Integrating conventional and complementary medicine

Whether you think the techniques are motivated by profit-making, cater to desperate and gullible people and could even be harmful, or that they relieve pain and cure illness, save lives and are suppressed by physicians who fear competition, complementary and alternative medicine (CAM) is definitely here to stay.

An impressive new English-language book, written by a veteran Hebrew University professor (emerita) of sociology and a young HU researcher with a newly minted doctorate in the field, is the result of a decade of joint research.

Titled Alternative and Bio-Medicine in Israel: Boundaries and Bridges, the volume does not judge whether CAM is effective or has been proven by scientific evidence. Instead, Prof. Judith Shuval and Dr. Emma Averbuch – supplemented by nine academic contributors – provides a fascinating historical analysis of CAM in pre-state and contemporary Israel. It is also a formidable examination of how CAM is carried out by physicians and those without formal medical credentials; the cultural and political context; conflicts and partnerships; and recommendations of where to go in the future.

Published by the Academic Studies Press in Brighton, Massachusetts, the 245-page hard-cover volume carries a hefty price of $70 for libraries and other academic institutions, but it is hoped that it will come out in a more affordable soft-cover format so that a larger audience can appreciate it.

The authors dedicated it to the memory of Bar-Ilan University sociology Prof. Revital Gross, a senior health researcher at Jerusalem’s Myers-JDC-Brookdale Institute, who died tragically of illness in her 50s last year.

“The volume is a very intelligent and serious piece of work,” comments Shaare Zedek Medical Center director- general Prof. Jonathan Halevy, who some five years ago published a Hebrew-language volume examining CAM techniques based on scientific evidence – or the lack thereof. “I think many of the claimed benefits of CAM are due to the placebo effect, but it can’t be ignored. It should be integrated into conventional medicine and provided by physicians trained in it. It can’t be provided by someone who takes a week-long course. And it should be supervised by state regulators. If it isn’t, it is second-best.”

The authors note in the preface that while the US National Institutes of Health have provided scientific evidence for the effectiveness of some forms of CAM, many of the methods have never been scientifically scrutinized or have not passed rigorous tests for efficacy.

“The lack of scientific evidence hardly troubles users of alternative medicine; what counts for them is the fact that in many cases it works – they have little interest in how or why. Failures are largely ignored, while success is touted.” They were intrigued by the fact that many physicians and other healthcare professionals refer patients to CAM practitioners when they cannot do more for the patient; and have studied CAM techniques and practiced it themselves as “integrated medicine.” A small number have even abandoned conventional medicine and shifted to a predominantly alternative form of practice.

The authors of Alternative and Bio-Medicine in Israel use the term “bio-medicine” to describe objective, evidence-based medicine practiced by MDs. They use “alternative” or “complementary and alternative medicine” for the mostly unproven therapies – terms that have changed from the time when MDs absolutely rejected it to when, today, many have an open mind, realizing that a growing number of patients seek it, enthusiastically endorse it or practice it. The therapies include acupuncture, herbal remedies, naturotherapy, shiatsu, reflexology, touch therapies, hypnosis, biofeedback, mediation, yoga, tai chi, Feldenkreis and Paula.

THERE WAS a time when the Health Ministry confiscated homeopathic preparations from pharmacies and health food stores. In 1991, the Israel Medical Association forced the Elon Commission on Alternative Medicine to shelf its report based on over four years of hearings because its conclusions were too radical, allowing almost anyone to offer CAM, with lawsuits by patients just about the only deterrence against quackery. Since then, the IMA has established a council on integrative medicine to represent physicians that are involved in it. In the face of ministry failure to take any action, practitioners are not licensed and almost anything goes.

The sociologist team report that five years ago, 12 percent of Israeli adults reported using an alternative practitioner at least once during the previous year – a 100% increase since 1993. Three of the four health funds (Clalit, Maccabi and Meuhedet) established their own CAM networks, and the smallest, Leumit, has CAM practitioners at some of its community clinics. However, health fund members have to pay for treatment fully or under subsidized supplementary health insurance polices.

Last year, there were an estimated 20,000 CAM full- or part-time practitioners in the country, but only 2,800 of them were members of professional organizations and an even smaller number were licensed physicians.

As Halevy states in his own book, CAM techniques do not cure but can relieve pain and other symptoms. He notes that some therapies, such as acupuncture and various stress-reduction techniques, have become integrated with conventional medical treatments.

The fact that CAM practitioners spend much more time with their patients than MDs and regard them holistically raises patient satisfaction, even if the methods do not cure.

An amusing historical recollection goes back to 1948, when Ephraim Katzir – then commander of the Israel Defense Forces’ Science Corps who in 1973 became Israel’s fourth president, persuaded Moshe Feldenkreis to join his rocket-development team. He proved useless in rocket science, but the Ukranian-born Feldenkreis, who had been hurt in a soccer injury, investigated knee movement, postural change and gait and “cured” himself. He eventually became the “personal healer” of then-prime minister David Ben-Gurion and taught him to stand on his head for extended periods to relieve his chronic back pain. Today, the Feldenkreis technique is still taught and used by CAM practitioners to treat orthopedic problems.

MKs such as Mordechai Ben-Porat endorsed alternative medicine in the early ’80s and railed against MDs for protecting their own turf.

According to the sociologists, “the legitimacy and credibility that CAM receives today developed from the establishment of a new elite consisting of practitioners and physicians practicing CAM... It in effect mediated between new perceptions of health and illness and traditional concepts of conventional medicine by conducting collaborative research programs, making joint appearances in conferences and building a cooperative work model in clinics. The most developed CAM programs in hospitals today are in oncology wards; they are not claimed to cure cancer but to relieve patients’ anxiety and pain and strengthen their coping strategies.”

Nevertheless, many CAM services at hospitals are held at arm’s length, with outpatient clinics physically located outside the core of basic hospital services and non-MDs who practice given less prestige or open consultation.

Those working in hospitals don’t receive accreditation, or even payment in many cases, unless they are MDs.

This are the “boundaries” and “bridges” that the authors refer to in the title.

HOMEOPATHY, DEVELOPED in the late 18th and early 19th centuries by a German doctor, Samuel Hahnemann, is based on highly diluted substances that in their original dosage would supposedly cause disease. As such, it negates scientific theory, but even some MDs use it. The authors quote physicians using their surnames followed by “Dr.” when they quote their positions on homeopathy in the chapter focusing on this therapy.

“The biggest obstacle in homeopathy is reconciling oneself to the existence of unobservable processes and phenomena. I found it very hard to accept the notion that things that we cannot see nonetheless exist,” said “Dr. Limor.”

“When I see a 3-4-month-old baby with recurrent ear infections, and I treat it, and the infections clear up, it’s very hard to believe it is a coincidence, that it’s mere psychology. Even veterinarians are using homeopathy,” said “Dr. Ephraim.” Yet others note that ear infections can clear up by themselves and that a large percentage of physical complaints disappear by themselves but can recur later as disease.

The sociologists note that relatively few Israeli nurses have incorporated CAM into their professional work, perhaps because the field of nursing has grown into an academic profession that integrates more advanced elements of biomedicine, social sciences, psychology, sociology and communications theory. Those interviewed by the book’s researchers said they “didn’t want to get in trouble” with their hospitals by introducing CAM methods in the wards.

Yet some midwives use it for women in labor, and a number of nurses use CAM in private practices off hospital premises. CAM provides nurses with an increased sense of autonomy, “enabling them to move beyond the control of the physician,” Shuval and Averbuch suggest.

The fact that giving birth is not regarded as a disease and that natural childbirth is popular in Israel also makes hospitals more amenable to CAM pain relief; and midwives are in most deliveries left alone by obstetricians who do not usually deliver babies but only intervene when there are complications.

Family physicians in the community are increasingly using integrative medicine in their practices, they write.

“Some patients chose me because they know I integrate CAM in my practice, but some don’t know and view me as a family practitioner. The [health] fund does not identify me as an integrative doctor in its list of practitioners,” one doctor says. “I would rather not use Western medicine when I know that CAM is more effective. It all depends on the specific situation... I try to convince the patient that CAM is better.”

“I don’t know what I would do if I were not a fullfledged doctor. It’s what gives me a tremendous amount of knowledge. I wouldn’t feel really confident dealing with patients without this basic knowledge,” says another.

“My problem is that it is illegal for me to provide private care (fee for service) to members of [a health] fund in my clinic – ever, at any time... what I can do is to refer them to... the sick fund’s CAM clinic network... I myself wouldn’t work for the [health] fund’s CAM clinics...

They opened them [only] to make money, and they have no ideals or principles... They impose lots of technical limitations on the length and number of treatments...

all to make sure they make a profit,” maintained a third physician.

THE AUTHORS interviewed policymakers, physicians and patients on the use of integrated care and sent a summary to the Health Ministry, IMA and health fund officials in key positions. Shuval and Averbuch asked them questions on their views and reactions. These varied widely, from those who said that CAM practiced by physicians meets a public need and is good as a holistic approach, to concern “about deceit and charlatanism even if CAM is administered by physicians since money is dazzling. It’s easy money... Because of the money, there will be many rotten apples (among the doctors) that forget where they came from and will offer only the alternative treatments.”

Some noted that it was impossible to offer CAM techniques in health fund facilities because doctors are bound to see a large number of patients per hour. The solution for some idealists and CAM devotees has been to set aside an extra (and unpaid) last hour of practice for people who want CAM treatments.

As the Health Ministry does not seem to be moving toward a resolution of the differences and disputes between conventional medicine and CAM, the authors suggest ways of bringing them together by using a “gradual approach to regulation in which the public needs to be protected and developing the regulation in cooperation with all stakeholders to gain their support.”

As is done in Alberta, Canada, they write, physicians could be registered as providing CAM after they show proof of acceptable education and clinical experience in this. Registration could be voluntary, allowing a physician to choose whether or not to participate. “The need for regulation is critical since [integrated care] involves high costs for patients and high income for physicians who may thus be tempted to enter the field, possibly compromising the quality of training in CAM methods.”

The authors stress that CAM is best provided by specially trained physicians. “Licensing for non-medical CAM practitioners is a complex problem that needs to be addressed creatively, taking into consideration the considerable differences among the various CAM specialties and their specific needs,” they write near the end.

As for the medical schools, students should be exposed to the basics of CAM , not in order to be trained as CAM practitioners but so they will have a basis for understanding the options available to their patients for referrals. They must also be to understand patients who have already undergone CAM therapy. If, as predicted, CAM treatments will be included in patients’ medical records, bio-medical practitioners will have to be able to understand them.