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As I travel across the U.S., I am often at universities such as Harvard, where there are not one, but two, mind-body programs. Or in New York, where, since 1994, Columbia- Presbyterian=s cardiac surgery program has routinely used music therapy, hypnotherapy, massage, reflexology, yoga, aromatherapy, and energy therapy in the treatment of open heart surgery patients. The next day, I might well be speaking to a hospital board where a director will first ask me what complementary medicine is, and then tell me in no uncertain terms that AHerbs and all the rest of that are malarkey.@ During a golf outing the following day, I may well find the same board member C on the recommendation of his golf pro C buying a copper bracelet for arthritis or magnetic pads for his shoes to improve circulation.

It can be disorienting out there.

No matter what the perspective, complementary medicine is all around us. Pick up a healthcare journal of some type, an airline magazine, or an upscale catalog, and you are likely to read about what NIH is doing with complementary medicine, see an announcement for a conference on alternative care or healing environments or an ad for aroma, herbal, or magnetic therapy. Payors are adding benefits, hospitals exploring healing environments and prayer, and boomers and young mothers in focus groups speak as casually about Echinacea (eck-ih-nay=-sha) C an herb European research verifies enhances the immune system C as they do of menopause or children=s ear infections.

What is complementary medicine?

There are many very different types of modalities under the umbrella terms, >complementary= or >alternative= medicine. The definition panel of the U.S. Office of Alternative Medicine has defined complementary medicine as Aa broad domain of healing resources that encompasses all health systems, modalities and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system or a particular society or culture in a given historical period.@ The same panel noted that the boundaries between different systems are not fixed, or even always clear.

Complementary medicine, then, is defined more by what it is not than by what it is. For those of us in the U.S., complementary medicine is any type of practice or therapy used in the prevention, treatment, or management of disease that is not rooted in western, or U.S., medicine. The term ACAM,@ for Acomplementary and alternative medicine,@ is becoming commonly used to denote these modalities as a group.

Other terms are Aintegrative medicine@ C medicine that integrates western and eastern medicine, or Aalternative@ or Aholistic@ medicine. It should be noted that today=s U.S. citizen may be the only one who thinks of these approaches as Aalternative.@ In most of the world, these are actually Atraditional@ medicine. Western medicine, after all, is only a century old. By comparison, what we call CAM has been used and refined throughout the world for 5,000 years or so.

One focus group participant put this in perspective: AIf it=s not invented here, we don=t believe it=s real. Don=t you find that a bit arrogant?@

What is the U.S. history on these modalities?

Even in the U.S., many of these modalities have been in use for centuries. A book, reviewed on National Public Radio, was recently published in the U.S. on healing recipes C recipes that have traditionally been used to promote healing. Indigenous Americans C like other indigenous peoples worldwide C have long used shamans and drumming for healing, practices now very much a part of this movement. Yoga, acupuncture, and ayurvedic medicine have been used for thousands of years.

Recently in the U.S., several indicators show a growing awareness of these therapies. In 1992, the National Institutes of Health established the Office of Alternative Medicine with a budget of $2 million. By 1998, the name was changed to the National Center for Complementary and Alternative Medicine (NCCAM), now with a $50 million budget.

In the meantime, from 1989 to 1994, there was a 92 percent growth in sales of Anatural@ products nationwide, with even U.S. Senator Orrin Hatch of Utah C not exactly known for liberal tendencies C fiercely protecting the vitamin industry in congress.

Half of the nation=s 125 medical school offer CAM courses, and more are investigating this option, spurred on by a 1997 AMA report on AEncouraging Medical Student Education in Complementary Health Care Practices.@ The same year, the Group on Educational Affairs of the Association of American Medical Colleges (AAMC) announced the formation of the Special Interest Group on Alternative and Complementary Medicine. More recently, the American Public Health Association has also recently formed a special interest group on CAM.

Why the sudden interest in CAM?

There are dozens of reasons, but the primary one may well be the emergence of the boomer woman.

Over the years, as a nation, we have learned lessons in medicine. One of the biggest C brought home by HMOs focusing on financial efficacy of therapies C is that medicine cannot accomplish everything. When consumers are asked why they use CAM, they most commonly describe a frustration with the limited scope of western medicine.

There is often a concern about prevention and management of disease they feel western medicine does not address. They are also concerned about too much use of chemicals and antibiotics in foods, for themselves and their children. Among many, there is a growing awareness that approaches elsewhere in the world yield outcomes at least as good as U.S. medicine. Most importantly, there are positive experiences with CAM. 

The boomer, born from 1946 to 1964, is arguably the largest and most influential demographic group in the U.S., one that will be driving healthcare decisions for the next four decades. The older boomer woman (45 and up) teethed on the Lamaze revolution, one of the first widely used alternative approaches in America.

A combination of relaxation, meditation, breathing and massage modalities, Lamaze swept the nation in the late >60s and early >70s, demonstrating with data, experience and finally with strong emotion that American medicine might just have been a bit warped about what was good for mothers and babies.

A revolution in childbirth followed, and today=s boomer woman never forgot that lesson. Now, as the first generation of women to have worked extensively outside the home C yielding experience with politics and power C she has the demographic, social and economic power to take it to new levels.

Eisenberg, in a landmark 1993 study published in The New England Journal of Medicine, identified the typical CAM user as female, age 35 to 49 (the boomer age group), non-black, having some college education and an income of $50,000/year or more. In HCI Market Research Group=s national research, CAM is almost exclusively a female boomer issue, with increasing interest by seniors, also identified in JAMA studies. Prior studies had identified that one out of three Americans has used chiropractic, acupuncture, homeopathy, or one of many other CAM modalities. The JAMA study found that 46 percent of Americans used at least one form of CAM in the preceding year, and that CAM practitioner visits (629 million) outnumbered visits to primary care practitioners (386 million). This is more than a blip.

A typical visit to an acupuncturist, massage therapist, or chiropractor costs $50 per hour or more. Many visits of this type are not covered by insurance, so out-of-pocket costs are high. Contrary to perceptions among some western medical providers, CAM is far from a >cheap alternative= to western medical care. Studies published in JAMA arrived at an average annual out-of-pocket expenditure of $500 per CAM user, and estimated that $21.2 billion was spent on CAM in 1997, with at least a third of that out-of-pocket C more than the total 1997 out-of-pocket expenditures for all U.S. hospitalizations. HCI MRG preliminary market research indicates a range in out-of-pocket spending among boomer women on CAM of from $0 to $10,000 annually, with an average of $600 out-of-pocket per CAM user after high spending outliers were excluded.

If you are a healthcare provider, don=t expect to unravel the usage picture easily. Most of these women would rather go to the theatre nude than admit to skeptical or critical providers that they use CAM. And, as the JAMA studies note, most mix CAM and western medicine; only 4.4 percent use CAM alone. HCI MRG finds that, for better or worse, these women govern the brew themselves.

The reasons are many. Researchers cite dissatisfaction with conventional care that is too authoritarian, ineffective, or focused on surgery or disease rather than wellness or maintaining good function and optimum health. In Britain, at Europe=s only public-sector hospital dedicated to complementary medicine, 26 percent of patients had experienced adverse effects caused by conventional treatment. Recent U.S. research with breast cancer victims notes that CAM may be sought out for depression or anxiety, or to help deal with the severe side effects of chemotherapy and radiation.

Alternative therapies are often seen as more participative and offering more choice. Women in focus groups often talk about the potential of CAM to reduce the need for, or dosage of, medications, such as estrogen during menopause. As a nation, we travel more and have incorporated more citizens and cultures of other countries; it is easier to see that there are ways other than ours. Finally, many have begun to see the limitations of our medical system, and often want more answers than conventional medicine provides for day-to-day management of health and illness.

What are they using?

There are four basic categories of CAM:

1. Hands-on therapies
2. Mind-body therapies
3. Herbal and mineral healing
4. Lifestyle therapies

The categories overlap; many practitioners use more than one type, and use of one type often involves use of another. There are also many subcategories. For instance, there are dozens of different types of massage therapy which is just one category of hands-on therapy.

The following are examples of the modalities included in each type.

1. Hands-on therapies

Massage
Acupuncture
Chiropractic
Traditional Chinese Medicine (TCM)
Naturopathy
Homeopathy
Reflexology
Touch for Health
Polarity therapy

2. Mind-body therapies

Relaxation
Hypnotherapy
Spiritual healing, prayer
Meditation
Yoga
Tai Chi
Therapeutic touch, energy healing/therapy
Hypnotherapy
Shamanism
Healing environments (aromatherapy, music and art therapy,                    plants/trees)
Ayurveda (including chakra work)

3. Herbal and mineral healing
       

                Vitamins
        Herbs
        Nutrition
        Aromatherapy
        Crystals
        Eastern medicine
        Magnetic therapy
        Chelation therapy

4. Lifestyle therapies

Trainers
Nutrition
Weight management
Smoking cessation programs

Among those most commonly used are aromatherapy (so common it is now in your local supermarket), massage, and chiropractic. In many categories, the boundary blurs between western medicine and CAM. Traditional and newer forms of psychotherapy, for instance, are clearly mind-body therapies.

How do you sort out what has value and what is, well, malarkey?

Great question, and one being increasingly examined by western medicine. Most CAM users say, ARead, ask questions, use common sense. Try it carefully and if it works for you, it works.@ But back to those board members.

Western medicine has put a tentative stamp of approval on some therapies, if with reluctance. Under substantial pressure, NIH in 1997 approved acupuncture for some types of pain relief, after research showed it worked. Yoga has been demonstrated to decrease hypertension, and massage can relieve stress. A traditional Chinese Medicine approach, moxibustion, works to convert breeches. And saw palmetto, an herb, is effective in reducing prostate enlargement.

These are reported in the JAMA study and others. But they don=t begin to cover the far-reaching range of alternative modalities C the vitamins, herbs, multiple types of massage, homeopathy, and other approaches you can find advertised in alternative newspapers and magazines, phone books, and health food stores, to name a few sources.

To make it more complicated, most CAM practitioners are also not regulated. There isn=t a Board of CAM you can call to check on your local practitioners. Of all the dozens of types of practitioners who offer CAM approaches, most states license only massage therapists, chiropractors, acupuncturists and, in some states, naturopathic physicians. And as anyone who has been involved in CAM can tell you, there are mediocre, good, and fabulous massage therapists, all licensed C to use one example alone.

One tip often emerges: the good CAM practitioners refer to other good practitioners. Word of mouth is often very accurate. And at least the risk is low. Yes, there are CAM therapies C usually herbs C that can hurt, but they are few and far between, and careful practitioners know exactly what they are, and are very careful to stay within limits. There are few risks to massage by licensed practitioners, most herbs, drumming, meditation, healing environments, and other CAM methodologies that hold promise to improve the quality of life and healing.

What do insurance plans think about all this?

There are regional differences. Just as the JAMA studies found more CAM consumer interest in the western U.S., insurance plans in western states are also more likely than traditional Midwestern insurance plans, for instance, to add CAM benefits. Although that, too, is changing: nationwide, 25 percent of insurers added some type of CAM benefit last year, and a 1996 survey with HMOs in 13 states indicated 58 percent planned to offer alternative therapies by 1999.

By 1997, 40 major insurance plans nationally offered some type of CAM benefits, including Aetna U.S. Healthcare, Kaiser Permanente, Oxford, Prudential, Blue Shield of California, and CHAMPUS. Benefits typically are member discounts for chiropractic, acupuncture, and herbal therapies, although one major plan on the West Coast offers members the ability to select a naturopath as a primary care physician.

When HMOs talk about the reasons for adding CAM benefits, they note demand by enrollees, an increased focus on holistic health and prevention, and cost-effectiveness.

What is the future of CAM?

If you look at nothing but the exponential increase in lay interest, it is clear that CAM will continue to be on the front burner. It has captured the interest of western medicine, and we will continue to hear about clinical trials, often hotly debated. Expect to see some pretty non-traditional providers teaching overview courses in medical and nursing schools, and that herbal remedy courses in pharmacy schools will become routine. Expect continued questions about vitamins, antioxidants, and herbs, and certainly expect that midlifers will want to hear about nutritional and lifestyle therapies as well as hormone replacement therapy (HRT). Expect new blends of traditional and CAM therapies, massage for hospital and labor patients, or for complex patients while they are undergoing traditional psychotherapy.

Many hospitals are exploring pilot programs in healing environments, or offering non-invasive CAM therapies through an outpatient setting (often via women=s centers) or to select hospital patients. The Columbia University program, with its multiple CAM modalities for open heart and other surgery patients, was almost completely market-driven. And even in conservative communities, many physicians are reaching out for help understanding the phenomena and working positively with CAM. In a recent HCI physician survey for one client in a very medically conservative area, 10 of 14 MDs surveyed were interested in inclusion of CAM methodologies in a new women=s center. Seven OB-Gyns wanted an herbalist on site, and four wanted massage therapists on site. Other MDs C including both OB-Gyns and urogynecologists C were interested in physical therapy, personal trainers, acupuncture and chiropractic on site at the women=s center.

The first step for most is market research, during which the following are identified and explored:

1. Potential markets
2. Currently accepted methodologies in the area
3. Unmet needs
4. Interest among payors and stakeholders, including medical staff
5. Interest among local CAM providers
6. Compatibility with current therapies and therapists
7. Potential revenues and costs.

Look at whether CAM modalities are entering or exiting the market, what types of services have been available, and are becoming available. Study how stakeholders react to the service. The initial stakeholder interviews should be conducted privately. The data from these interviews will then form the basis for bringing those with interest together into a steering group to explore further development. You should definitely document how the implementation of CAM modalities might impact the reputation of the institution. This will be a key question of many, and you should know the answer ahead of time C it is often positive. Likewise, you should know how the reputation of your institution impacts the success of your potential CAM program, which might well drive location and marketing issues.

Read and listen with both curiosity and healthy skepticism but an open mind. Go to conferences. Begin slowly and with those therapies that make good common sense, such as healing environments. After all, what would you rather smell if you were hospitalized C ammonia or vanilla?

Use pilot programs and advisory boards, carefully selected for open, inquisitive minds and credibility. Expand as the market is ready, involving western-trained physicians who have experience with CAM therapies. Find champions. And enjoy the blend with traditional therapies that always emerges, often with little effort.

References

CAM was the theme of the November 1998 issue of The Journal of the American Medical Association, 280(18), which included several articles. The Eisenberg article (see below) was the most comprehensive, but there were others on moxibustion, saw palmetto, and other therapies, as well as U.S. and international trends.

Blanks et al, AA Retrospective Assessment of Network Care Using a Survey of Self-Rated Health, Wellness, and Quality of Life,@ The Journal of Vertebral Subluxation Research, vol. 1, #4, 1997.

Eisenberg et al, ATrends in Alternative Medicine Use in the United State, 1990-1997, The Journal of the American Medical Association, Nov 11, 1998, 280(18):1569-1575. This article includes an extensive reference list.

Kao, Laurel Skruko, AComplementary and Alternative Medicine (CAM) and Managed Health Care: Setting an Agenda,@ American Journal of Chinese Medicine, 1998, Vol. XXVI, No. 2, pp 231-249.

Oz, Whitworth and Liu, AComplementary Medicine in the Surgical Wards@ (Columbia University program), JAMA, 279 (9), March 1998, pp 710-1.

Wetzel et al, ACourses Involving Complementary and Alternative Medicine at U.S. Medical Schools,@ JAMA, 280(9) pp 784-7.

American Association of Acupuncture and Oriental Medicine; (610) 266-1433
American Association of Naturopathic Physicians, 2366 Eastlake Ave. East, Suite 322,
  Seattle, WA 98102; (206) 298-0126
American Foundation of Traditional Chinese Medicine, San Francisco, CA;
  (415) 776-0502
American Holistic Medical Association, 6728 Old McLean Village Drive, McLean,
  VA 22101; (703) 556-9728
Association for Network Chiropractic, 444 North Main Street, Longmont, CO 80501;
  (303) 678-8086
The Foundation for Shamanic Studies, PO Box 1939, Mill Valley, CA 94942;
  (415) 380-8282
Herb Research Foundation, 1007 Pearl Street, Suite 200, Boulder, CO 80302;
  (303) 449-2265
Milne Institute (CranioSacral therapy), PO Box 220, Big Sur, CA 93920; (408) 667-2323
National Center for Complementary and Alternative Medicine, National Institutes for
  Health, Bethesda, MD; (888) 644-6226
One Foundation (Neuro Emotional Technique [NET] Chiropractic Practitioners), Box
  84952, San Diego, CA 92138; (760) 633-1663.

Internet C Again, a Very Partial List

www.onefoundation.org (under construction) 

Many thanks to the following CAM practitioners in Salt Lake City, Utah, who reviewed this article and contributed materials and ideas:

Michael Cerami, DC, Network Chiropractic
Amy Cortese, BS, MS, CSC, Faculty, The Foundation for Shamanic Studies
Michael A. King, LMT, Touch for Health Instructor, Utah College of Massage
          Therapy
Debi Mathis, CSCS, NSCA-Personal Trainer
Mark Resetarits, DC, Chiropractor
        Lisa Neuhof, LMT, CranioSacral Massage Instructor, Utah College of Massage
          Therapy.

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Mary Anne Graf can be reached at 801-488-4340.

From The Ireland Report on Succeeding in Women's Health, September/October, 1999.

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