-party payers now reimburse for some CAM interventions. This is a result of patients' desire for such services and 
employers responding to their employees' requests to do so as a benefit of the workplace. Thus, to be competitive in the marketplace, the third-party payer, such as a 
managed care company, agrees to provide a rider for some CAM modalities. Also, government health care support services are increasing their coverage of CAM, so 
the physician is likely to see such services available to a wider range of patients than currently exists (
43
).
Reimbursement can carry the imprimatur that: 1) CAM professional standards are in place; 2) there are appropriate indications for its use; 3) there is a favorable 
risk–benefit ratio in its application; and 4) the intervention is clinically efficacious and cost effective. Important operational issues must be established before affirming 
that these conditions exist. This includes establishing an authoritative panel of experts who will create criteria for: 1) appropriate referral and use; 2) cost and clinical 
effectiveness; 3) audit; and 4) determination of liability. Reimbursement is then based on a service done by payer-accredited providers. A provider can be a CAM 
provider, but also can be a physician provider who is trained in a CAM modality (
44
).
Reimbursement also can result in the creation of protocols and plans of care for specific diagnoses that require shared responsibility between conventional and CAM 
providers. Such an integrated health plan assumes that both medical doctors and CAM providers understand each others' performance standards, share the same 
outcome goals for the patient, will be responsible for and responsive to monitoring and evaluating the treatments being given, and will work together in respectful and 
cooperative tandem. Given the level of antipathy that can exist between CAM and conventional groups, it is not certain that this cooperative venture can and will 
happen, although many groups are moving toward developing such integrated models of practice.
Liability and Regulatory Considerations
As the physician begins to address CAM in his or her practice, it is likely that referral to CAM practitioners and use of CAM practices and products along with 
conventional medical management will increasingly occur.
What risks does the practitioner take in beginning to address and use CAM alongside conventional practice? Is there an increased risk of malpractice or medical 
board action and scrutiny? The development of legal and regulatory issues related to integrated practice is still in its infancy, and at the same time is changing rapidly. 
A more personal and communicative practice generally reduces the risk of malpractice difficulties from patients in general. A limited scope of practice can also reduce 
the degree of risk. Full-time CAM practitioners have lower malpractice risk and insurance rates than do conventional physicians. However, in the legal system, 
conventional practitioners who use CAM may have less protection related to scope of practice and assumption of risk. Thus, although the improved patient 
communication and satisfaction that may come with an integrated practice may reduce the risk of malpractice claims from patients, liability may not be reduced if such 
a claim is filed.
Studdert (
16
) has evaluated malpractice liability issues for CAM providers. He has found that, although the number of claims and the claim rates for CAM providers 
are lower than for conventional providers (e.g., about one-third the rate for chiropractors than for medical doctors), the type and reasons for bringing claims against 
CAM providers are similar to claims against conventional physicians: misdiagnosis, failure to diagnose, continued treatment in the face of adverse effects, overly 
aggressive treatment, and so on (
16
).
Increasingly, courts have been willing to recognize school-specific standards for diagnosis and treatment where the legislature has recognized the legitimacy of the 
alternative practice through licensure. Patient “assumption of risk” is often cited as the rationale for adopting this position. It is reasonable to expect that for 
conventional physicians, conventional standards of care will be applied (including more stringent standards of “assumption of risk”), although there is little current 
case law to confirm this.
Disciplinary action from state medical boards and country regulatory authorities may also pose a risk for physicians who decide to make CAM services available in 
their own practice. Historically, use or association with CAM therapies has been a reason for professional and regulatory discipline. (The reader is referred to 
Chapter 
1
 and 
Chapter 3
 for a discussion of historical and ethical aspects of professional discipline related to CAM.) Recently, some state medical boards have taken action 
against physicians who incorporate CAM practices based on standard of care and prevailing practice rules. The risk of prevailing practice as the basis for disciplinary 
action may decline as the awareness of wide practice variations in conventional medicine is documented, and also as states adopt laws for legal protection from such 
action brought solely on the basis of CAM use (so-called  access to treatment laws). A summary of these issues and current legal precedents is available elsewhere 
(
45
).
Although the risks of malpractice and medical discipline appear relatively small, the conventional practitioner is best advised to take precautions when beginning to 
address CAM areas in his or her practice. 
Table 2.7
 summarizes these steps. Ensuring that treatment or advice for patients using CAM is above standard-of-care for 

conventional medicine is wise. In addition, one should ensure that 1) competent conventional medicine (either from the physician or by referral) is provided; 2) 
potential risks (both direct and indirect) are minimized; 3) some reasonable body of competent opinion or published evidence exists for the practice; and 4) all 
treatments, referrals, and recommendations are thoroughly documented in patient records.
Table 2.7. Guidelines for Reduction of Malpractice and Liability Risk
It is not advisable to rely on more liberal strategies, such as assumption of risk by the patient, reliance on a respected minority opinion only, use of an innovative (not 
experimental) approach or rationale, or an expanded informed consent form. Although such approaches are often used for defense in conventional medicine, using 
more conservative strategies with CAM is best (see 
Table 2.7
), even when documented safety and efficacy data exist for the treatment. Because regulatory and 
disciplinary bodies, such as state and federal legislatures, state medical boards, and the courts, have not provided guidelines in these areas, the true risk is unknown, 
and the aforementioned points should be taken only as suggestions. A detailed summary of the legal issues surrounding CAM practice in the United States is 
available in a recently published book by Cohen (
45
); these issues are summarized in a chapter in the  Textbook of Complementary and Alternative Medicine.
FUTURE PROSPECTS FOR INTEGRATED MEDICINE
We can assume that patients will continue to use CAM, particularly for the symptomatic relief of chronic and stress-related disease. Also, patients will expect to be 
reimbursed for a growing number of CAM interventions. Physicians, therefore, will find themselves increasingly approached by patients who expect them to have 
knowledge of and be willing to work with CAM.
Many medical schools now offer elective CAM courses (
45a
). Also, formal CAM instruction is provided by many family practice residency programs (
46
) and 
increasingly in CME (continuing medical education) courses from universities. These educational approaches may result in an increase in physician referral to CAM 
providers and in the learning and use of various CAM interventions by medical doctors.
Historically, the mutual resistance of both conventional medicine and CAM to work together for the benefit of the patient has resulted in name calling and the use of 
pejorative adjectives. As the ethical principles of beneficence and respect for patient autonomy come to the forefront, we can hope to find that all such adjectives are 
replaced with the new term integrated health care.
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CHAPTER 3. E
THICS AT THE
 I
NTERFACE OF
 C
ONVENTIONAL AND
 C
OMPLEMENTARY
 M
EDICINE
Essentials of Complementary and Alternative Medicine