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Looks at the political and linguistic battles between mainstream medicine and the emerging consensus favoring integrative health practices.
A Long-Time CAM Supporter Takes a Timely Look at the ‘Mushy’ Vocabulary of Complementary and Alternative Medicine
Earon S. Davis, J.D., M.P.H
On the occasion of the name change at the National Institutes of Health, I have found it necessary to provide some background into the terminology that current exists in the courses I teach and the larger world I inhabit. Many of my students find the CAM terminology to be confusing. Often, they are fully aware of the perspectives of mainstream medicine but unaware of what CAM is and where it is going. Indeed, logical minds are not comfortable with the constantly changing, "mushy" terms of CAM. Given the conceptual differences between CAM and mainstream medicine, and their competition for influence in our culture and economy, one will not find permanent precision and absolute clarity. It is more of a process of jumping in and feeling your way around.
Why is it so important to note a changed name of a field at the National Institutes of Health? Well, the National Institutes of Health is where science and policy are integrated in our country. This is where the leaders of medicine, industry and government come together to set a framework for understanding and pursuing the scientific and medical needs of our nation. While there are different movements and different terms circulating around the country and the world, having consistent language is vital in communicating and building cohesive approaches and programs related to the field of health.
In order to understand the vocabulary of CAM, I think it is important to note that there was really no such thing as CAM until the very late 1900’s, when it was referred to as “Alternative Medicine.” According to the NCCIH website1, in 1991, an office was established in the National Institutes of Health to collect information on promising, unconventional therapies that were in use in order to begin evaluating whether any of them had potential benefits. In 1993, that office became the Office of Alternative Medicine (OAM).
In 1998, OAM was elevated to the status of a Center within the National Institutes of Health and the name was changed to the National Center for Complementary and Alternative Medicine (NCCAM). To me, that move represented progress in the process of bringing CAM into the realm of respectability within the medical community. The addition of the word, “complementary” furthered the notion that even a conservative physician could recommend a CAM practice to a patient when it appeared to be reasonable and helpful.
It was no longer a battle between Mainstream and Alternative Medicine, which in the 1970’s had led to a U.S. District Court ruling (the U.S. Court of Appeals affirmed and the U.S. Supreme Court declined to review the case) forcing the American Medical Association to stop trying to destroy Chiropractic.3 That case made it clear that there were limits on how mainstream medicine (e.g., the once powerful AMA – the American Medical Association) could limit individual access to practices that the public found useful and appealing. Since the AMA was unable to prove that Chiropractic was a fraud and ineffective, the stage was set for expanded State licensing of non-mainstream health practices and the growth of more practices that might eventually find their way into mainstream society and medicine.
In November of 2014, the name of NCCAM was changed to the "National Center for Complementary and Integrative Health" (NCCIH). This change brings clearer recognition of a truce between mainstream medicine and at least those practices that have received validation through the process of mainstream scientific research.
CAM is an umbrella term (concept) that was developed to include all of the medical and health practices that exist which do not fall into the accepted confines of mainstream, conventional, allopathic medicine. Clearly, this is a mixed bag, with some practices having substantial scientific validation and other practices having none. Therefore, what one person considers CAM may be considered “quackery” to another person and mainstream medicine to yet another individual. It all depends upon one’s perspective.
To further confuse things, there is also no such thing as mainstream medicine, either. There is no clear cut way to describe all of mainstream medicine, other than to include everything commonly taught in medical schools and reimbursed by insurance companies. Such a broad term, of course, has many exceptions and mainstream medicine includes many thousands of practices that are unproven and still in stages of development and research. Mainstream Medicine is, therefore, just a rough, collective term for the diverse, but generally accepted, practices, in western medicine today.
An earlier edition of Micozzi’s groundbreaking textbook on CAM2 was named “Fundamentals of Complementary and Integrative Medicine.” Perhaps the author and Publisher were anticipating a change in terminology or perhaps they were hoping to trigger such a change. The various names (complementary, alternative and integrative) have different intentions and meanings, depending upon the context.
Currently, I think that the recent change to "Integrative Health" (NCCIH) is probably motivated to work around the resistance of mainstream medicine to the term "Alternative” medicine. It is also driven by a desire to avoid opposition from mainstream doctors who don't like the term "Medicine" being used for something that is not mainstream medicine, and even practiced by non-M.D.’s. Doctors often assert that only M.D.'s (and D.O.'s) are able to legally practice Medicine and that therefore nobody else should use that term. Thus, we may have just witnessed an important negotiated settlement making it easier for un-researched modalities to be studied by mainstream researchers.
Words such as therapy and practice are among other choices for describing not-specifically-medical interventions. Perhaps the safest way to carve out different approaches to health and wellness is to put them outside the domain of “medicine” and into “health.” Some will see this as mere politics and public relations, but this is the medico-legal world in which we live, and in which practitioners seek the freedom to practice in ways that are meaningful and successful to them. Physicians are technically free to use or recommend complementary and integrative therapies to the extent that organized medical societies don’t decide that they have endangered patients and the reputation of medicine.
In the bigger picture, I think that mainstream doctors sometimes take defensive postures against unconventional practices out of concern for patients, but also to confront serious challenges to mainstream medicine orthodoxy. Instead of the reductionist “Disease Model”, many consumers, health practitioners and physicians are in favor of a holistic “Health and Wellness Model”. In the midst of this change, transformation and struggle, here is my understanding of the differences between the different terms:
Underlying the confusion with the various terms is the fact that these terms apply to how a given practice is used, rather than anything inherent about the practice, itself. Therefore, if someone treats cancer by using acupuncture and herbs, and avoiding standard medical treatments, that is an “Alternative Medicine.” If someone uses acupuncture and herbs in addition to standard medical treatments, that is “Complementary” or “Integrative,” depending upon the scientific basis in the treatment.
So, a treatment plan is “Mainstream” if it relies solely upon mainstream medicine. It is “Complementary” if it relies upon both mainstream and other practices that have some credibility. The treatment plan is “Integrative” if it relies upon mainstream and other practices that have a scientific basis. It is “Alternative Medicine” if the treatment plan has no scientific basis and avoids all mainstream medicine.
It is also important to note that primary care physicians are in a very different position than academic specialists and organized medical societies. They are confronted with a patient, an individual, with their own unique health issues and backgrounds. From this perspective, most medical interventions are experimental. They may or may not work. When options are few, it may make good clinical sense to try approaches that are not “mainstream.” Some doctors do this more than others, but it is important to understand that many, many primary care doctors, and some specialists, attempt to integrate non-mainstream approaches into their practices. In this way, “Integrative Medicine”4 has become an influential movement within mainstream medicine.
Hierarchy of Acceptance and Scientific Validation
of Medical and Health Practices
1. Mainstream Medicine requires scientific proof of relative safety and efficacy unless grandfathered in as standard practice. Note that half of mainstream medicine practices are not validated by clinical research studies.
2. Integrative Medicine requires some scientific evidence of safety and efficacy, but not mainstream acceptance.
3. Complementary Medicine (or Complementary Health practices) requires some general evidence of safety and the willingness of doctors to try it, but does not require mainstream acceptance.
4. Alternative Medicine requires no scientific evidence of any kind and is generally rejected by mainstream medicine. In a way, anything goes, since Alternative Medicine also entirely rejects mainstream medicine. Some doctors use some Alternative Medicine practices as complementary or integrative, however.
5. Traditional Medicine practices are ancient/aboriginal practices that are “Alternative”, but may be used at times as Complementary or Integrative if a doctor thinks it is appropriate.
The state of the various CAM terms is in constant flux. Therefore, if you are certain that you understand the precise meanings of all of these terms, you are probably wrong. Instead, I'd suggest approaching these terms as dynamic, evolving and used by different parties in different ways. It is important not to overlook that there is an ongoing, historical process of upheaval in the conceptual base of our health care system.
In past years, mainstream medicine held a relatively tight grip on what was "okay" and what was "not okay." Because of widespread disenchantment with the costs, risks and side-effects of mainstream medicine, and the growing popularity of non-standard techniques and practices, there are many struggles to change the conceptual landscape of medicine. Hence, the confusion. Hang on, because things will continue to change. In fact, the next time I write on this topic it may well be under the title of Complementary and Integrative Health.
Notes
2Micozzi, Marc S., Fundamentals of Complementary and Integrative Medicine, Third Edition, Saunders/Elsevier, 2006.
3Wilk v. American Medical Association, 895 F.2d 352 (7th Cir. 1990). The case was affirmed by the 7th Circuit U.S. Court of Appeals and review was declined three times by the U.S. Supreme Court.
4According to their website, “At Duke Integrative Medicine, you experience a new approach to medical care that brings you and your provider together in a dynamic partnership dedicated to optimizing your health and healing. Our approach focuses on all of who you are, recognizing that the subtle interactions of mind, body, spirit and community have a direct impact on your vitality and well-being.” http://www.dukeintegrativemedicine.org/, retrieved 3/25/2015.
Earon S. Davis has been involved with the world of Alternative Medicine, CAM/CIH since the late 1970’s. He has a master’s degree in public health from UCLA and a law degree from Washington University. Earon has had careers in law, environmental regulation, health advocacy, nonprofit management, massage and bodywork, and university teaching, along with awards and recognitions.
Currently, Earon is a full-time adjunct faculty at Kaplan University’s School
of Health Sciences, in the Health and Wellness Department, where he
teaches courses on CAM, Stress Management and the Capstone course
in the undergraduate Health and Wellness bachelor’s degree program.
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However, your intro describes, perhaps, some conspiracy theory related to the CERN Hadron Supercollider. Proposing that there is a portal allowing evil in like so many fears of science during the Middle Ages leading to atrocities like the Inquisitions. While colliders like this are helping us understand the universe and its makeup, releasing demons is the least of our concerns.
The storyteller's chance meeting of a beautiful young woman at a bed and breakfast is normal and wonderful. But, she seems to be quite psychologically disturbed. I have met some crazy women, but none that ever called me, "Sir." It wouldn't take me long to avoid her. Instead, the storyteller is drawn in and begins to have have a romantic connection. And an understanding of what is possessing her? I see parallels in this story to the Exorcist. While I enjoyed the movie version with its foul mouth, levitation and twist around head shock tricks, I've turned off the TV version for being a badly warmed over version of the original.
The story has no ending. There is the possibility of a romance or uncovering what is going on with the woman but it ends leaving everything up in the air.
Ron