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Volume 3, Number 2 June 2005

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CommentaryResponse to the IOM Report on

Complementary and Alternative Medicine

by the IHPC

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he Institute of Medicine report, Complementary and Al-ternative Medicine in the United States, is a praiseworthy

ttempt to examine US complementary and alternative med-cine (CAM) usage, help set priorities for the National Insti-utes of Health in conducting CAM research, and describether important goals in making CAM appropriately avail-ble to the US public.

The report looks at CAM education (for both conventionalnd CAM practitioners) and explores the emerging researchvidence about CAM. It proposes an ethical framework foruture research, practice, and policy. Since the Integratedealthcare Policy Consortium (IHPC) advocates for publicolicies supporting high quality integrated healthcare ser-ices, including the full range of health disciplines, we com-end the Institute of Medicine for its interest in a wide range

f issues.In particular, we agree with the IOM committee that:

● All health practitioners should receive education aboutCAM during their professional training. We would addthat such training will be most effective if all the healthprofessions, both CAM and conventional, are includedin the planning process.

● Nutritional supplements should be accurately labeledand consistent in quality. From our viewpoint, currentFDA authority, if fully implemented, appears to be ad-equate to meet this goal. We also agree that there shouldbe increased incentives and support for research on theefficacy of dietary supplements.

● NIH and other public and private agencies should spon-sor research to compare outcomes and costs of combi-nations of CAM and conventional medical treatmentsand varying models of care delivery.

● CAM practitioners should be involved in this research,to ensure that it reflects as much as possible the actual

ways in which CAM is used. s

543-1150/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.oi:10.1016/j.sigm.2005.04.004

There are also some points of concern we would like toighlight. The 17-member committee included 10 MDs, 5hDs, and 2 members with a Master’s degree in public health.n the whole, it represented primarily the conventionaledical establishment, and its report reflects that viewpoint.here are five licensed CAM professions (chiropractic, mas-age therapy, acupuncture, naturopathic medicine, and di-ect-entry midwives), but their views are not expressed in theeport. This means the committee report does not fully ex-ress the values and viewpoints of many different healthcareisciplines collaborating in a truly integrated healthcare sys-em. (We appreciate that an advisory group was formed thatrought more voices to the discussion; that was an after-the-act decision made in the face of substantial protest about theommittee’s membership.)

Too often, the committee looks at specific CAM therapiesn isolation. While the report refers frequently to variousAM therapies, it rarely talks about the CAM professions orisciplines. In fact, the phrase “CAM therapies” appears 299imes, while “CAM professions” is used 8 times, and “CAMisciplines” is used only twice. If the CAM professions hadeen represented on the committee, they could have empha-ized the value of the CAM disciplines as comprehensiveystems of care and provided significant input to what con-titutes the appropriate use of CAM by the patient commu-ity. What we have now is the equivalent of a report on heartypass surgery, from a study committee that included noardiac surgeons.

That said, there is much in this report we value and sup-ort. In the chapter on Integration of CAM and Conventionaledicine, the committee says that the “overarching rubric” to

uide the development of decision-making frameworksshould be the goal of providing comprehensive care that isafe and effective, that is collaborative and interdisciplinary,nd that respects and joins effective interventions from all

ources.” We wholeheartedly agree.

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34 S. Quinn

The committee recommends that the same standards ofvidence for treatment effectiveness be applied to all treat-ents, whether currently labeled as conventional medicine

r CAM. However, it takes the extremely important step ofcknowledging that, while pharmaceuticals are generallyvaluated through randomized controlled trials, this is not anppropriate research model for many forms of CAM. Theommittee describes other research methods that can be usedo evaluate CAM treatment effectiveness, including observa-ional studies, case control studies, studies of bundles of ther-pies, and studies that specifically incorporate expectationffects. We welcome their explicit acknowledgment of thealue of a wide range of innovative research protocols andould emphasize that there may be valuable new models yet

o be identified.The committee notes that, while many medical schools

urrently offer some education about CAM, there are nouidelines on what should be taught and great variation inhe content and methods currently used. The committee rec-mmends that “health profession schools (eg, schools ofedicine, nursing, pharmacy, and allied health) incorporate

ufficient information about CAM into the standard curricu-um at the undergraduate, graduate, and postgraduate levelso enable licensed professionals to competently advise theiratients about CAM.”We agree, and note that some training about CAM would

lso be advisable for healthcare professionals who are alreadystablished in practice. In addition, members of the CAMrofessions frequently could benefit from appropriate infor-ation about the skills and competencies of the other CAMrofessions. In other words, the development of a core cur-iculum on CAM that could be used in all health professionchools would contribute greatly to the development of anntegrated healthcare system.

We particularly value the committee’s stand against coop-ation of CAM therapies. “Medical pluralism should be dis-inguished from the co-optation of CAM therapies by con-entional medical practices,” they write in the chapter, Ethicalramework for CAM Research, Practice and Policy. They add. . . certain CAM therapies may be delivered within the con-ext of a conventional medical practice in ways that dissociateAM modalities from the epistemological framework that

uides the tailoring of the CAM practice. If this occurs, the

ealing process is likely to be less effective or even ineffective,ndermining both the CAM therapy and the conventionaliomedical practice.” This point is of the utmost importance

n achieving the full potential value of integrated healthcare.Many of the laudable IOM goals will require substantial

unding. For example, the committee calls for increasedraining in research for CAM professionals, and it recom-ends that CAM practitioners formulate practice guidelines

or their own therapies. These are worthy goals, which weupport, but we note with great concern the lack of essentialunding to achieve them. Conventional medicine has beenunded generously, by private donors, business interests, andhe federal government, for many years. For the alternativeisciplines to train research scientists and develop practiceuidelines will require a similar investment of sustainedunding. It is remarkable how much professional develop-ent has already been accomplished, given the severely con-

trained budgets of most CAM academic institutions.While the IOM report on CAM offers a valuable framework

or further discussion, it tends to propose broad goals, with-ut suggesting the specific steps that must be taken for thoseoals to be achieved. We need to envision the broad pathwaynd also the specific strategic action steps that will take us tohose goals. As we reach more precise agreement on specificbjectives, we must also look more closely at the obstacleshat stand in our way and develop mechanisms to resolvehem.

IHPC has already begun this process by hosting the Na-ional Education Dialogue to Advance Integrated Health Care:reating Common Ground in early June. This three-day meet-

ng is bringing together representatives of conventional andAM educational institutions at Georgetown University Con-

erence Center for a frank discussion on common goals inducation and ways to achieve them. Participants will exploreest practices in interinstitutional relationships, discuss the ele-ents of an integrated care curriculum, and build a foundation

or future cooperative efforts to improve education within bothAM and conventional academic institutions. For a copy of the

eport from this meeting, please email the Project Director,ohn Weeks, at kimballweeks@yahoo.com.

Sheila QuinnBoard Chair

On behalf of the IHPC Executive Committee