IOM report on CAM highlights a decade of change

Townsend Letter for Doctors and Patients,  April, 2005  by Elaine Zablocki

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In mid-January the prestigious Institute of Medicine released a 330-page report called Complementary and Alternative Medicine in the United States. The work of a 17-member committee, based on five public hearings plus an extensive search of the literature, this report will influence US attitudes and actions towards integrative medicine for years to come. It exemplifies how much progress we've made, and also how far we still have to go.

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The committee that wrote the report included 10 MDs, 5 PhDs, and two members with a master's degree in public health; all the committee members play influential roles within the conventional medical establishment. Initially the committee also included two members with closer ties to the CAM community, but after the first meeting they were removed, "due to concerns about conflicts of interest or bias," according to a spokesperson for the IOM.

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Even though one of the remaining committee members is a licensed acupuncturist, and one is a certified massage therapist, it's fair to say that this committee generally represents the views of conventional clinicians. Their report could be subtitled "what conventional medicine thinks about CAM."

A Decade of Progress

The most striking thing, when you first glance through this report, is how much the landscape has changed in little more than a decade. When David Eisenberg, MD, published his landmark article on CAM usage in January 1993, pointing out that Americans were spending $10 billion a year out of their own pockets on alternative therapies, the news came as a big surprise to most healthcare leaders.

Today, when Stuart Bondurant, MD, executive dean of Georgetown University Medical Center, opened the press conference on the report, he announced that "CAM is here to stay," adding that "more than one-third of American adults routinely use CAM, spending more than $30 billion a year of their own money."

This change is reflected in the report's key recommendations:

* Doctors, nurses and other health professionals should receive education about CAM treatments during their professional training.

* Healthcare licensing boards and accrediting agencies (for both CAM and conventional medicine) should set competency standards in the appropriate use of both conventional medicine and CAM therapies, consistent with practitioners' scope of practice.

* CAM practitioners should formulate practice guidelines for their own therapies.

* Product quality of nutritional supplements should be improved, with increased accuracy in labeling and stronger enforcement against misleading claims.

* NIH and other public and private agencies should sponsor research to compare outcomes and costs of combinations of CAM and conventional medical treatments, and varying models of care delivery.

* CAM practitioners should be involved in research in order to ensure that research reflects as much as possible the actual ways in which CAM is used.

The most fascinating chapter in this report (and one that really shows how far we've come) is chapter 4, on innovative research methods for CAM. The traditional gold standard for medical research is the randomized controlled trial, in which researchers hand out a real pill to some patients, a fake pill to other patients, and neither the physician nor the patient knows who's getting what. It's difficult to do this sort of research with many CAM treatments, for many reasons. Practitioners often use a combination of methods. Treatment is so individualized that four patients with the same symptoms may receive very different advice and therapies.

But it is possible to find other ways to study CAM, the committee said. "Addressing the special challenges ... for research in CAM will require a broadening of thinking about the types of study designs that can produce valid evidence of treatment effectiveness." In particular they mention observational studies, case control studies, and studies of bundles of therapies, as possible research methods to evaluate CAM.

Also take a look at chapter 6, which presents an ethical framework for CAM research, practice, and policy. The committee acknowledges that there are "multiple valid modes of healing" and that "investigation of CAM practices entails a moral commitment of openness to diverse interpretations of health and healing." It warns against co-option of CAM therapies by conventional medical practices.

Guarded Optimism

Representatives of the CAM professions have greeted the report with guarded optimism. "In general this is a pretty good report, in fact better than I expected," says Joseph Pizzorno, ND, president emeritus of Bastyr University, and editor of Integrative Medicine: a Clinician's Journal. "I like the orientation towards research, and the emphasis on product quality in botanicals and nutritional supplements. I like the fact that practice guidelines for CAM therapies will be developed by CAM practitioners. Frankly, I think these recommendations are good and I hope they're implemented."