Now,'Integrative' Care

Carol green was busy filling out medical-school applications several years ago when she had an epiphany. She could devote herself to a single healing tradition, she realized, or she could take a chance on something more inclusive. "I was interested in integrating Eastern and Western philosophies and finding a common language." So Green tossed her med-school applications and pursued a degree in traditional Chinese medicine at the New England School of Acupuncture. Today she has a busy practice at the Marino Center for Progressive Health in Dedham, Mass. She loves sharing her knowledge of herbs and acupuncture with patients. And though she worried at first that conventionally trained physicians would shun her, she has found they're as eager as she is to break down old boundaries. She sends her patients to M.D.s when she can't help them--and M.D.s send just as many to her. She gets referrals from internists, orthopedic surgeons, even psychiatrists. "Why should people use just one modality?" she asks.

Nearly half of all U.S. adults now go outside the health system for some of their care. We make more visits to nonconventional healers (some 600 million a year) than we do to M.D.s, and we spend more of our own money for the privilege--about $30 billion a year by recent estimates. Complementary and alternative medicine, or CAM, is not a single, unified tradition. The term covers practices ranging from the credible (acupuncture, chiropractic) to the laughable (coffee enemas). Because few of these therapies have been thoroughly evaluated in controlled studies, their effectiveness is still widely debated. But no one now disputes their significance. "The treatments are already in widespread use," says Dr. Susan Folkman of the University of California, San Francisco--"and the public believes in them."

So after dismissing CAM therapies as quackery for the better part of a century, the medical establishment now finds itself racing to evaluate them. At many of the country's leading hospitals and research institutions, conventionally trained physicians are studying herbs, acupuncture, tai chi and biofeedback as rigorously as they would a new antibiotic. The short-term goal is to identify the CAM practices with the greatest benefits and the fewest hazards, and to make them part of routine clinical practice. But this movement is more than a search for new remedies. Its larger mission is to spawn a new kind of medicine--an integrative medicine that employs the rigor of modern science without being constrained by it. If the dream is realized, the terms "complementary" and "alternative" will become meaningless, proponents say. We'll have one health system instead of two, and healers of every stripe will work together while being guided by science.

Until a decade ago, no one realized how quickly the health system was splitting in two. The wake-up call came in 1993, when Dr. David Eisenberg of Harvard Medical School published a now famous survey showing that 34 percent of all U.S. adults had received at least one unconventional therapy in 1990. The medical community was flabbergasted, but the excitement was just beginning. CAM use increased by an additional 25 percent between 1990 and 1997, according to a later survey by Eisenberg's group, and the percentage of Americans taking herbs nearly quadrupled. Consumers weren't abandoning conventional medicine. But because few people were telling their M.D.s about their other sources of treatment, an estimated 15 million were risking adverse interactions between supplements and prescription drugs. Alarmed by this breakdown in communication, Eisenberg's group called on "federal agencies, private corporations, foundations and academic institutions" to "adopt a more proactive posture" on CAM.

That wish was quickly realized. In 1998, the National Institutes of Health turned its tiny Office of Alternative Medicine into a full-strength federal agency and christened it the National Center for Complementary and Alternative Medicine (NCCAM). Its budget, which once hovered around $2 million a year, rose quickly to more than $100 million. The money and excitement spread quickly to the philanthropic and academic worlds, spawning not only new research but whole new programs at many leading medical schools. Today Columbia, Duke, Harvard and the University of California, San Francisco, all have centers for integrative medicine, and at least two thirds of U.S. medical colleges offer courses in CAM. The number of hospitals offering complementary therapies doubled between 1998 and 2000 (topping 15 percent), and even health --insurers warmed up to some therapies.

Not everyone is pleased, of course. The Washington Monthly has dubbed NCCAM "an expensive medical swindle being abetted by the nation's leading medical schools." And when a White House commission called last spring for more efforts to integrate safe, effective CAM therapies into conventional medicine, a group called Citizens for Science in Medicine accused the panel of trying to "overthrow science-based medicine" in favor of "unvalidated voodoo." Such polemics were once commonplace, but the old party lines on CAM--both the uncritical enthusiasm and the uninformed hostility--are now dissolving. "We're not out to promote or debunk anything," says Dr. Stephen Straus, the conventionally trained physician who heads NCCAM. "We want to test therapies that have a plausible basis and address some unmet need."

NCCAM's signature projects are large clinical trials designed to assess the merits of popular therapies. For example, researchers in 11 states are now enrolling osteoarthritis sufferers in a five-year, $16 million study of the supplements glucosamine and chondroitin sulfate. Over the course of the study, each volunteer will take one of five identical-looking pills: a placebo, a prescription medication (Celebrex), a glucosamine supplement, a chondroitin supplement or a pill containing both of the supplements. By tracking everyone's symptoms, side effects and disease progression--and comparing outcomes for each of the five groups--researchers will gain unprecedented insights into the risks and benefits of each regimen. NCCAM is sponsoring similar studies to see whether acupuncture can ease arthritis pain, whether vitamin E and selenium help prevent prostate cancer and whether Ginkgo biloba can preserve mental function in healthy old folks.

While these huge clinical trials plod --along, researchers are using state-of-the-art laboratory techniques to glimpse the physiological effects of different CAM remedies. At the University of California, Irvine, for example, radiology professor Zang-Hee Cho uses a high-speed imaging technique called fMRI (functional magnetic resonance imaging) to watch what happens in the brain when acupuncture needles enter the foot. Cho showed four years ago that an acupuncture point traditionally used to ease eye problems did in fact stimulate the visual cortex. In a more recent study he found that needling other points on the foot can modulate activity in the four brain areas involved in pain perception, enabling people to hold their fingers in 122-degree water without discomfort. "We used to think these were mysterious energies," Cho says, "but not anymore. As we learn how acupuncture really works, we may find that one well-placed needle can do what we now do with 20."

There's no substitute for knowledge. By placing CAM under the microscope, scientists will no doubt gain a better sense of which therapies work, how they work, whether they're safe and who is most likely to benefit. But making CAM more efficient is one thing, restoring a measure of humanity to the health system quite another. What draws people to CAM and integrative medicine is not a desire for efficiency but a longing to be cared for. From a patient's perspective, acupuncture is a ritual in which a therapist touches you and talks to you and helps you feel better. By the logic of scientific medicine, acupuncture is an encounter between a patient and a needle. Its true effect is the one you can measure after factoring out such "confounders" as care and compassion. "Some things that count can't be measured," says Dr. Tieraona Low Dog, an Albuquerque, N.M., internist and a leader in the integrative-medicine movement. "We need a health system that can do more than count."

Can a system built on one paradigm accommodate another? Is there room for care and compassion within science-based medicine? Anyone who doubts it would do well to visit New York's Weill-Cornell Center for Integrative Medicine. Its medical director, Dr. Mitchell Gaynor, is a conventionally trained M.D., board certified in both oncology and hematology. When a newly diagnosed cancer patient comes into his office, he takes a history and physical, goes over CT and MRI scans, reviews the pathology reports and discusses the likely effects (and side effects) of --surgery, radiation and chemotherapy. Then instead of bidding the patient good day, as convention dictates, he helps her cope with the experience of life-threatening illness.

When 54-year-old Marisa Harris showed up in Gaynor's office four years ago, she had just learned she had stage 4 cancer and a life expectancy of roughly nine months. What could the medical world do for her? she had asked several oncologists, and each had given her the same answer. She would get five to six months of debilitating chemotherapy. Then she would die. Gaynor reviewed her chart, took some blood, then delivered an utterly different message. "You know," he said, "there's a lot you can do for yourself." He asked her about her fears and regrets, even her diet, and suggested strategies for asserting control over her life. Gaynor didn't argue with her initial decision to forgo chemo, but he invited her to join his support group and meditation class. Those experiences changed everything.

Harris thought the doctor was planning to make pasta when he arrived at the meditation class bearing an assortment of metal and crystal bowls. The bowls were in fact musical instruments from Egypt and Tibet. As Gaynor tapped them with a wooden mallet, Harris says she felt the music "washing through every cell in my body"--a fair description considering that water (which makes up 70 percent of our mass) is a perfect medium for sound waves. The words of the other doctors--"incurable," "medically untreatable," "nine months if you're lucky"--were still echoing oppressively in Harris's head. But meditation helped her quiet them and summon her dad's old refrain: "We're survivors; we don't give up." Within four months, she had changed her mind about chemo. With Gaynor's encouragement and the support of her peers, she was able to approach it not as perdition but as "a wonderful gift." She experienced what she now recalls as "a state of grace and healing." Four years later, she's as happy as she has ever been in her life.

Why is such care still the exception instead of the rule? Training is part of the problem. Though many medical schools now offer elective courses in integrative medicine, few of today's doctors have learned to look beyond lab tests to grapple with the patient's experience of illness and --quest for health. The future looks bright, though. In addition to revamping their curricula, some medical colleges are now offering fellowships to help practicing physicians catch up. And 12 leading medical schools have recently formed a consortium to push for what its founders call "fundamental changes in the way we are training future physicians." It shouldn't be a hard sell. Surveys suggest that doctors are as unhappy as patients about the current state of health care, and that most are eager to expand their roles. "Duke is as classical as any medical school," says Dr. Ralph Snyderman, the school's chancellor. "But our faculty shows overwhelming interest in integrative care." When Duke polled 200 of its affiliated doctors, half said they would happily collaborate with CAM providers and 30 percent expressed interest in studying CAM therapies themselves.

There is one other catch, and it's a big one. From Medicare down to the smallest private health plan, the reimbursement system is still strongly biased against holistic care. The nation's insurers spend $30 billion a year on bypass and angioplasty for cardiovascular disease, for example, but only 40 of them cover the lifestyle-based program developed by Dr. Dean Ornish--despite repeated demonstrations that it is safe, effective and vastly less expensive than surgery. "Integrative medicine can be viable in a small practice where patients pay as they go," says Dr. Mary Hardy, director of the integrative-medicine program at L.A.'s Cedars Sinai Medical Center, "but it's still hard to succeed on a larger scale." In Hardy's hospital-based clinic, M.D.s serve as team leaders, and patients draw freely on many traditions at once. But their insurance tends to cover only what is conventional.

This will surely change. Insurers, including Medicare, are now launching small pilot projects in integrative medicine. CAM treatments have begun to show up in the American Medical Association's vast directory of billable procedures. And the flurry of research now going on will give insurers a clearer sense of what works and what is affordable. Snyderman believes the transformation underway could prove as epochal as the birth of scientific medicine a century ago. What's at stake is not just the status of some individual therapies but the whole meaning of health care.

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