Talk:Complementary and alternative medicine

Chelation therapy for things like heavy metal poisoning are probably not considered alternative medicine. Is the author thinking of a particular kind, like ETDA with heart diseases? David E. Volk 14:52, 13 April 2008 (CDT)

Change article title to Complementary and Alternative Medicine

I believe making such a change would be more consistent with general usage in the broad fields of health. In the terminology of the National Center for Complementary and Alternative Medicine, alternative medicine describes "whole systems" that totally supplant mainstream medicine or different whole systems. Complementary medicine can work with whole systems, including mainstream medicine. Howard C. Berkowitz 21:00, 19 November 2008 (UTC)

Agree, with redirects from Complementary medicine and Alternative medicine. D. Matt Innis 01:39, 20 November 2008 (UTC)

Sorry for the undo...

But I strenuously object to separating complementary and alternative medicine at a high level, although there can indeed be separation within individual disciplines. See the National Center for Complementary and Alternative Medicine taxonomy, which is not, at all, U.S. specific. If you want language revered, I'd appreciate more of an explanation. Even if it's simply that something is confusing, I'd like to know what is confusing. A confusing aspect may be a term of art that needs explanation or linking.

For example, there are advocates of Traditional Chinese medicine, which include acupuncture, to insist that it is a whole system. As you will see in the main TCM article, the Chinese goverment does not. I am personally quite willing to recommend acupuncture as an complement to pain management and rheumatology, both human and veterinary. It may work, it may not work, but it is also being done in an interdiscipinary way. Anecdote is not the singular of data, but I've seen people close to me sicken and die because they insisted on alternative medicine only.

The broad area of manipulative therapies, including chiropractic, osteopathic medicine and osteopathy, physical therapy, and massage, as well as a few other areas of physical medicine, are searching for new syntheses. For example, I know a few complementary practitioners that have dual-certified in chiropractic and physical therapy. They say chiropractic gives them the best tools for flexibility and pain control, while physical therapy is better for restoring strength. These practitioners routinely work with conventional physicians of many specialties, including rheumatology, pain management, neurology, orthopedics, and physiatry. Howard C. Berkowitz 14:38, 4 December 2008 (UTC)

I think I see what you are saying.. perhaps that you want the theories explained only on the pages that are titles specifically for each alternative or complementary practice. I haven't thought that one through; there might be a reason to have a page on Alternative medicine - though I think most that were once alternative are being integrated slowly. Everyone seems to be crossing lines of what used to be "turf". I have no trouble with the beginning of the sentence that you removed. Maybe just remove the part about "these are explained on the Alternative medicine (theories) page. Matt Innis

Does "alternative" mean only "alternative" to conventional medicine? Certainly, once you start integrating, at least as I understand the concept, you are becoming complementary. I like NCCAM's term "whole system", which clearly identifies "classic" disciplines that do not share paradigms.

Other than to call it not-biomedicine, or maybe not-other-whole system, I literally don't know how to define alternative medicine. It is not synonymous with complementary.

I don't have an answer to whether a combination of classic homeopathy ONLY with classic chiropractic is alternative or complementary, but I'd lean toward alternative. To me, alternative means "biomedicine, get lost." Complementary says "we may each have something to contribute." "Basic" complementary might be an internist sending a patient with acute low back pain to a chiropractor. I'm thinking, though, of some chiropractors at an interdisciplinary symposium, who were suggesting that the manipulations might be helping not so much because they reduced subluxations, but the high-velocity movements caused neuromodulator release. They were very complementary, especially when the neurologists got together with them and the acupuncturists that added electrical stimulation, all guided by an anesthesiologist who started as a dentist. (Really!) Howard C. Berkowitz 00:23, 5 December 2008 (UTC)

Well, I think "alternative" is a word derived by conventionalists (for lack of a better term). It was never meant to really define these different philosophies in any other way but "different than conventional". It is probably meant to be vague - in an effort not to offend or promote. When "conventionalists" begin to see value (of some sort) in some of these methods, they call them "complementary", and if they really like them, they give it the "integrative" brand. It's marketing. Now that "alternative" practices have been able to improve their brand, I would suspect that the name will be changed to something less appealing. Meanwhile, I wouldn't mind seeing someone like Martin work to write something about the evolution of "alternative" approaches to healthcare. It seems that might be part of his expertise, so why not. D. Matt Innis 14:20, 5 December 2008 (UTC)

I have not followed this discussion, so I may have missed something obvious. Matt are you thinking that this article will consider the demarcation problems and the evolution of the relationship between these approaches and health sciences? While there should be two new articles describing complementary medicine and alternative medicine? Chris Day 14:35, 5 December 2008 (UTC)

Hi Chris, I don't see the need for two articles because I think the demarcation is not designed to be clear (I am open to other arguments on this). I think that Martin's edit suggests an article that examines the history of alternative theories (that incidently should include the birth of scientific medicine). Martin mentioned Paracelsus, who is certainly important to this train of thought. I would imagine that anything along this vein would enlighten the reader as to the why's and when's of these approaches and why and when they appeared and disappeared and why they were either left behind or continue to propogate. D. Matt Innis 15:45, 5 December 2008 (UTC)

Conventionalists

• Premise: the term for the person with the lowest class rank in medical school, or the boarded specialist with the most fossilized view once established in her profession, is "doctor".
• Premise: the term for the person with the silliest ideas in a "new" or "rediscovered" healing art, if the members of the art use titles, is "doctor".

Even without moving outside "mainstream" medicine, there are conflicts of ego and power, even among the most qualified physicians. It took decades for Michael deBakey and Denton Cooley to begin to speak to one another again, even though they literally had hospitals across the street from one another. Everyone knew gastric ulcers were due to stress and needed surgical treatment — until Barry J. Marshall and J. Robin Warren had an all-expenses-paid trip to Stockholm for one of the relatively rare Nobels given recently for clinical, not theoretical work: that most ulcers are caused by curable Helicobacter pylori infection.

When I hear the term "conventionalist", I cringe. The very real psyche it reflects has nothing to do with CAM versus mainstream. What I do see is that an ever-increasing group of mainstream physicians, and indeed an enlarging group of people from other systems, are working together in an integrative way.

CAM, as an article, covers something that I think is reasonably well-defined, with logical subarticles for particular disciplines. CAM, in turn, could reasonably be a subset of an article that talks about progress and change in generic care of sick people and encouragement of people to be well, an awkward phrase but deliberately selected not to use "health sciences", "healing arts", "CAM", etc. That broader article could address some of the ethics of current pharmaceutical marketing, both direct-to-consumer (unique to the U.S.) as well as hardcore business marketing to physicians. By all means, include the British policy work that goes beyond safety and efficacy testing, and considers if a new treatment is sufficiently better than the old that its cost and disruption justifies its introduction.

Martin's comments on ethics and the like are not unique to CAM. Matt's comments about "conventionalists" adopting things shown to work are not unique to conventional vs. CAM. I propose we keep CAM, do not have a separate Alternative Medicine, and seriously discuss a higher-level integrative article that certainly can include many social and philosophical issues. That integrative article can include the broad issues of whether healthcare is a right, and link to more specific issues of philosophy and policy such as futile care, informed consent, euthanasia, etc.

I hope such an article can be guided by the Osler quote that keeps getting removed from Homeopathy:

"A new school of practitioners has arisen which cares nothing for homeopathy and still less for so-called allopathy. It seeks to study, rationally and scientifically, the action of drugs, old and new."(Sir William Osler, quoted on page 162 of the Flexner report)

Can CZ, at least, appropriately synthesize, rather than raise artificial barriers? Howard C. Berkowitz 17:18, 5 December 2008 (UTC)

Sorry to make you cringe, hehe. I don't see Martin's ethics comment? I agree that an Integrated medicine article would be great as well. I also think that an article that brings together all the different theories that we call Alternative medicine into one place is a good thought if written properly. D. Matt Innis 23:18, 5 December 2008 (UTC)

Maybe I overreacted to your point, but I hesitate to separate complementary and alternative medicine, with one caveat. The caveat is, to use NCCAM's model, is that the true "alternative" paradigms are "whole" systems, which do not want to integrate with other approaches. Some of this comes across in the homeopathy article, where it seems that attempts to find similar ideas in biomedicine are angrily slapped aside, or trigger tirades about 19th century issues. In contrast, I see a great deal of search for common elements between reasonable people in traditional Western and Chinese medicine. To borrow from Colin Powell, almost anything is possible when people focus on the goal at hand, rather than who will get credit for success.

So, I see a CAM article with subarticles for schools of thought, and only reluctantly an "alternative medicine" article limited tp "whole systems". Please correct me if I misunderstand, but my impression is that there is one ("classic"?) whole system part of chiropractic that insists it has the definitive insight into all sickness and health, and treats as apostates anything that suggests that, say, chiropractic manipulation and pharmacological antiinflammatories might have synergy. The default assumption in homeopathy seems to be that it is a whole system. Howard C. Berkowitz 00:11, 6 December 2008 (UTC)

I think we are essentially saying the same thing. I am not in favor of separating CAM. I am in favor of a CAM article and a separate article that explains where alternative medicine theories come from - not one that tries to explain the difference between complementary and alternative. Just one that explains the "evolution" (to steal Chris' word) of these theories. I think this was Martin's thought that I was supporting, but I may have misinterpreted his intentions. Chiropractic has elements of all three, alternative, complementary and conventional. It might be that all of them do to some degree, including medicine. Everyone's beliefs are unique to them, not their profession.D. Matt Innis 03:07, 6 December 2008 (UTC)

We are probably in agreement, but here's a question: is there enough in common among forms of alternative medicine to have one set of theories? Most do have a sense of the body generally healing itself, which really isn't that different than the biomedical view of optimal function. Where they start to divide (and ovelap) is, roughly (NCCAM uses a model similar to this), into:

1. Self-healing through a distinct flow of energies, which might include acupuncture and chiropractic. These tend to include manipulation, and American osteopathic medicine is about the best example of complementary/combined. I'm not sure I'd put physical therapy and physiatry outside mainstream
2. Less directional and mind-body focused, including reiki, shamanic healing, meditative forms, etc.
3. Less directional but systemic, including homeopathy, aromatherapy, and naturopathy; these tend to involve ingesting things rather than manipulation or mental interaction

Just as a parallel, a lot of conventional pain management, especially using the Melzack & Wall gate control theory, does recognize a flow model of sorts. Mind-body include psychoneuroimmunology and the psychodynamic disciplines, and blur into psychopharmacology in class 3. Metabolic and immunologic medicine ties into #3, although many alternative practitioners reject that idea.

I'd just like to see a reduction in the apparent anger in the homeopathy article, which differs from my experience in the other CAM disciplines where I have some exposure. Mind you, I remember, at the end of an interdisciplinary back pain symposium, the chiropractors said they were giving each other "standing adjustments". Sure looked like hugs to me, which definitely have their therapeutic role!Howard C. Berkowitz 03:24, 6 December 2008 (UTC)

"Most do have a sense of the body generally healing itself, which really isn't that different than the biomedical view of optimal function". I think that an article that examines the evolution of alternative "thoughts" in healthcare will reveal this same observation. From there, the value of each will become apparent without us having to loose our neutral approach.

There is a time and place for everything. While I don't deny that prayer will help a person whose arm is amputated in a collision, an EMT is who I want there when it happens (although if one is not available, I'll accept the prayer and a little handholding as well!) D. Matt Innis 03:37, 6 December 2008 (UTC)

Of the hand that's lying on the highway or the hand that's trying to fashion a tourniquet around the upper arm stump? Hayford Peirce 03:42, 6 December 2008 (UTC)

Hehe :-D If someone is willing to hold that hand on the detached arm, they are sicker than I am! It would be nice if they would help me with the tourniquet, too, while they are mumbling. D. Matt Innis 03:47, 6 December 2008 (UTC)

Well, I'm sure that a little quickly applied Aromatherapy will make things well! Hayford Peirce 03:54, 6 December 2008 (UTC)

Surely that would improve the aroma coming from my britches ;-) D. Matt Innis 04:05, 6 December 2008 (UTC)

I don't know if I'd call it aromatherapy, but I can definitely think of some cases where some conventionalists could function only with the help of aromas. There's a very odd custom among some of the hardest conventional physicians, when they sense a more junior colleague about to lose it in sheer horror. I needed both something to mask the smell, as well as a hug and reassurance, when I was assisting in getting tissue samples from a patient with gas gangrene. Others have needed that when dealing with their first major burn cases.

While I use essential oils mostly because I find them pleasant, I look at a lot of aromatherapy not as "disease-modifying", but as a useful part of comfort care. There have also been some interesting recent trials that suggest the aroma alone may not have a measurable effect, but, for example, a combination of essential oils with massage may.

Good point, and I think that is the essential issue - that there is value in everything, it is just that sometimes it is not worth the cost. I bet you would have paid anything for that comfort care. Also, we have to know what to measure before we can claim that something is not measureable. I don't have to tell you that neurotransmitter titers are minute and unless we know where to look and measure, we won't find it. All we will have to measure is patient satisfaction, which does give us an idea that we need to be looking for something. Even the placebo effect "must" have a chemical explanation, unless you believe in voodoo. D. Matt Innis 04:31, 6 December 2008 (UTC)

The voodoo that you do, etc.

Matt, have you ever read Michael Harner's The Way of the Shaman? Harner was a conventionally trained anthropologist, who became, to the dismay of many academic anthropologists, a "participant observer". He actually trained as a shamanic healer. In the course of his training, some of his mentors very calmly and carefully explained that there was effective sleight of hand in the shamanic spitting healing ritual. The sleight of hand, however, was to give the patient something to focus upon, while the shamanic practitioner did things at a much more subtle mind-body level.

Those methods, as do many other techniques, work in a specific cultural context. Where I do have a problem, however, is where we do know what to measure, yet alternative practitioners deny the methodology using nothing more than fear. When someone tells me that a definitive infectious disease, verifiable by several evolutions of Koch's postulates, must not be prevented with vaccines or treated with antibiotics, the whole system loses credibiity. If someone wants to talk about how things work in what I'll call a parallel system of vital force or qi, I can get along with that — but when they start talking about "immune system", I'll demand the same objective data I would expect from a medical immunologist. It's the too-emotional claims that hurt some of the potential for CAM.

Kellen may not have been diplomatic, but there is a reality of futile care, and he was addressing it. It utterly infuriates me when, say, an herbalist denies pain control to an end stage cancer patient and insists on only using the "pure natural forms". I've seen both CAM and conventional practitioners extend false hope, and continue suffering. There is a real balance between Dylan Thomas writing "do not go gentle into that good night/rave, rave against the dying of the light" and Robert Louis Stevenson's "gladly did I live and gladly die/and I lay myself down with a will." Howard C. Berkowitz 04:54, 6 December 2008 (UTC)

If someone wants to talk about how things work in what I'll call a parallel system of vital force or qi, I can get along with that — but when they start talking about "immune system", I'll demand the same objective data I would expect from a medical immunologist. It's the too-emotional claims that hurt some of the potential for CAM. We agree here.

I've seen both CAM and conventional practitioners extend false hope This is another story. I was glad they let my father-in-law pass when he developed pneumonia after 15 years with Alzheimers. They could have revived him had it not been for his living will, but he was miserable for the last two to three years of his life. But these are not CAM issues. D. Matt Innis 05:18, 6 December 2008 (UTC)

Oh, agreed. It happened that Kellen was addressing a CAM insisting on prolonging life, but, in about 1975 and with a living will, I could make no headway with VA hospital physicians insisting on heroics. I doubt they would have tried it today, but then, at least two full codes on a patient whose breast cancer had metastasized to bone, meaning that chest compressions smashed everything they touched. Oh, they didn't want to give her adequate opioids due to fear of addiction. So, do take some of my talk page comments in perspective, when I said I wanted comfort care and I was lectured how I could be "healed", whatever that means, rather than submitting to "euthanasia" instead of being treated by the h-word.

We simply don't know, from a Newsweek article, the full context of Kellen's remarks or of the case. It does not strike me as reasonable, however, to try to ban his remarks because they offend homeopaths. Howard C. Berkowitz 05:26, 6 December 2008 (UTC)

I agree that things have changed since the 70's. I think all physicians felt they had a moral responsibility to do their best and let a higher power pull the plug. I think CAM providers had the same sense of responsibility to their higher powers that dicitated that they "remove interference" to natural healing which would include pain medication. Again, I think this has changed as failure tends to be the best educator. I am not as concerned that Kellen said anything in particular as long as the subject is covered. This is what I think Citizendium has over wikipedia; we don't have to source these things. We can say them and ask them based on our own intelligence and it is up to the editors of the article to discuss the subject thoroughly. It is not a matter of being pro-CAM or con-CAM, it is a matter of pro's and con's of CAM. There is a slight, albeit important difference. A Jehova's Witness would choose homeopathy based on what you would consider a con. D. Matt Innis 16:08, 6 December 2008 (UTC)

Times and places

I still remember the looks at the ER at George Washington University hospital's ER, when a traffic accident victim showed up, a bystander-applied tourniquet around his neck, "to stop the very dangerous head bleeding". It was lucky, I suppose, that the head injuries were clearly incompatible with life. Yes, there is a time and place for a tourniquet, and the Army has been making some very good doctrines: you may need one when you have to get someone out of enemy fire, but rarely otherwise.

Matt, I've only seen CAM articles stay in sound and fury in homeopathy, where I've been trying to get a sense of that time and place. There's quite likely some meat to the mind-body, clinician-patient relationship, if that isn't too mixed a metaphor. Unfortunately, the article tends not to go into time and place, but enmity, which includes quite a few generalizations about conventional medicine that may have been true a century or two ago. There are places I simply will not go in the interest of neutrality, if I think the "sympathetic position" may kill people or create unneeded suffering. If that's expected of me, I don't belong here.

Maybe there's a back door to the snarl there, by more agreement at CAM that then takes a side door to the problem child. ~~

A particularly good example

Of the complexity comes when you bring up Jehovah's Witnesses, as opposed to, say, Christian Scientists -- and which also brings in third-party ethical/legal aspects.

Contrary to widespread opinion, Jehovah's Witnesses do not, at all, reject conventional medical therapy. Their objections center around a Biblical passage that says "thou shalt not eat blood", which they interpret as an absolute prohibition against transfusion and use of clearly derived blood products. With that caveat, they will accept even open-heart surgery, as long as it is guaranteed they will not receive blood. They seem to have no problem with some of the synthetic surrogates, such as fluorocarbons that carry oxygen and carbon dioxide. Some major departments will accommodate them; Loma Linda, which is Seventh Day Adventist, is one, I believe.

Christian Scientists would be closer, in that they want pure faith healing. Even so, there have been numerous court decisions that they are free to make that decision as adults, but they cannot make it for minor children. There have been a number of court cases where, variously, the courts took a child away from the parents to get conventional treatment, or the parents were prosecuted for manslaughter or murder for not allowing such treatment. There also have been convictions for deaths suffered during rebirthing and indeed some religious healing rituals.

Yet another direction goes with futile care. The Catholic Church has changed its position to "no heroics", permitting some things that may be close to the line of passive euthanasia, but drawing a line at active euthanasia. Without taking a position on it, this sort of religious issue is at the core of many abortion and related controversies.

Now, here's where it gets really interesting. Assume some society that has legislated health care is a right. Conventional medicine says that further active treatment of a particular patient is futile. The patient or surrogate demands treatment by foo-ism (fufu, on the other hand, is a quite nice West African porridge). Who pays?

What about adults that request termination of treatment, based on quality of life, not impending death? While I don't know it to be available on line free, perhaps the best case study is by Timothy Quill, who had a long-term patient develop a still potentially manageable leukemia, but was unwilling, and apparently rational, about refusing treatment. What made it a challenge is that she asked Quill for a prescription for a lethal drug, which, after much soul-searching and consultation, he gave, contrary to the state law in question.

The point of this ramble is that there is choice involved, and CZ can point out the choices. It must not, however, provide a venue for continued fights, based on situations 200 years old, between different approaches to health. It needs to be cautious in letting on discipline attack another when one's attack is based on faith and the other on evidence. Unfortuntately, none of these subtle issues, which I have tried to address in articles such as futile care, have been addressed in homeopathy, which has stayed an edit-warring, allopaths-are-scum-even-if-they-don't-exist, battle for far too long.

Everything I've raised, as well as the legal and ethical issues, are legitimately part of integrated health care in CZ. We allow ourselves to be distracted. Howard C. Berkowitz 17:55, 6 December 2008 (UTC)

Neutrality

As a citizen, this article does not appear neutral. It does not in any way address anything other than the critics perspective. It needs attention or maybe moved from article space. D. Matt Innis 18:18, 13 December 2008 (UTC)

Matt, I don't disagree completely. Here is a proposal: Keep the first two paragraphs that define the difference between complementary and alternative medicine. I did write part of those, but I did not write the section that follows.

What I had been thinking of doing was to port or adapt the system of describing CAM techniques that is at National Center for Complementary and Alternative Medicine#Organizing CAM knowledge and research. I'd use that as a starting point for what I see as the main purpose of this artice: identifying the disciplines that go into CAM.

If we follow the model that this article is primarily the "core" to which the individual disciplines link, it wouldn't be appropriate to have extensive criticism here, because almost all criticism is discipline-specific. The one piece of criticism that I would like to have in this article, and I don't think it's there now--let me try some draft wording; assume the NCCAM terminology is ported here.

Conventional physicians do express concerns over whole systems, because they may either not identify dangerous conditions that are treatable by conventional medicine, such that the patient does not have the information to decide to give informed consent to alternative treatment alone. Another aspect of that concern is that some conditions can respond to mainstream medical treatment early in the process, but delay of diagnosis could put the patient in a situation where the conventional treatment would no longer be effective.

add to this, not criticism While some conventional physicians will reject any complementary method for which they do not know the exact mode of action, there are many productive, collaborative treatments by teams of mainstream and complementary (but not whole system) practitioners. For example, it is quite comment for pain medicine specialists to use complementary methods.

Howard C. Berkowitz 18:44, 13 December 2008 (UTC)

That sounds like a reasonable start. The main thing is that we don't leave it as "only" one perspective. D. Matt Innis 20:46, 13 December 2008 (UTC)

I'm not sure what you meant by perspectives. Were you speaking of the medical vs. CAM view, the classification system, or what? The NCCAM classifications has some minor problems, but, all-in-all, I think it's very logical and neutral. Whole system (using their term) vs complementary, holistic, or whatever seems very key.

In some areas, there's about as much point in putting out the detailed arguments of the sides as there is of putting out the pro- vs. con- arguments about a matter of religious faith: either someone has faith in a revelation, or they don't. In the case of some of the alternative systems, it sometimes, I think, comes down to faith and is not subject to argument or scientific proof. Howard C. Berkowitz 20:52, 13 December 2008 (UTC)

Oops, I see what you mean. I agree that if something is neutral it can stand alone. It just shouldn't read as only critical or only supportive. I also agree that faith goes a long way in peoples decisions, but perhaps even faith is based on some logic. Maybe we should have this under the religion workgroup! (just kidding:-) I can say that, you cant :-)D. Matt Innis 21:01, 13 December 2008 (UTC)

OK, I'm editing now to put in a slight modification of the NCCAM table. You'd think part of NIH would use the Medical Subject Heading terminology everywhere? Yeah, right. I haven't yet deleted any of the critical stuff, but just moved it around.

Hehe, so which part of the new stuff is the positive spot:-) We really need to teach you how to write for the enemy. :-) D. Matt Innis 23:20, 13 December 2008 (UTC)

Positivity?

Well, understand that I see this article, with the things that I added, as essentially categorizing and indexing.

I could write at some length about the use of complementary medicine in pain management, mental health, and several other areas. At this level, I thought the brief mention of complementary medicine and pain management was quite positive. There's also some superb cooperation between traditional tribal healers and epidemiologists; the best example that comes to mind is the Hantavirus Pulmonary Syndrome that wouldn't have gotten solved without the Navajo elders and the Public Health Service epidemiologists working as a team.

You can get me to write neutrally about alternative whole systems, as long as I have adequate information. I could probably do a decent job on a fair bit of TCM, although I prefer the Three Roads complementary model. In the main alternative system at hand, I simply have not gotten enough coherent undrestanding, other than what sounds like fundamentalism, to write about it.

I could probably write quite positively about acupuncture, visualization and meditation techniques, art therapy, some manipuation, and a number of fields where I have a good understanding of their paradigm. Indeed, in some cases, I even use or recommend them. Howard C. Berkowitz 23:52, 13 December 2008 (UTC)

Well, we've got a beginning. Who decides whether something is CAM? Maybe we can start there. D. Matt Innis 01:11, 14 December 2008 (UTC)

That's really a good question, and has two parts. The second is when and if it stops being CAM and starts being mainstream. For example, I was amazed to see art therapy listed by NCCAM. It's a very standard thing to see in psychiatric and rehabilitation hospitals.

When it starts being CAM is a good question that I don't think has a good answer. I could personally argue that a technique developed by an individual mainstream physician, not published, and not formalized either is, or is not, complementary medicine. Let me take two examples from physicians I know. Chuck is a DO, board-certified in family and emergency medicine. He uses manipulation that he was trained to do in his osteopathic medical school. In some cases, he will manipulate under general anesthesia. He, I know, considers this fully within his scope of practice. Michael, however, is a MD, board-certified in internal medicine, who does a lot of work with people that call themselves CAM practitioners. I've seen him use and teach manipulation and massage techniques he learned from a chiropractor. His formal training and certification did not include manipulation, but is this equivalent to off-label use of a drug, which is considered mainstream?

No simple answer. Does massage therapy, performed by a licensed massage therapist or physical therapist become mainstream when done under a physician's prescription? Technically, it's under the MD/DO's authority.

When my grandmother told my mother not to take me to the doctor for a sore throat, but wrapped my neck with a cloth with some "stuff" on it and fed me chicken soup, was she being a (1) traditional and (2) alternative practitioner because she advised against using conventional medicine? Howard C. Berkowitz 02:06, 14 December 2008 (UTC)

Does massage therapy, performed by a licensed massage therapist or physical therapist become mainstream when done under a physician's prescription? Technically, it's under the MD/DO's authority. Perfect, don't you think there is something funny there? We should write something about that

I made some changes to make the article more neutral. I am not married to any of the language and am willing to discuss any of them, so feel free to improve whatever you like. D. Matt Innis 02:11, 14 December 2008 (UTC)

Your last edit is a good example to think about.

"as some alternatives show as much efficacy as conventional methods". As I remember, the last NIH Consensus Conference on acute low back pain showed that chiropractors had the best evidence-based outcomes.

Thinking out loud, where I see the most acceptance is in team models, where there is cross-referring. My primary internist referred me to a dual-certified chiropractor/physical therapist to deal with some musculoskeletal problems. In my conversations with that DC/PT, he described, very reasonably, a number of things that if a self-referred patient reported, he'd either refer them or call an ambulance.

In Virginia, only MD/DO's can do acupuncture. The ones that I know just regard it as one more technique they use as part of their practice. In other words, the Commonwealth of Virginia defines acupuncture as exclusively within the scope of practice of medicine. Is that even complementary?

For me, the important thing for any practitioner, of any training, is to know the scope of their own abilities, and when to recognize things that need referral. For example, I can pull down a standard emergency medicine text, and it will tell the board-certified emergency physician to refer to an opthalmologist, neurosurgeon, or hand surgeon for certain specific things. If the EM doc tried to treat the condition himself, when the specialties were available, is he doing alternative medicine?

Matt, this text, I think, needs to articulate the differences between whole system alternative practitioners who will never refer, complementary nonphysician practitioners who cross-refer, and even physicians who try to do things outside the scope of their training.

The phrasing here is actually too simplistic, but I'm not sure how to fix it. Maybe it needs to be preceded by introducing the idea of scope of practice. No doubt there are chiropractic adjustments, which, if performed by an orthopedic surgeon without the specific training, could cause permanent damage or death, the latter when he thought he was watching a chiropractic education video but didn't realized it was a mislabeled ninja movie. I have lots of orthopedist jokes, so I can believe one might not wonder why the chiropractors were all in black and wearing masks. Howard C. Berkowitz 02:24, 14 December 2008 (UTC)

Sounds reasonable to me. I don't think we have to get too wordy, though, or we risk losing the audience. Also, we should write in such a way that we don't endorse any of those groups that you mentioned. Let the information speak for itself. D. Matt Innis 02:57, 14 December 2008 (UTC)

By the way, concerning the text, "as some alternatives show as much efficacy as conventional methods". Are there other reasons biomedicine would accept some methods? D. Matt Innis 03:04, 14 December 2008 (UTC)

Let's think of just mainstream for a moment. Surgical procedures don't have to go through formal approval, as do drugs. Some years back, before coronary artery bypass grafts, some bright surgeon came up with an operation called internal mammary artery ligation. The theory was that by tying off an essentially useless artery in front of the heart, it would drive blood into the heart.

Nice idea. Didn't work. I don't know if this particular procedure was approved by a human experimentation review panel, but such panels are far more likely to accept something if there is a molecular, animal, or other model of why it should work.

So, having a good model might be a reason to try things without efficacy data; it happens constantly with drugs and procedures developed by physicians. Things such as art, music and dance obviously exercise different parts of the brain. While these things are more mainstream to me, think of treating psychological trauma, especially in children, that is too frightening to talk about, but they might draw or paint.

Another reason to be more accepting of a method is that it's very hard to think of a way that it could do damage (e.g., visualization as a pain management technique). This is one of the pro-homeopathy arguments, as opposed to herbalism using plants of unknown composition, concentrations of ingredients,

Yet another would be that it's a complementary method to be used within a broader medically managed context (e.g., aromatherapy for surgical patients). This is a big one -- if physicians are involved, the argument that a CAM practitioner might miss something important tends to go away. Howard C. Berkowitz 03:24, 14 December 2008 (UTC)

I think you are right that that is the thinking. The bottom line is exactly what we have written. It almost looks as though there is no problem with alternative methods as long as they are used in combination with conventional methods, to some degree. That tends to make the argument that science is the reason tend to go away as well. Very rarely are we (all practitioners) looking at textbook cases of much of anything. On any given day, I would suspect that 95% of all patients are suffering from chronic or self limiting conditions. Is there any specific reason why alternative therapies should not be used for these people, especially if side effects are not as significant as the medications? How do we handle that? D. Matt Innis 03:43, 14 December 2008 (UTC)

So when does it become integrated medicine? D. Matt Innis 03:50, 14 December 2008 (UTC)

As you know, I'm doing a lot of work on the Vietnam War (I hear you thinking "Howard has lost it"). One of the rejected strategies was the "oil drop"--start with secure villages and then start spreading out, both providing security and also improving infrastructure. Perhaps a section in this article might be on integrative medicine, which is a superset of complementary medicine, but very different from alternative medicine. I'm thinking of some pain management and psychiatric programs that are integrative. For example, in the particular psychiatric unit I was observing, one patient hadn't spoken a coherent sentence in weeks or months, and medications weren't accomplishing much.

They did, however have a very active art therapy program, which was very flexible and nonthreatening. As I remember, he was enjoying a coloring book and crayons, although not very accurately. A new patient came in, and surprised the therapists a little by asking for charcoals; it turned out the new guy had some substantial training, talent, or both. He was regarding the therapy as a break in the boredom, but was doing a very accurate still life of some objects in the room. The incoherent patient suddenly said "I'm very impressed. You are very talented."

That was the breakthrough. The one place he'd start to talk was in the art room. Some of the psychiatrists came and talked to him during the sessions, and finally got the clues they needed to plan both different medications and psychotherapy. It was a perfect example of the use of multiple intelligences, or multiple brain pathways. No one could have known that visual stimuli were the way to this patient; based on that, they also were considering Eye Motion Desensitization Reprocessing rather than more verbal psychotherapies.

Good pain management programs, as well as programs for chronic diseases, especially for diffuse things like fibromyalgia and CFS, also work that way. I remember a chronic back pain patient for whom they combined analgesics (not stinting), acupuncture, facet joint injection with corticosteroids, and chiropractic. All of the specialists constantly talked to one another and focused on avoiding dangerous interactions as well as things they didn't know how to solve.

I happen to be on a very complex cardiac drug regimen, where I was deeply involved in the treatment choices. Lots of molecular pharmacology went into it, along with research-level diagnostics. I have a friend who keeps wanting me to take herbals, which scares me to death -- I know not just the direct interactions among my drugs, but how their excretion pathways play together, upregulating, noninterfering, and downregulating. Putting unknown phytochemicals into that is not a risk I'm willing to take. Yet, for a pain syndrome no one has figured out -- might be combination of neurologic, cardiac, and musculoskeletal -- I've already had some manipulation and acupuncture, and would be willing to try others. I've used visualization for pain control for many years. It's balancing risks. Someone that wants me to stop all my meds and go with homeopathic remedies would have me out of the office so fast that I might not bother opening the door.

It's about balancing risks and informed consent, and, to be frank, that's one of my big problems with the whole-system homeopaths. I don't have enough understanding to make what I would consider an informed judgment to use the technique, and I don't know if they can or will tell me. Howard C. Berkowitz 04:16, 14 December 2008 (UTC)

I think those are very real concerns. PS, don't stop the meds and don't take any herbs. Meanwhile, don't let that cloud your sense of neutrality. D. Matt Innis 04:52, 14 December 2008 (UTC)

Herbs in perspective

I am, incidentally, both a very good herb gardener and cook. Even there, one learns about the power, good and bad, of plant extracts. I believe the first science article for which I was paid was about the electrolyte imbalances that could be caused by overindulging in licorice.Howard C. Berkowitz 04:57, 14 December 2008 (UTC)