BY ADAR NOVAK
DIETARY SUPPLEMENTS AND HERBAL REMEDIES DOMINATE supermarket aisles. Stories about everything from acupuncture to shark cartilage supplements appear in the health sections of major U.S. newspapers and television networks. Insurance companies provide lists of participating complementary and alternative medicineCAMproviders. Even the federal governmenttypically not an early adapterstarted exploring the state and efficacy of CAM, establishing the National Center for Complementary and Alternative Medicine in the NIH.
So how has the increased popularity of CAMdefined by the NIH center as diverse medical and health care systems, practices, and products not considered part of conventional medicineaffected the academic, research, and clinical climate at P&S? Most agree the P&S approach to CAM is open-minded, yet skeptical and evidence-based. But getting to that point wasnt easy, says Dr. Herbert Pardes, president and CEO of New York-Presbyterian Hospital. As P&S dean in the 1990s, Dr. Pardes was instrumental in the 1993 creation of the Richard and Hinda Rosenthal Center for Complementary and Alternative Medicine, the first such center established at an Ivy League medical school and among the first in the nation.
We took it on despite people giving us a lot of heat, he says. I became aware of the fact that increasing numbers of ordinary citizens were using complementary and alternative medicine. We needed careful and helpful doctors to help educate the public and medical school students and to do research and figure out what is good and what isnt good.
Language in the Rosenthal Centers stated objectivesto facilitate and conduct rigorous scientific investigation to evaluate the effectiveness, safety, and mechanisms of action of alternative and complementary remedies and practicesreflects that careful approach. Soon after it was established, the center conducted a survey of Health Sciences faculty and staff to assess their interest and involvement in CAM. Dr. Fredi Kronenberg, director of the center and professor of clinical physiology (in rehabilitation medicine), received about 400 affirmative responses from faculty and staff in most schools and departments. Creation of the Rosenthal Center made it acceptable for people to discuss their interests. Certainly, some think this is a waste of time and resources, but the majority are in the middle, saying Were good scientists; show us the data.
Despite initial positive feedback, two P&S alumni threatened to picket the centers first continuing medical education course on botanicals in 1996. The course was offered to doctors, nurses, and other health-care professionals to introduce them to commonly used botanicals, alert them to which ones have been studied, and help them become conversant in the subject with their patients. Not only did the alumni not picket, one of them accepted Dr. Kronenbergs invitations to speak to P&S students and Columbia journalism students taking a course in science and medical writing.
Theres a purpose served by skepticism and opposition, Dr. Kronenberg says. It keeps you on your toes and attending to the details. She adds that the 8-year-old botanicals course has been taught every year to increasing demand; more than 1,000 practitioners have participated through the years. A new course, Integrative Pain Medicine, initiated in 2002, will be offered annually.
The Rosenthal Center will celebrate its 10th anniversary in November. Weve come a long way, from faculty afraid to have us put on paper the work they were doing to a situation where we now have investigators calling to discuss research opportunities, says Dr. Kronenberg. As the funding has increased, so have those interested in conducting the research needed to develop the evidence base that so many are anxiously awaiting.
Though the Rosenthal Center doesnt offer clinical services, Dr. Kronenberg fields calls from patients requesting referrals, from doctors seeking referrals for their patients, from practitioners who offer CAM treatments, and from researchers with an interest in CAM who want to network with colleagues who have similar interests. Most of the centers educational and research programs have focused on womens health and aging, with an emphasis on botanical remedies from traditional systems of medicine. Dr. Kronenberg conducts FDA-approved research on black cohosh, an herbal treatment, to determine whether it diminishes the frequency and intensity of hot flashes and helps maintain bone density and cardiovascular health in postmenopausal women.
The Columbia Integrative Medicine Program, also founded in the early 1990s, exists to evaluate and provide guidance for the use of (CAM) in restoring patients health and to offer every patient and caregiver access to appropriate therapies. The Department of Surgery-based program provides patients with referrals and services (guided imagery audio tapes, massage, and yoga); conducts research; and organizes events, such as a monthly lunchtime lecture series.
The programs name reflects its approach, says Traci Stein, a Department of Surgery manager who runs the program. Most of the time were not advocating replacing conventional medicine with these therapies. The trend has been in recent years to move toward integrative because it describes a marriage of CAM therapies that have some scientific basis for efficacy and safety with conventional medicine. Even with a clear scientific approach, the integrative medicine programlike the Rosenthal centerfaced initial opposition.
In 1994, when we started the program, there was real sentiment this was quackery, and that anyone involved is a charlatan, says Dr. Mehmet Oz, the programs medical director and a professor of surgery. Rejection became tolerance and people who tolerated the program initially became more understanding. Theres been an evolution. People were not sure of what we were doing. I think we have demonstrated that our goal is not to advocate, but rather to evaluate potential therapies.
The Rosenthal and integrative medicine programs paved the way for other CAM-related projects at Columbia. Dr. James Dillard, assistant clinical professor of rehabilitation medicine, recently became the first physician at the medical center approved to perform inpatient acupuncture. The Department of Urology opened the Center for Holistic Urology. Pediatric Oncology opened the Integrative Therapies Program for Children with Cancer to serve children, their families, and the medical community through education, research, and clinical care. The program in 2000 published results of a survey of children with cancer that showed that 84 percent of patients were using some form of CAM.
The recognition of patient use of CAM has fueled interest in P&S students, who grew up in an era in which patients started taking greater control of their health. So many people use supplements or alternative treatments and are told to consult their physician, but many physicians havent been taught about these things, says Max Fischer05, who, with other members of the P&S World Medicine Club, organized a well-attended talk by Dr. Oz last October in a CAM seminar series for students. Doctors have frequently told me that they wish this were something they could have learned about in medical school. We can expect some patients to ask us about it, and were not providing them with the best service we can if we cant answer their questions.
Medical students have to be grounded in the basics, says Dr. Stephen Straus, a 1972 graduate of P&S who directs the NIHs National Center for Complementary and Alternative Medicine, but I do think there are themes within CAM that resonate with the public. One of the emphases common in CAM is the notion that the needs of the individual patient should be attended to more. Managed care has constrained our options, and we still need to give patients our time and the care they deserve. The field of CAM takes credit for its emphasis on a holistic or individual approach, asserting what physicians have always known to be good medicine.
Communication about CAM between doctors and patients should be two way. It is critical for physicians to know about any supplements or CAM techniques their patients are using because it could contraindicate other medicines or procedures a physician may try, Dr. Oz says. Many supplements can cause coagulopathies that can cause concern during invasive procedures.
Doctors also need to know what CAM treatments patients pursue because the doctor might think his or her treatment was effective in a successful outcome, when CAM might be responsible.
Cristina E. Farrell05, co-chair of the World Medicine Club, has started a yoga class for students and has been helping coordinate the seminar series for Health Sciences students on CAM. She agrees that physicians need to learn more about CAM to help their patients. While there are some great opportunities to learn about CAM, they are not offered in a way that every medical student would be exposed to them. It is still very much seen as an elective portion of the education.
Dr. Constance Park, associate clinical professor of medicine, adviser to the P&S World Medicine Club, and director of education and training for the Rosenthal Center, stresses that the CAM presence in the curriculum aims to build on the biopsychosocial approach to medicine, recognizing that the patient is a total person in mind, body, and spirit, and that illness is a human event. That means assessing patients in their entirety and as members of communities, understanding that illness is not just a biological process, and respecting patient beliefs with regard to issues of spirituality and cultural preferences. She adds that discussions of CAM help students develop skills for critically assessing medical literature while promoting cultural sensitivity and communication skills.
The P&S curriculum offers a variety of opportunities to learn about CAM. First-year students can take a CAM selective in Clinical Practice 1 and participate in evening presentations on the subject. Second-year students are offered medical humanities seminars in Clinical Practice 2 on Yoga and Mindfulness-based Stress Reduction and Acupuncture Theory and Practice. The second-year curriculum includes a session on integrative pain management and pharmacology lectures on CAM in the oncology and endocrinology sections. For students in the third-year primary care clerkship, faculty are preparing case studies on pain management, interactions between drugs and supplements, and traditional medicine and healing practices. Fourth-year students may take a pharmacology selective on the use of natural products and often choose CAM topics for papers and their selectives in Clinical Practice 4. In addition, 25 students each year take Dr. Parks monthlong fourth-year elective, A Critical Assessment of CAM.
Dr. Kronenberg acknowledges the difficulty in incorporating more into an already full medical school curriculum, but says this challenge is being addressed by a new Consortium of Academic Health Centers for Integrative Medicine, which includes (as of this writing) 12 prominent academic medical centers, including Columbia-Presbyterian, whose goal is to help transform medicine and healthcare through rigorous scientific studies, new models of clinical care, and innovative educational programs that integrate biomedicine, the complexity of human beings, the intrinsic nature of healing, and the rich diversity of therapeutic systems.
Brownell Anderson, senior associate vice president for medical education at the Association of American Medical Colleges, confirms that many medical schools have been incorporating CAM into their curricula in recent years. Ten years ago, you would not have found much, if any, mention of alternative medicine, says Ms. Anderson. Now the AAMC has a list of more than 40 schools that address CAM in various ways, from patient cases to courses titled Wheres the Science? and Wellness and the Art of Healing. The NIH center Dr. Straus leads supports medical school curriculum development in CAM as part of its mission.
Despite increased interest in CAM by medical students and CAM use by patients, medical students should approach the subject and potential techniques with open-minded skepticism, says Dr. Richard Sloan, professor of behavioral medicine in psychiatry at P&S, who is widely quoted as a critic of research that purports to link religion and prayer with health. There is no such thing as complementary and alternative medicine, Dr. Sloan says. There is medicine that works or medicine that doesnt. If it works its not complementary, and if it doesnt we should abandon it. However, he adds, physicians should know what to advise patients when asked about treatments and methods. That doesnt mean you have to buy into it. You have to know what the evidence base is.
Managed care may be one factor in a patients decision to turn to CAM practitioners, says Dr. Sloan. Patient interest in alternatives may be an expression of a pervasive dissatisfaction with both ultra-specialized physicians who dont look at the whole patient and the problems with managed care.
Still, Dr. Straus says, its important to explore what possible solutions CAM may have to offer.
My entire education and career has been about sciencea rational way of understanding and discovering, says Dr. Straus, an internationally recognized expert in research and clinical trials. But we do not yet know everything we need to know, and we must go through the process of searching for better ways. If there are opportunities in complementary and alternative medicine, we have a responsibility to pursue them.