SPEECHES

Complementary & Alternative Medicines:
Towards Integrated Healthcare

Professor Kerryn Phelps
ARCHI Conference
Surfers Paradise, Queensland 2004

DEFINITION
What is Integrative Medicine?

Integrative Medicine is NOT an interchangeable term with complementary or alternative medicine, although many people confuse them.

Integrative medicine is about incorporating modalities of health care into practice so that practitioners can expand the options available to patients, with health care providers from different paradigms ideally working in cooperation rather than competition.

Ideally, it is about combining the best of allopathic medicine with the best of CAM practices into comprehensive treatment plans, working with the body's natural healing potential and based on the individual patient's needs and preferences.

Integrated healthcare is not just about procedure or substances.  It is about a philosophy of living, helping to create optimum environments for good health.
This may sound like so much commonsense but historically, and still today, there are impediments to achieving this balance in the health field in a way which sets aside turf wars and jealousies, and focuses solely on the wellbeing of the patient.

It is an honour for me to be asked to open this important conference: "COMPLEMENTARY AND ALTERNATIVE MEDICINES: TOWARDS INTEGRATED HEALTHCARE"
I will show you how healthcare is about to come full circle.  From its beginnings as an integrated and holistic art, through the epochs of allopathic- scientific practice you will see how healthcare is literally evolving back to its roots as an integrative system of health maintenance and disease management.

THE PAST
Dis- integration and Reductionalism

Aristotle (384-322 BC) was one of the first proponents of the holistic model of healthcare, believing in the combination of the physical and spiritual elements of the human condition.
Rene Descartes came along in the early 1600s and philosophically split the mind and body.
Sometime after that the reductionist movement sought to find simple explanations for the function of the human body. 
The Flexner report of 1910 ensured that medical training was based on the scientific model, maintaining the principle of the Cartesian split or the mind/body duality. 
Subspecialisation of medical care followed and further philosophically fragmented the human body into its composite organs and systems.  Rater than subspecialisation, you could use the term "partialisation".
While there is undoubtedly merit in the concentration of knowledge and expertise in specialised areas, this fragmentation simply does not account for complex or chronic disease or the significant effect of psychological and spiritual factors in the health and healing of the whole person.

"us and them" mentality

There is still a prevailing, though gradually dwindling "us and them" mentality.  The allopathic medical practitioners in the blue corner.  The CAM proponents in the red corner. 
Mistrust between practitioners working in different fields has been based on historical factors.
Let's look at some of them:

  • Non-medical practitioners often see people who have been disillusioned, mistreated, disappointed or unable to be helped by traditional Western medicine
  • Medical practitioners often see patients who have tried alternative treatments unsuccessfully or where diagnoses have been missed or were wrong.  With the human tendency to generalise personal experience, these encounters influence how you view other paradigms.
  • "Alternative" is often held to be synonymous with "unproven". 
  • "Allopathic" is often held to be synonymous with "soul-less".
  • Many doctors remain unaware of the evidence for CAM
  • Medicine: deliberate lack of integration of mind-body-spirit to pursue the scientific model.
  • Different paradigms speak different languages eg "yin and yang"; Chakras are not easily explained in allopathic language.
  • Scientific evidence for some modalities relatively recent or published in other languages is so not readily available to English language-trained doctors.  Yet there is often a false sense of security that all allopathic treatments are all strongly evidence-based. (we need only look to past failed experiments like mobilisation under anaesthesia for back pain, bone marrow transplantation for metastatic breast cancer or the "HRT for all" bandwagon)
  • "Lunatic fringe" making claims which have not or cannot be substantiated and may do harm or delay effective treatments, or unqualified unregulated practitioners adversely affecting the reputation of highly trained and skilled practitioners.
  • Lack of standardisation or regulation of education courses and qualifications of some practitioners.

Mistrust and misunderstanding have led to a potentially dangerous stand-off between doctors, other health professionals and patients.

Turf wars

During my time as Federal AMA president, I sought to medico-politically mainstream complementary and alternative medicine. This was not as easy as it may sound.  In order to achieve this, a position statement is a necessary prerequisite.  I can tell you now that I faced an almighty battle on several fronts.

There were those doctors who did not feel the AMA had any business even discussing CAM, let alone developing policy from scratch.

There were other doctors who fought against the concept of medical practitioners having a responsibility to develop a working knowledge of the evidence for alternative treatments.

Others seemed to have the attitude that if it wasn't taught in medical school, it had no place in medical practice.

It reminded me of a story from my student days.  I had just completed my surgery exams.  During the exam, I was given a problem that involved a group of symptoms that made no sense to me.  It was clear that this had not been in the "syllabus" for that term.  Shortly after I left the exam, I encountered my surgery professor on the ward.  He asked me how the exam had gone, and I told him how annoyed I had been that there was a question I could not answer because the condition described had not been taught to us.  He nodded and smiled, then he gave me some advice I have carried with me throughout my clinical career.  He said, "Any condition of the human body, any problem that could ever present itself to you in practice requiring diagnosis and management…that is the syllabus for medical training."
And so it is with the story of everyday clinical practice.  For most of us, medical training could not hope to prepare us for every possible clinical problem or for the expectations of today's consumers or the consumers of the future.  We are regularly presented with problems, some of which cannot be solved with the tools of our particular trade.  That is no reflection on us as individual practitioners, or on our profession.   Just as I do not have the training or the skills to remove a cerebral aneurysm or perform an anterior resection, I do not practice acupuncture or hypnotherapy, but I see patients who benefit from those treatments and I happily refer them to skilled practitioners when it is appropriate.
The idea is to expand the options available to our patients by working in co-operation with other practitioners.

NOW

Practice of healthcare is in a state of rapid transition.  Some of the features of the new landscape include:

  • Patient empowerment… change in therapeutic relationships
  • Less tolerance for uncertainty
  • Increased technology
  • Increasing desire for spiritual dimension to healing
  • Increasing demand for evidence

We are entering a phase of PARADIGM SHIFT: "When you challenge paradigms, expect anger to follow"…Carl Sagan

COMMUNICATION TRIANGLE

It is clearly important for medical practitioners to encourage patients to talk to them about their use of complementary medicines and therapies so that they know what other medicines patients are taking and what other treatments they are using. 

It is also going to be increasingly important for doctors to be sufficiently informed about complementary medicine to enable them to advise patients about potential benefits and any adverse effects, including possible interactions with prescribed medications.

If there is no evidence that a treatment is effective then the doctor is able to point this out.  If there is evidence that a product or treatment is potentially harmful then the patient should be informed.

Patients value this type of advice from their doctor.  They are then able to make informed choices.

Medical practitioners must be more involved in the reporting of adverse events associated with complementary medicine.

There needs to be a more coordinated and extensive system of reporting of adverse events in relation to complementary medicines.

There are also situations that give rise to concern - particularly where, for example, patients may forgo a medical diagnosis and best practice treatment in an unfounded belief that a complementary practitioner has the skills to manage a medical condition.

This is of even greater concern where the patient is a child or otherwise unable to make an informed choice of their own.

We must find ways of informing and empowering consumers while respecting their right of choice over health care treatments.

Doctor and Patient

It is essential that patients inform their medical practitioner of complementary medicines and/or therapies they are using.

However, it is estimated that only about a half of patients tell their doctors when they are using complementary medicine.
This has inherent clinical dangers because of the potential for incompatible treatments or substance interactions.

Other health professional and patient

Patients are not always adept at giving their health history.  As a very simple example, I often ask patients if they have ever had any admissions to hospital or surgical procedures.  The answer will come back "No".  I then ask if they have had their appendix removed "Oh, yes!"  Many patients are unaware of the dosages of their medication or the ingredients in their OTC medications.
Non medical CAM practitioners need detailed information about their patients so that they can take all factors into consideration when they are recommending treatment.

It is essential that consumers have improved access to well-researched information about CAM so that they are empowered to question and to raise relevant issues with any practitioner they consult and to make well informed choices.
This is yet another strong argument in favour of patient-held records.

Doctor and other health professional

GPs and other medical specialists communicate in writing with each other as a matter of course.  Professionally, a GP would not continue to refer to any specialist who did not provide timely feedback on a patient's progress. 
As allopathic and CAM practitioners improve communication and cooperation with each other, so communication links will need to be established or strengthened.  In this way, relevant patient information can be transmitted for the benefit of improved patient care.

Why "complementary" or "alternative" healthcare? (CONSUMER PERSPECTIVE)

The two main reasons given for turning to complementary healthcare products are because they are seen as natural alternatives or because of dissatisfaction with other treatments.

The most common reason given for using complementary medicines was to prevent illness, in particular to avoid respiratory conditions, such as colds, pain and headache relief. (Source: TGA website)

User Profile:

More than 60% of Australians use at least one complementary or alternative healthcare product each year, These products include vitamin, mineral, plant or herbal, naturopathic and/or homoeopathic preparations and nutritional supplements.
In both Australia and America, the person most likely to use complementary healthcare products is female, aged between 30-50 years, has tertiary qualifications, earns over $50,000 and is employed in a professional or managerial position.
A recent report published in the Journal of the American Medical Association (JAMA) found that doctors are just as likely as the rest of the population to use complementary therapies.

MENOPAUSE
…AND WHY IT HAS ACCELERATED THE PROGRESS OF INTEGRATIVE MEDICINE

North American Menopause Society statement 2003

"In women who need relief for mild vasomotor symptoms, NAMS recommends first considering lifestyle changes, either alone or combined with a nonprescription remedy, such as dietary isoflavones, black cohosh, or vitamin E.
Prescription systemic estrogen-containing products remain the therapeutic standard for moderate to severe menopause-related hot flashes..… Clinicians are advised to enlist women's participation in decision making when weighing the benefits, harms, and scientific uncertainties of therapeutic options. "

As you can see, the integrative model of healthcare has already been adopted by organizations such as NAMS.
This statement takes into consideration lifestyle factors, nutritional supplements, evidence-based herbal remedies, patient choice and pharmaceutical options.
How did this come about in an environment where previously HRT was the gold standard for preventive health in old age?

HRT confusion

Women's Health Initiative Study and the Million Women study demonstrated an increased risk of combined therapy on the incidence of

  • breast cancer
  • coronary heart disease
  • stroke and
  • venous thrombo-embolism and
  • dementia

HRT

  • Increased the women's risk of breast cancer. Oestrogen alone (Premarin), preliminary results showed no increased risk of breast cancer or heart disease but did find a slightly increased risk of stroke.
  • made tumors harder to detect, leading to potentially dangerous delays in diagnosis.
  • was found to be of limited benefit for reducing fracture risk.

WHI: HRT and QUALITY of LIFE

WHI found that for women in the study - most of whom didn't have troublesome menopausal symptoms - combination hormone therapy did NOT provide a meaningful improvement in s quality-of-life measures:
sleep, emotional health, general health, physical functioning and sexual satisfaction.

Hormone Replacement Therapy

  • "…hormone replacement therapy works for symptoms but not for future health, which is not what had been widely promised"
  • "Meanwhile, women with menopausal symptoms have to make decisions"
  • McPherson, K: BMJ Feb 2004; 328:357-358

Evidence-Based "Alternatives"

Soy Isoflavones
Black Cohosh
Hypericum (St John's Wort)
Gingko biloba
Multivitamin
Calcium supplementation
Dietary Adjustment
Exercise
Stress management

Positive results for menopausal symptoms in small randomized controlled trials

Paced respiration
Cognitive behaviour therapy
Relaxation

The management of menopause is just one of a multitude of clinical areas where the practice of integrative healthcare is the gold standard. Other clinical areas where this model applies are:

  • Prevention of cancers (bowel, prostate, breast)
  • Arthritis
  • Chronic fatigue
  • Chronic low back pain
  • Irritable bowel syndrome
  • Chronic pain syndromes
  • Mental health
  • Living with cancer
  • Palliative care

THE FUTURE

  • A CONSUMER-LED revolution…Growing use of complementary medicine in the community. 
  • Evidence-based choices (CAM is not one big homogeneous mass)
  • Regulation
  • Education…healthcare providers and public
  • Greater communication and co-operation

CONSUMER-LED REVOLUTION

There is a well-established and growing using of CAM in the community.  The advent of consumer empowerment and unprecedented access to information on the internet has led to a well-resourced, demanding consumer who wants answers.

RESEARCH and EVIDENCE

Scientific evidence is providing the bridge between the silos of allopathic and complementary health care. 

DEFINITION OF EBM

"Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."
Sackett L. et al; BMJ 1996;312:71-72

"Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care"
Sackett L. et al; BMJ 1996;312:71-72

This key principle of evidence based assessment should be the basis of evaluating complementary medicines and therapies and their use by health professionals.  It should also be the basis of any collaborative relationships between medical practitioners and complementary therapists. 

Need to also bear in mind that not all therapies are easily amenable to scientific testing. 
It is estimated that only 15-40% of allopathic treatments have been properly scientifically tested, so medical practice does not have a monopoly on evidence.

The Cochrane collaboration is a work in progress
EBM is not an alternative to skilled clinical judgment.  Nor is it free of controversy
There is an established hierarchy of evidence, however EBM is not failsafe.  It does not always take into account the patient's beliefs and expectations, the practitioners' experience, judgment or intuition or the unique and sometimes intensely personal interaction between patient and practitioner.
Another word of caution is that by relying solely on that which has been proven before, we may never explore the cutting edge…after all, the very source of scientific success is trial and error, chance discovery and gut feeling.

That being said, integrative healthcare relies on good science and good judgment to tailor the best possible healthcare choices for individuals.

It is essential that scientific research is increasingly carried out in such a way as to permit complementary medicines and therapies to be assessed on an evidence basis.  This will require a commitment of public and private funding. Interdisciplinary research will become more common.

IMPLICATIONS for PROFESSIONAL LIABILITY

I firmly believe that issues of legal liability will become increasingly important for both practitioners of CAM therapies and the medical profession.

We need to establish what constitutes a duty of care for medical practitioners in relation to complementary medicine. 
A new and evolving standard of care as evidence increases for alternatives.  Therefore the legal standard of care for doctors and other healthcare providers is necessarily evolving.
One example I see on a regular basis is the pre-anaesthetic history with herbal medicines that influence anaesthesia or coagulation needing to be specifically asked about and discontinued.
Other issues that are raised include the acceptable levels of evidence on the basis of which doctors can feel confident in integrating use of complementary medicines and therapies into medical practice and to recognise contraindications.  Timing is an issue as there is a lag time from publication of evidence to acceptance of therapies as evidence-based.

Moreover, if a CAM treatment has been shown to be safe and effective, the ethics and laws around informed consent mandate that a doctor should offer the choice to patients.  Clearly, if a CAM modality has been SHOWN to be unsafe or ineffective in a particular clinical context, a healthcare practitioner cannot recommend it even if the patient insists.

For complementary therapists, the issue of respecting the boundaries of competency will, I believe, become crucial.  There is also an issue around CAM practitioners failing to advise patients of a more effective conventional treatment and to fully inform patients if there is insufficient evidence to

Lack of regulation of non-medical healthcare providers brings with it an element of risk to doctors wanting to refer patients.

REGULATION

Australia has one of the most rigorous regulatory frameworks in the world for CAM However, there is room for improvement without stifling development of the industry.  For example, there needs to be greater regulatory enforcement over the importation and use of raw herbs.

There is a need for appropriate regulation of complementary therapists.  Such regulation should ensure that non-medical complementary therapists cannot claim expertise in medical diagnosis and treatment, and that medical practitioners are aware of the choices available to patients.

Regulation would facilitate the referral of patients by medical practitioners to other healthcare providers.

All healthcare providers should be an integral part of a systematic approach to information about adverse events and alerts, with practitioners providing and receiving information from the TGA.  Such a system should also involve consumers.

INFORMATION AND EDUCATION

When I started my medical training, one lesson was made very clear.  The study of medicine is a lifelong pursuit.  You can never know it all.  As both an art and a science, healthcare is an ever-evolving and growing field of knowledge.
Increasingly, medical practitioners will require a basic understanding of Complementary Medicine and should receive sufficient training in their undergraduate, vocational and further education to enable them to discuss such issues with their patients on an informed basis. This training should also enable medical practitioners to incorporate complementary therapies into their practice if they so decide following due consideration of the evidence. 

In the last five years, a number of Australian university medical schools have introduced aspects of Complementary Medicine into their undergraduate courses. The depth of such curriculum coverage appears to vary but most medical schools have appropriately adopted an evidence-based approach to the subject matter. In pharmacy it also appears that many universities have introduced some coverage, mainly on herbal medicines. It appears that new graduates will increasingly have had some exposure to an evidence-based approach to complementary medicine, although more uniform and adequate coverage would require the agreement of standards in this area. Educational institutions and professional colleges need to ensure that medical education provides basic information about Complementary Medicine in relevant areas such as pharmacology and evidence based therapies.

Continuing Professional Education

As with any developments which impact on medicine, information about Complementary Medicine should be included in continuing education.

What is currently lacking is ready access to a comprehensive set of information on complementary medicines for health professionals, such as doctors and pharmacists, that will provide a base that may be updated through continuing education. Pharmacists and doctors also require:

  • the skills to evaluate the evidence on complementary medicine;
  • an understanding of their roles in providing evidence based information/advice;
  • an ability to access more detailed information when the need arises.
  • an ability to explain the regulatory framework developed by the TGA and the role it plays in certifying safety and efficacy.

It is important that medical practitioners are informed about the potential benefits and any potentially adverse effects of complementary medicines and therapies.
The use of CAM is now so established and widespread that medical practitioners should be required to attend continuing medical education programs which include information about CAM. 
A number of university postgraduate courses are also being offered which are relevant to doctors and pharmacists.

Medical practitioners should specifically ask patients about their use of Complementary Medicine and take account of this in their management of conditions and be sufficiently well informed about Complementary Medicine to be able to provide advice to patients when appropriate.

It is very pleasing to see the emergence of peer-reviewed journals and the inclusion of CAM research in medical newspapers and journals.  The government and professional bodies have a responsibility to develop similar information sources on complementary medicines and therapies for use by medical practitioners as exist for mainstream medicines and therapies.

It is the responsibility of medical colleges to develop educational and practice standards relevant to Complementary Medicine for use by medical practitioners and medical practices.

CONSUMER EDUCATION

Just as consumer education in areas of pharmaceuticals and medical care is a crucial component of patient empowerment, it is important that the public gains greater awareness of:

  • the need to continue to assess the evidence for safety and efficacy of complementary medicines and therapies in a range of clinical circumstances, such as pregnancy, childhood, diabetes, old age and so on.
  • the potential for interactions between complementary medicines; and pharmaceuticals; as well as
  • the role of the TGA and the difference between listed and registered products.

Patient outcomes depend on doctors, pharmacists, and other healthcare providers providing evidence-based information about complementary medicines. This information must be communicated more clearly and, in an ideal world, there would be greater communication between doctors and pharmacists and natural therapists.
It is essential that patients continue to seek appropriate medical care and do not jeopardise the management plan prescribed for medical conditions.
This may be partly based on a fear that their doctor will not approve of their use. And as a result, GPs tend to underestimate the extent of use by their patients. This is something that must change. And the key to that change is evidence. This is not the preserve of the medical profession.  It will be demanded by all practitioners of complementary therapies. Safety and standardisation must and will become hallmarks of the industry. There must be proof that any medicines or therapies work and are safe. Is the patient - the consumer - getting the desired outcomes and value for money? Are their health outcomes improving?

As doctors respond to the growing interest and demand from the public for alternatives, and complementary and alternative health care providers embrace the desirability of scientific proof of safety, efficacy and quality, patients will increasingly reap the benefits of "the best of both worlds". 
The turf wars of the past and present must not be allowed to pollute the future of healthcare.

Integrative medicine IS the Medicine of the Future.  Our universities, colleges, practices and processes must move to embrace this concept or they will become out of touch and irrelevant.