Years in the Making
Integrative Medicine's Uphill Battles
This week, I attended the A4M conference - the American Academy of Anti-Aging medicine. It was refreshing to see a large conference center filled with hundreds of doctors who have stepped away - or are in the process of leaving - the conventional medical paradigm. Most Americans are fed up with the current “sick care” system we have and are seeking (hoping for?) something new, something better. It appears that more and more physicians are fed up too.
I thought this would be a good time to write about the evolution of integrative medicine - how we got here. The past defines the present. Let’s put it all together and form something new.
By definition, allopathic medicine is how medical doctors (MDs) and other professionals (such as nurses, pharmacists, and therapists) treat symptoms and diseases: with drugs, radiation, or surgery. Other names for allopathic medicine include conventional medicine, mainstream medicine, Western medicine, and orthodox medicine. In contrast, Complementary and Alternative Medicine (CAM) is defined as an approach to addressing health concerns which is mostly not pharmaceutically based, and therefore, have long been considered to be substandard, even woo-woo care, by allopathically trained physicians.
Wake Up Call
In 1990, an article was published in the New England Journal of Medicine (NEJM) by Eisenberg, et al, called, “Unconventional Medicine in the United States -- Prevalence, Costs, and Patterns of Use.” Using a phone survey, with each call averaging around 25 minutes in length, Eisenberg found that one third of the 1,539 persons he and his team spoke with had seen a provider of “unconventional therapy” over the preceding year. The most disturbing part of the study to mainstream medical doctors was this:
Among those who used an unconventional therapy for serious medical conditions, the vast majority (83 percent) also sought treatment for the same condition from a medical doctor. However, 72 percent of the respondents who used an unconventional therapy did not inform their medical doctor that they had done so.
Extrapolation to the U.S. population suggested that in 1990, Americans made an estimated 425 million visits to providers of unconventional therapies. This number exceeded the number of visits to all U.S. primary care physicians that same year (388 million).
Expenditures associated with use of unconventional therapies amounted to approximately $13.7 billion, three quarters of which ($10.3 billion) was paid out of pocket. This figure was comparable to the $12.8 billion spent out of pocket that year (as co-pays and deductibles) for all hospitalizations in the United States.
I still remember when this study came out. I was working full time in the ER, where I had been the Director of a Level II trauma center in Findlay, Ohio for four years. I remember my physician colleagues walking around in “shell shock” over these numbers. A staggering, bone-numbing chill passed through the allopathic industry and my physician friends were shaken to their core.
This landmark study became known as The Eisenberg Study. I recall hearing the murmurs and the angry grumblings of the various subspecialists when they were in the ER central station and when we were in the physician’s dining room. They often huddled in the hallways, discussing the findings.
Did you read that Eisenberg Study? People are spending billions in cash on nonsensical, non-conventional ‘treatments’! They’re throwing their money away! Don’t they know this stuff could hurt them? I started asking some of my long-time patients directly - and I found the survey was true! My patients haven’t been telling me about the vitamins and herbs they are taking. Some are seeing an acupuncturist AND a chiropractor and…OMG- they’ve been using homeopathy to stop taking many of the medications I have prescribed! I don’t have time to explain this to them or debate with them about their bad decisions….
A few years later, Eisenberg and his team did a second survey, but this time, the study encompassed a much larger population of individuals (9,730 surveyed). Called “Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey.” They found the trend had not slowed down; in fact, it had greatly increased:
The amount spent on alternative therapies – mostly out of pocket and non-insurance based care - was estimated at $22.6 billion in 1990 and $32.7 billion in 1997. Total expenditures paid to practitioners of alternative therapies was estimated to have increased by approximately 45% between 1990 and 1997, exclusive of inflation.
Overall prevalence of use non-pharmaceutically based solutions increased by 25%, and the total number visits increased by an estimated 47%.
Moreover, the use of alternative therapies had become distributed widely across all socio-demographic groups.
The results and comparison of these two surveys suggest that the prevalence and expenditures associated with alternative medical therapies in the United States had increased substantially from 1990 to 1997.
Here to Stay
That dollar expenditure on alternative treatments has stayed relatively constant over the last 20 years. A 2016 press release from the National Center for Complementary and Integrative and Health (NCCIH) found that Americans continue to spend roughly $30.2 billion per year out of pocket on non-mainstream care: $28.3 billion for adults and $1.9 billion for children.
That same press release also reported how much Americans spend on different types of approaches:
Americans spent $14.7 billion out-of-pocket on visits to practitioners such as chiropractors, acupuncturists, and massage therapists. The mean annual out-of-pocket expenditure per person was $433.
Americans spent $12.8 billion out-of-pocket on vitamins and supplements. Of note, that is about 1/4 spent out of pocket on prescription drug co-pays. The mean annual out-of-pocket expenditure in this category was about $368.
Total amount spent on self-care books, CDs, newsletter subscriptions, podcasts, etc, was around $2.7 billion. The mean annual out-of-pocket expenditure per user was $257.
Research begins. Really?
In 1998, somewhat in response to pressure from the general public and somewhat due to unfounded concerns for ‘safety’ about the use of these frivolous treatments, the NIH established The National Center for Complementary and Integrative Health. The NCCIH has categorized most of complementary medicine into two categories: (1) natural products, such as vitamins, minerals, herbs, and homeopathics, and (2) mind-body practices, including yoga, chiropractic, massage, acupuncture, yoga, meditation, and massage therapy.
While the stated mission of the NCCIH is to “define, through rigorous scientific investigation, the usefulness and safety of complementary and integrative interventions and their roles in improving health and health care,” in the grand scheme of healthcare, it has barely made a dent in the pharmaceutical paradigm. Its budget in FY2023 is only $170.3M. Compare thatto the FY2023 budget of the FDA ($8.4 billion), the FY2023 budget of the CDC ($10.675 billion), and Pfizer taking in >$100B in 2023 alone.
The Language Progression of Non-Conventional care
From the first ‘shocking’ revelations, these ‘hocus pocus’ therapies were collectively called alternative medicine. This disparaging term lumped all non-drug therapies together as the alternative to Real Medicine. The label implied an Either/Or health choice: EITHER you followed what your physician recommended within the allopathic and pharmaceutical model OR you went rogue and relied on quasi-scientific alternatives.
As the demand for more natural, less invasive, and less toxic forms of healing increased, the concept of ‘alternative medicine’ created a division between medical providers and their patients as consumers. Many times, when patients sheepishly fessed up and admitted they were taking a botanical instead of their prescribed blood pressure medicine or seeing a chiropractor instead of doing physical therapy and using pain medication, they were confronted with an angry, even irate, primary care doctor. And even when they defended their choice, reporting the herbal product or the spinal manipulation was not only working, but had no side effects and they felt better overall, their words generally fell on deaf ear.
The fall out included being sent a cold letter, discharging them from the practice for being “non-compliant.” What it really meant was they were being cast out for being disobedient.
Over time, allopathic physicians marginally (or perhaps begrudgingly) began to accept that perhaps there was some merit to some of these silly therapies even though they had not been subjected to THEIR Gold Standard of evaluation: a double-blind, placebo-controlled clinical trial. The term “alternative medicine” began to morph into “complementary medicine.”
This perfunctory nod toward acceptance allowed natural, non-invasive methods to be used together WITH pharmaceutical treatments, but they were still considered to be substandard, non-mainstream and not “real medicine.” By the mid-1990s, the natural healthcare industry had evolved to include specialized diagnostic tools, including blood, saliva, hair, and stool tests, looking for abnormalities, imbalances, and missing nutrients as the source of symptoms. Instead of using a medication to simply suppress a symptom, physicians and practitioners would add a complementary therapy, such as suggesting vitamin C or adding a multivitamin.
Complementary care suggested these therapeutics “added value but were subservient to” allopathic solutions. I opened my first clinic in Cleveland, Ohio March 1996; whenever I heard the term “complementary treatment,” I cringed at the reference. It felt like a non-mainstream tool was nothing more than dab of catsup on the side of a plate of French fries. It added something, but you could easily do without it. Even though the modalities had successfully helped millions of patients identify and resolve the root cause of their conditions, these programs were mostly tolerated by most physicians. The new and growing paradigm certainly was not embraced.
The Institute for Functional Medicine (IFM) was founded in 1991 by Jeffrey and Susan Bland. Functional medicine is a systematic approach to the prevention and management of chronic disease using nutrition, lifestyle modification, and the elimination of environmental toxicities. The IFM model is taught in modules, with an appreciation for the impact of cognitive and emotional distress on overall health. Treatment plans are individualized for each patient instead of a one-size-fits-all overall plan per condition. According to their website, IFM has educated more than 16,000 practitioners from 70 countries.
As recently as 2018, the American Academy of Family Physicians still declared that Functional Medicine lacks supporting evidence and includes “harmful” and “dangerous” treatments. I personally find this amusing because most of what is taught in the functional medicine modules is what we should have learned in medical school!
American Academy of Anti-Aging Medicine (A4M)
Founded in 1992 by Dr. Ronald Klatz and Dr. Robert Goldman, A4M was established for continuing medical education in longevity and anti-aging medicine. A4M’s website describes their educational programs as:
“An active way to build a new healthcare paradigm driven by evidence-based personalized medicine, leading to optimize longevity, wellness and vitality, grounded by strong research and science, and led by advanced-thinking clinicians.”
I’ve attended the A4M meetings on and off for many years. Their largest conference is always the second weekend in December in Las Vegas. The vendor area often has 100s of exhibitors; may times I would buy a “vendor area only” pass and spend 3 full days learning about the ‘latest and greatest’ tests, technologies, supplements, business tools, and more. For an active practice, this is where you could learn if an older product or test had been upgraded or if there was something new that was more beneficial.
Integrative medicine is a popular term nowadays. The separation of care has come full-circle; integrative medicine “uses the right tool for the job.” Practitioners who consider themselves to be Integrative use the full array of allopathic assessment tools (labs, x-rays, and procedures such as colonoscopy, stress test, or cardiac calcium score assessments) and more holistic assessment tools (thermography, unique lab assessments, or saliva hormone assessment) but then use a wide range of of therapeutics, from prescription medication to ozone/IV therapies to lifestyle/ nutritional options and beyond.
Integrative medicine practices often have a variety of practitioner types working together. For example, at Tenpenny Integrative Medical Center, we two MDs, two DOs, a Chiropractor, physician’s assistants, nurse practitioners, RNs, medical assistants, and office staff. We order appropriate tests and then have a large menu of options for treatments. I’m always proud to say that since 1996 we have had patients from all 50 states and around 18 countries come to our clinic to get well.
In 2022 a new study reviewed more than 5,000 published articles over the preceding 15 years and the synthesized the acceptance and use of complementary and alternative medicine (CAM) among medical specialists. Researchers found that CAM is now used or being recommended by 45% of practitioners. The highest use was found in Obstetrics and Gynecology, followed by Family Medicine, Psychiatry and Neurology, Pediatrics, Otolaryngology (ENT). It has taken a while – more than 30 years – but progress has been made.
More and more people are seeking a more natural, holist approach to healthcare and wanting to walk away from solely pharmaceutical based “solutions.” Will we be able to stay on this course, to let food be our medicine? Can we grow enough of our own food, purify enough chemicals and metals from our water, filter enough pollutants from our air to keep our body healthy?
Time will tell, but I’m betting on humanity’s resiliency to figure it out.
Next week: The History of Osteopathic Medicine