Alternative medicine in conventional medicine

The expansion of offering so-called complementary and alternative medicine services in the context of "conventional" medical centers and private medical practices has been on my mind of late. Orac just recently posted an encore discussion of the topic that makes for good reading. Serendiptously, a number of British scientists issued yesterday a scathing indictment of the British National Health Service (NHS) Trusts for their financial support of alternative therapies in the UK while access to known, beneficial conventional medicines is often denied. Among those signing the letter to the NHS is Sir James Black, the 1988 Nobel laureate whose team brought us histamine-H2-selective antagonists for gastric ulcers and beta1-selective adrenergic antagonists for heart disease.

The British have had a very open and sober discourse on alternative medicine for a number of years. Part of the problem with discussing this issue in a scientific context is that alternative medicine ranges from conceptually-accessible plant-based herbal medicines to homeopathy and crystal healing. Dismissing all of alternative medicines is like making that converse statements that drugs are dangerous. The British are different, however, since the NHS will pay for some alternative therapy services. Hence, the issue is of greater public concern since all citizens ultimately pay for alternative medicine whether they agree with it or not.

In the US, the issue is more straightforward because very few managed care companies reimburse the insured for alternative therapies and services. Hence, a number of academic medical centers have jumped onto the alternative medicine bandwagon because most of those seeking services have the financial capacity to pay for services out of pocket. As a result, alternative therapies in the US are becoming the medicine of the rich and famous.

A bigger issue, worthy of further discussion after upcoming grant deadlines, is that US academic medical centers are promoting these services under the guise of "integrative medicine." In some institutions, these efforts are rigorously overseen, led by MDs well-trained in internal medicine and an appropriate sub-specialty, and only offered where evidenced-based medicine supports their use. In other institutions, integrative medicine programs operate as programs on the fringe, aggressively promoted to the community but often not even known to researchers and clinicians and within the very same institution.

A commentor at Respectful Insolence recently raised my awareness of the Consortium of Academic Medical Centers for Integrative Medicine, programs within academic medical centers in North America offering some sort of alternative medicine services. Those that I know of personally vary considerably in the quality and scientific rigor of their programs; even more interesting is the glaring omission of outstanding integrative medicine centers who are not part of this collaborative group. Were they not invited to join? Or, did they choose not to participate?

As a PhD researcher whose training and career has always been associated with US medical schools, I firmly believe that it should be safer and wiser for a patient to pursue alternative medicine approaches in academic medical centers than in the community. Contingent to this belief is that academic medical centers will be committed to providing the highest-quality, most rigorously supported therapies and services based in scientific fact and evidence-based medicine.

The biggest challenge to this notion, though, is how well these integrative medicine programs are themselves integrated within the medical center/health system to which they belong.

Moreover, if academic medical centers get into this business, should there be integrative medicine services specific to each medical specialty as opposed to one large overriding integrative medicine service? Compare everyone's hot-button target NCCAM who tries to fund research for all types of alternative modalities across all types of diseases to the quietly and highly-successful OCCAM that operates under the roof of the US National Cancer Institute, researching those modalities most likely to benefit the cancer patient and cancer survivor.

Some of my colleagues contend that there should be no need for integrative medicine. Test alternative therapies, keep what works and incorporate it into conventional medicine, and discard the rest.