The Future Of Medicine
A roundtable discussion of practitioners, educators and natural product providers on how complementary health care models are changing Western medicine.
NP: What are the main challenges facing the complementary and alternative medicine (CAM) industry?
Guiltinan: Regulation and oversight by states is a major issue for naturopathic medicine and some other CAM professions. The naturopathic medical profession is licensed in 18 states and jurisdictions currently in the U. S. Efforts to increase the number of states who license and regulate naturopathic medicine are ongoing through state professional societies and the national organization, the American Association of Naturopathic Physicians (www.naturopathic.org).
Reimbursement is also a major issue for most CAM professions. While government and private payers reimburse broadly for conventional medical services, that is not the case with CAM services. Some states, such as Washington, have passed laws requiring insurance companies doing business in that state to cover services provided by any kind of licensed care provider in the state (any covered provider law). Efforts are being made now by many CAM professions to ensure the enforcement of the anti-discrimination piece of the Affordable Care Act (ACA), which prohibits discrimination of any licensed health care professional in a given jurisdiction.
Teitelbaum: The pharmaceutical industry and allopathic medicine have essentially bought a government-mandated monopoly. They are also one of the major advertisers in the media, which has allowed them to push dysfunctional regulations on both state and federal levels that often make it illegal to even discuss research on natural therapies (see Senate amendment 2143 to S3187, where 78 Senators voted against making it legal to discuss research on natural therapies, and only 15 voted in favor). Meanwhile, media outlets such as CNN and USA Today will ignore research showing that there are more than 30,000 preventable deaths a year from arthritis medications, as well as research showing natural options for arthritis to be more effective than these medications. At the same time, USA Today ran a 2.5-page spread pushing to make natural remedies unavailable. This suggests a major bias in the media, where pharmaceutical medicine has the best positioning money can buy.
Dehen: Others have portrayed natural medicine practitioners in ways that have worked against us professionally. We have often faced criticism for not providing rigorous scientific validation of the effectiveness of our CAM therapies. There is also a misunderstanding and lack of education about the medical training of naturopathic doctors and other CAM providers. This lack of comprehension presented opportunities for detractors to stereotype us as charlatans and quacks. These unflattering projections contain an underlying implication that Nds and other CAM practitioners are medically irresponsible and cannot be trusted as serious practitioners.
In recent decades, though, the natural medicine professions have countered such misunderstanding with appropriate government and educational milestones. The pioneers persisted and the image of naturopathic physicians is transforming as we rebrand ourselves as the holistic primary care physicians we are: Doctors who are educated and trained to order labs, prescribe medications, perform minor surgery and, increasingly, design and conduct evidencebased research studies.
NP: Have you observed a shift in the traditional health care model to including alternative treatments?
Guiltinan: Overall, there is more openness to CAM in the health care industry now than there was 10 or 20 years ago.Some conventional providers, health care systems and medical schools have begun to teach and practice “integrative medicine,” which incorporates some of the principles and modalities used by CAM professions. Some of these practitioners and health systems have incorporated CAM providers into their clinics as well.
Dehen: I have observed a shift.Recognizing the overwhelming importance of behavioral changes in preventing and treating morbidity in the industrialized world (IOM, 2001) has altered the exclusively pharmaceutically based model. For example, it’s no longer acceptable to treat a diabetic with insulin alone—nutrition is key.Diabetic patients now must receive nutritional and behavioral counseling. Cardiac care patients receive exercise and physical therapy advice as soon as they are diagnosed.
Bush: The proverbial curtain has been raised exposing the limitations of the traditional health care model. I can point to three things that made seismic changes to the patient-doctor/patient-health care industry relationship:
First, in July 2002 the Women’s Health Initiative study discontinued their planned nine-year study on estrogen/progesterone treatments due to the evidence that the benefits of the therapy did not outweigh the risks. Millions of women were on this therapy at the time, and confidence in their doctors and the health care industry was strained as many sought alternative approaches for women’s health.
Second, as the diagnosis of autism skyrocketed, the general public began their own grassroots efforts to change how their children were treated, often looking outside of the mainstream for answers and hope that were not addressed.
Third, the internet provided easy access to medical information, instant communications and virtual support groups, which has completely changed the way patients interact with their doctors. The more informed patients are to their treatments, side effects and alternative approaches, the greater the movement toward complementary and alternative health.
Myers: It is interesting to note that on MedScape—a physician-targeted news site from WebMD for specialists, primary care physicians and other health professionals— of the top 10 articles of 2013, five were on natural health interventions (four positive and one negative). While our headquarters are in the Midwest, I travel across the U.S. meeting with health care professionals. I see a distinct difference between urban areas and smaller cities, in that there is more available integrative medicine and acceptance (on average) by mainstream health care in these locales.
Skowron: Traditional health care is still based on fear of death/disease, and fear of litigious implications. Physicians perform unnecessary testing, treatments and surgeries in fear of being sued. The shift, or pendulum swing, is from the patients, who are realizing (with benefit of the internet) that traditional medicine is going to an extreme, and for their own health and wellbeing are looking for another solution.
In the 20th century, knowledge was power, but with the internet, anyone can have as much knowledge (or more) than the physician. The best strength the physician now has is experience and, hopefully, wisdom.
NP: What role has research played in changing the view of the CAM model, including the use of supplementation?
Killpartrick: Research has played a great role in reaffirming the life-changing clinical results ‘alternative’ practitioners have produced for many of their patients for decades. For those types of practitioners, research is a bonus. For people who require studies, the research has the potential to prove the efficacy of the treatment while also providing some context and clarity as to the physiologic changes and therapeutic effect of a specific treatment.
Teitelbaum: Research continues to help advance and support the importance and effectiveness of CAM. Close-minded individuals continue to simply ignore the research, which puts them more out of touch with reality, while CAM physicians become increasingly effective in helping people. There are thousands of important studies, but one I would note is my published double-blind, placebocontrolled study using an integrated CAM treatment approach in CFS and fibromyalgia showed a 90 percent average improvement rate (P < .0001 versus placebo).
Dehen: Research has been seminal to the rise of awareness, acceptance and inclusion of CAM. Some noteworthy examples include the many studies that demonstrate that the use of fish oils can help reduce the risk of heart attacks and strokes; studies that support the ability to prevent and reverse type 2 diabetes with diet, exercise and lifestyle modifications; as well as studies that demonstrate the use of meditation, support groups and tai qi can improve outcomes in cancer patients.
Data is the great equalizer—and for Nds, it’s empowering. Those who say they practice evidence-based medicine must accept data that demonstrates value and effectiveness of therapies, regardless if the therapy is a new drug or tai qi.
Sharpee: Research has played a significant role in changing the perspective of integrative medicine approach to health care. For example, in a recent symposium “The Effectiveness of Natural Products and Integrative Medicine for Pain Management” (www.naturalhealthresearch.org), practitioners provided a summary of the evidence on the effectiveness of multiple treatment modalities to relive pain as options to prescription drugs. Options included acupuncture, physical therapy and dietary supplements like boswellia, bromelain, curcumin, ginger, omega-3 fatty acids, corydalis, SAMe, MSM, scutellaria and acacia.
Myers:We have had many studies published on EuroMedica products or branded ingredients recently. In 2011, a study was published in Osteoarthritis Cartilage that compared BCM-95 Curcumin blended with BosPure Boswellia (found in our product Rhulief Plus) to celecoxib, a generic of Celebrex, the No. 1 prescription drug for osteoarthritis of the knee. The results showed our blend was superior to the drug for overall pain relief and distance walked without pain, and equal on parameters of improved flexibility.
In 2012, a study published in Phytotherapy Research compared our BCM-95 high absorption Curcumin (found in CuraPro) to dicolfenac sodium, a generic of the prescription drug Voltaren, in rheumatoid arthritis, and the improvements equaled that of the drug, but without the problematic side effects.
And in 2013, Phytotherapy Research published another study comparing BCM-95 Curcumin to fluoxetine, the generic of Prozac, in major depressive disorder. The natural product equaled the efficacy of the prescription drug.
When natural medicine companies can share this level of scientific proof and documentation, it is more difficult for mainstream medicine to be dismissive of these impressive results.
NP: Once the issues with the Affordable Care Act (ACA) are resolved, what role will CAM (including supplementation) play in the new “traditional” model?
Dehen: The ACA is helping usher in changes that have the potential to increase access to natural medicine practitioners. For example, Senator Harkin inserted a section into the ACA that states that insurers may not discriminate against licensed health care professionals “working within the scope of that provider’s license,” including Nds and Lacs. This federal requirement may lead to powerful changes in health care—and how it’s viewed and practiced in our country.
In addition, most people are unaware of a provision within the ACA that may have a significant impact on how CAM therapies are used. This provision came in response to charges by conservative Republicans that the ACA would lead to so-called “Death Panels.” The Death Panels, they claimed, could prematurely terminate the lives of elderly and critically ill patients due to the exorbitant costs of care associated with these populations.As a result, Congress took action. They wrote legislation into the ACA creating a Patient Centered Outcomes Research Institute (PCORI).
PCORI’s mandate is to fund research that puts patient needs and interests first when comparing different treatment approaches to a given condition. PCORI is forbidden by law from considering financial cost as a comparator when considering two different treatments for the same condition. Instead, PCORI is invested in discovering what patients want and if the treatments are effective, irrespective of whether the treatments are pharmacologic, surgical, alternative or something else. I sit on an advisory panel for PCORI; they intentionally seek input from CAM practitioners, knowing that the public wants alternative modalities to be available to them. That’s what being “patient-centered” means.
Sharpee: In my opinion, the current issues with implementation of the ACA are not affecting consumers’ view of integrative medicine. However, delaying implementation would delay a broader use of this “New Medicine” and the use of dietary supplements to prevent disease. With implementation, more consumers will come to understand that certain supplements can help to prevent or at least reduce the incidence of metabolic disease. This will only strengthen consumers’ view of the benefits of an integrative medicine approach, but also that supplementation at preventive intake levels in high-risk populations can reduce the number of medical events associated with heart disease, age-related eye disease, diabetes and bone disease.
I understand that a major provision of the ACA is prevention and personalization of medicine. This represents a clear opportunity for integrative medicine to maximize a disease prevention strategy through prescribing dietary supplements for a variety of chronic diseases. Recently, the use of dietary supplements has been shown to provide significant benefits as a low cost disease prevention strategy (see “Smart Prevention-Health Care Cost savings Resulting from the Targeted Use of Dietary Supplements” at www.supplementforsmartprevention.org). With broader dissemination of this and similar information on the cost benefits of chronic disease prevention with dietary supplements, the role of integrative medicine practitioners prescribing supplements will grow.
Bush: The ACA will increase funding for outcome studies, place more emphasis on preventative medicine and start the move away from fee-for-service reimbursements. CAM excels in these metrics and should find a greater role in our nation’s health care once the playing field is flattened a bit more.
Further, CAM offers some of the best preventative medicine at the most competitive costs. Chiropractic medicine has proven cost savings in addressing common back problems, naturopathic medicine has proven cost savings in treating the most common pediatric conditions, acupuncture’s effectiveness at reducing costs in managing patient’s pain, and studies have shown that incorporating massage into conventional medical management shortens hospital stays and improves outcomes. Likewise, studies are showing effectiveness of a number of supplements making them viable alternative to more expensive medication (e.g. SAMe vs. SSRIs).
As our country shifts toward outcome-based medicine, it will be impossible to ignore the health and cost benefits that complementary and alternative medicine offers.
Guiltinan: One of the changes in health care as a result of this law will hopefully be to put more emphasis on and resources toward wellness and health promotion. Naturopathic physicians and other CAM providers are well trained in these important areas and will be able to participate in a reformed system that encourages and invests in wellness, prevention and health promotion activities and services.
Teitelbaum: If common sense, both medical and economic, is applied, then CAM will play a larger role. I suspect, however, that the health care industry owns both sides of the debate at this point. I suspect this institutional bias against CAM will not change until our health care system gets closer to bankruptcy and has truly absolutely no choice but to make rational changes or collapse.
NP: With the health care model evolving, how can practitioners better prepare to provide the best service for more patients, as well as be active contributors to the industry?
Bush: CAM practitioners should leverage their costs savings approaches to large local employers as a way to save them health care dollars. Many practitioners are doing this already through corporate saving programs, but the market for these programs is in its infancy and will grow in the upcoming years.
Killpartrick: In addition to keeping costs low for patients, expand therapeutic approaches to include modalities that generate tangible results. And consistently transition patients from a reactive mindset to a proactive philosophy to their health.
Skowron: CAM practitioners need to specialize. With so much information being available on different illnesses, patients want to go to the expert—whether it’s the pediatrician or the natural pediatrician, the oncologist or the natural oncologist.
Dehen: Today’s practitioners must commit themselves to continuous learning and professional development to stay abreast of current research and trends in medicine.Clinicians need to accept that what they learned in medical school is obsolete almost as soon as they begin to practice. They must be willing to continually update their knowledge, attitudes and competencies for as long as they remain in practice. They must also be willing to participate in a system that increasingly requires practitioners to share data, chart notes and resources.
Guiltinan: In this era of massive amounts of information, one important way practitioners can better prepare themselves to meet the population’s needs is by understanding what an important educational role they can play for the patient. Helping patients navigate the overwhelming amount of material available about health on the internet and how to identify reliable information will become increasingly important.Additionally, educating and motivating patients about how to most effectively take responsibility for their own health and wellness is a skill all providers should develop as health care reform moves forward.
Teitelbaum: It’s important that naturopathic physicians continue to push state-by-state to get appropriate scope of practice rights based on their training. In addition, by increasing communication between different CAM health care providers (as is occurring at www.ffpnforum.org), we can start to develop a more sane, healthy and effective health care model for our patients/clients. As the current health care system fails, having developed a backup self-pay system that works, based on what is both safest and most effective, as well as on realistic economic forces, we will be in position to offer an alternative that is proven to work.
Our health care system is an incredibly dysfunctional dinosaur that is headed toward a cliff. I choose to simply get out of its way and offer those who come to me the most informed, effective, safe and compassionate care I can.
FOR MORE INFORMATION:
Bastyr, (425) 602-3000, www.bastyr.edu
Dr. Killpartrick,www.suncookvalleychiropractic.com
Dr. Skowron, www.naturopathicanswer.com
Dr. Teitelbaum, www.vitality101.com
EuroMedica, www.euromedicausa.com
NCNM, www.ncnm.edu
Protocol For Life Balance, (877) 776-8610,www.protocolforlife.com
Socialvite, (866) 290-9694,www.mysocialvite.com
The panel of experts that lent their insights to Natural Practitioner (NP) is:
Rebecca Bush, ND
CEO of Socialvite, a supplement provider based in Minnesota, where 15 percent of every product order is donated back into the natural health care community.
Regina Dehen, ND, LAc
Chief Medical Officer of the National College of Natural Medicine (NCNM).
Jane Guiltinan, ND
Dean of the School of Naturopathic Medicine at Bastyr University.
Adam Killpartrick, DC, CNS
NP Editorial Advisory Board Member in private practice at Suncook Valley Chiropractic in New Hampshire.
Cheryl Myers
Author, integrative health nurse and dietary supplement expert, is the Chief of Scientific Affairs and Education for supplement manufacturer EuroMedica in Wisconsin.
Jared M. Skowron, ND
Founder of the UB Pediatric & Autism Clinic and Vice- President of the Pediatric Association of Naturopathic Physicians, is an NP Editorial Advisory Board Member in private practice at Harvest Park Naturopathic Medicine in Connecticut.
Rick Sharpee, PhD
Science Research Manager with supplement manufacturer NOW Health Group/Protocol For Life Balance based in Illinois.
Jacob Teitelbaum, MD
Director of the Fatigue and Fibromyalgia Practitioners Network; author of the iPhone & Android application “Cures A-Z,” as well as several books, and NP Advisory Board Member.
