Post on 30-Jan-2023
Advance Access Publication 26 September 2007 eCAM 20085(4)409ndash413doi101093ecamnem104
Commentary
Divining integrative medicine
Steven H Stumpf1 Simon J Shapiro2 and Mary L Hardy3
1Stumpf Consulting Calabasas 2BWell Clinic Santa Monica and 3Simms-Mann Health and Wellness ProgramVenice Family Clinic Los Angeles CA USA
Keywords Complementary medicine ndash Integrative Medicine ndash Traditional Chinese Medicine
Introduction
Medicine like scientific inquiry is necessarily dynamic
As our understanding of health and disease continues to
grow medicine as we know it will change Alternative
therapies and perspectives that are coming to light will
be illuminated by modern methods of inquiry applied to
pre-modern healing systems At the same time patient
demands and cultural concerns about health and healing
influence the expansion of conventional medicine The
integrative medicine movement is a reflection of how
these issues have tumbled together creating a medical
field that is at once undefined and almost indescribableIntegrative medicine is growing in popularity among
consumers and healthcare providers alike An August 7
2006 article in the Los Angeles Times (1) asserted under
the heading Twice as Strong that lsquoWestern medicine
team[ed] up with acupuncture yoga and herbs to fight
both disease and pain [is] going mainstreamrsquo Three
regional clinical programs were described Each was
based in a conventional medical clinic each identified
as an integrative or multidisciplinary practiceReaders of the Twice as Strong article (Los Angles
Times daily circulation is approximately 850 000 as of
March 2006) (2) and viewers of The New Medicine
television show broadcast March 29 2006 (estimated
audience between 4 and 9 million) (3 4) learned that
conventional biomedicine is undergoing a transformation
from within The popular message is that this movement
is led by conventionally trained physicians who are
opening their practices to include mindndashbody therapies
as well as traditional techniques from other medical
cultures such as acupuncture and oriental medicine(AOM) However this is a narrow view We holda particular interest in the integration of AOM withconventional medicine where the breadth of this phenom-enon can be readily comprehendedThis emergence of integrative medicine in the public
eye is full of irony giving rise to our question whatcomprises integrative medicine exactly It is not com-plementary and alternative medicine (CAM) (5) It isa phenomenon that has defined itself with requirementsfor membership self-determined by each practitioner whochooses to promote her practice as integrative medicineConsider the following brief descriptions of integrative
medicine providers
A physician who completed a 300 h acupuncturecourse for physicians prefers to refer out forneedling to licensed acupuncturists He identifiesas an integrative practitioner relying on hisstrong research skills and belief in nutrition asmedicine He has a full practiceAn acupuncturist teaches at many of the AOM
colleges in Southern California Born and trainedin China she is widely recognized as an authorityin orthopedic integrative medicine She readsX-rays tongue pulse and inserts needlesShe prescribes herbs She treats side effects ofchemotherapy Her practice is fullA conventional physician witnessed Chinese
medicine on the mainland in the early 1980sWhen he became ill upon return to the UnitedStates he found a Chinese practitioner of AOMafter exhausting conventional medical solutionsHe is now an herbal expert in demand as aspeaker He knows herbs will be the lastmedicine to enter the integrative medicine circle
For reprints and all correspondence Steven H Stumpf EdDTel +1-818-571-3930 E-mail sstumpfcharternet
2007 The Author(s)This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (httpcreativecommonsorglicensesby-nc20uk) which permits unrestricted non-commercial use distribution and reproduction in any medium provided the original work isproperly cited
He fights to include the most basic herbalformulas in his multi-discipline integrative clinic
An American acupuncturist who becameinvolved with Chinese medicine in the 1950shas been a witness to the history of AOM in theUSA He was among the first to earn anOMD degree (Oriental medicine doctorate) anearly degree requiring 1000 h The currentmasterrsquos degree requires nearly 3000 h Hebelieves physicians could learn enough aboutAOM in 1000 h maybe less given their stronggrounding in organ systems basic anatomy andphysiology He believes traditional Chinese med-icine and conventional Western medicine are veryclosely aligned both allopathic with a centralemphasis on the neurovascular system He refersto his practice as One Medicine
Integrative medicine is as much a prototypical grass-roots populist movement as it is a medical approachthat has sprinted ahead of any simple fixed and lastingdefinition As a descriptive term integrative medicine ismulti-functional and prone to metamorphosis It is fullof nuances that correspond to various factors includingthe background of the author(s) attempting to describe itIntegrative medicine is bound by context and orientationnot fixed by any set of criteria at any level It is worth-while to ask the question how will we understand exactlywhat is integrative medicine
Malleable Definitions
Integrative medicine has gone through several generationsof lsquodefinitionalrsquo changes The greatest change is fromCAM to integrative One of the majormdashand earliest(1999)mdashCAM textbooks was Essentials of CAM editedby Wayne Jonas and Jeffery Levin (6) Although the titlestill reflected the model of CAM the introduction ofevidence-based medicine was prominent One of theintroductory chapters is lsquoHow to Practice Evidence-Based CAMrsquo Two more recent textbooks IntegrativeMedicine by Benjamin Kligler and Roberta Lee (7) andIntegrative Medicine by David Rakel (8) both prefer theterm integrative to CAM The preface in Kligler assertsthis new medicine is lsquorenewing the soul of [conventional]medicinersquo The foreword to Rakel authored byAndrew Weil draws a clear distinction between CAMand integrative medicine Weil distinguishes CAM asmodality-focused especially regarding treatments nottaught in conventional schools of medicine He alsodistinguishes integrative medicine as evidence-basedRakelrsquos integrative approach puts a lsquoholistic understand-ing of the patientrsquo at the center of the interaction (8)This emphasis on the patient continues in the Kliglerand Lee textbook both in the forward also writtenby Andrew Weil and in the preface These similarities
are not surprising as all three authors trained withAndrew WeilThe most important textbook written from a lsquoCAMrsquo
perspective is the Textbook of Natural Medicine edited byPizzorno and Murray (9) both naturopathic physiciansThey do not present the materials as an integrativemedicine textbook even though many naturopathsconsider themselves the prototype integrative physicianIt is presented as a science-based textbook of naturalmedicine in effect an evidence-based practice modelInterestingly the first chapter is lsquoEastern Origins ofIntegrative Medicine and Modern Applicationsrsquo The firstedition was written in 1993 (currently in 3rd edition)One of the earliest physician-edited textbooks on
integrative medicine is the Micozzi series The firstedition was published in 1996 prior to Jonas One caneasily track the nuances driving definitional changewith each new Micozzi text The 2006 third editionof Fundamentals of Complementary and IntegrativeMedicine (10) was titled Fundamentals of Complemen-tary and Alternative Medicine (italics added) in the firsttwo editions The prefaces in each edition illustrate thecontext-laden drivers for arriving at a suitable definitionIn the brief half-page preface to the 1996 first editionCAM is lsquoa classic consumer movement and a currentsocial phenomenon of significant dimensionsrsquo (11) CAMis also metaphysical as the reader is assured his views willexpand regarding how lsquolight time touch sensationenergy and mind enter into health and medicinersquoIn the 2001 second edition (12) CAM is almost
anti-scientific The much longer preface hints at particlephysics and the reductionism of modern Westernmedicine as philosophically opposed to mindndashbodymedicine and naturalistic views of human healthEnergetics is tied to CAM and the brain is offered asa region for lsquoremappingrsquo such that the mechanismsof action of energetics might be revealed As in the firstedition economics earn mention eg the growth ofalternative medicine is based upon what Americanslsquowant and are willing to pay forrsquoIn the third edition CAM shares the limelight with
integrative medicine The movement has become aphenomenon supported by well-established data demon-strating popularity support and growth
Beyond Definitions
For the consumer and many providers the term CAMhas already been supplanted by the term integrativemedicine Integrative medicine may hold more relevancefor a widening range of providers that self-identify withthe new medicine For example the American MedicalStudents Associationrsquos Humanistic Medicine ActionCommittee simply combines the two terms publishingan lsquoICAMrsquo newsletter and hosting an online lsquoICAMrsquo
410 Divining integrative medicine
resource centermdashIntegrative Complementary andAlternative Medicine (13)Defining the concept of integrative medicine is one first
step towards understanding the phenomenon Howevera definition is more likely to emerge from key issuesthat are shaping the future of integrative medicine Theseissues inevitably come to the fore when practice racesahead of regulation They are clinical care researcheducation standards as well as economic opportunitiesWe allude to these topics here with intention to addressthem more substantially in subsequent reports Identifica-tion among integrative medicine providers could progressfrom our current state of self-determination to bilateralpeer approval and finally bilateral certification (Fig 1)There is no unifying conceptual framework (14) of
integrative medicine just as there are no unifying trainingstandards or scope of practice Attempts at one unifyingdefinition are limited by context often seeming speaker-dependent In terms of collaborative medical practice inwhich the patient and doctor are partners integrativemedicine has been described as lsquoa comprehensiveprimary care system that emphasizes wellness and healingof the whole person (bio-psycho-socio-spiritual dimen-sions) as major goals above and beyond suppression ofa specific somatic diseasersquo (15) From the perspectiveof scientific research for example NCCAM (the NationalCenter for Complementary and Alternative Medicineunder the National Institutes of Health) complementaryand alternative medicine includes lsquohealthcare practicesoutside the realm of conventional medicine which are yetto be validated using scientific methodsrsquo (16) Accordingto NCCAM integrative medicine lsquocombines mainstreammedical therapies and CAM therapies for which thereis some high-quality scientific evidence of safety andeffectivenessrsquo (17) A more transcendent view definesintegrative medicine as lsquohealing-oriented medicine thatre-emphasizes the relationship between patient andphysician and integrates the best of complementaryand alternative medicine with the best of conventionalmedicinersquo (18)Practitioners outside conventional medicine often
express concerns about lsquomainstreaming alternativemedicinersquo that will result in alternative practitioners
being lsquorelegated to a subservient position under Western
medical doctors being forced into a paraprofessional
role leaving doctors with the final approval in a power-
based modelrsquo (19) Additional concerns about assimila-
tion include the dilution of CAM therapies and the loss
of diversity within the field(s) However many leaders
believe that continuing movement towards integrative
medicine will encourage transformation of lsquothe entire
system toward the values of holistic person-centered care
without losing access to the science and technology based
cures of conventional medicinersquo (5)The Bravewell Collaborative a philanthropic organiza-
tion which supports an impressive array of developments
in integrative medicine highlights the systemic challenges
inherent to the movement by posing the question
lsquoHow can a highly formalized and large-scale system of
institutions (conventional medicine) and a small-scale
informal system of individual practitioners (CAM)
integrate the best of both to form a better overall
health care systemrsquo (5)Bravewell anticipates two developmental spectra
lsquoexpansion of access to diverse CAM therapiesrsquo and
lsquotransformation of the conventional healthcare systemrsquo
Four possible outcomes to the development of integrative
medicine are suggested (i) high transformation of the
conventional system with high expansion of CAM
wherein lsquoconventional medicine is highly transformed by
IMCAM and CAM therapies are proven and accessiblersquo
(ii) high transformation of the conventional system with
low expansion of CAM wherein lsquoconventional institu-
tions expand their own ideas about prevention public
health and patient educationrsquo thereby starving lsquoresources
and attention from CAM so that its expansion is stalledrsquo
(iii) low transformation of the conventional system with
high expansion of CAM wherein lsquoconventional medici-
ne stays basically the same [while] at the same time
CAMIM research and outcomes-data further define the
value of CAM [and] IM and CAM institutions
flourishrsquo and (iv) low transformation of the conventional
system with low expansion of CAM wherein the
lsquoconventional system does not change and the momentum
for CAMIM stallsrsquo (5)
Who Practices Integrative Medicine
No one really knows As noted most coverage whether
in popular media or scientific literature is focused on
conventional physicians who have integrated aspects of
CAM into their medical practice or who serve as the
head of an lsquointegratedrsquo team of diverse practitioners
from different disciplines Ironically this group is very
likely the smaller cohort among a much larger group of
providers who identify as integrative practitioners or who
operate in self-identified integrative practices including
Figure 1 Identification among integrative medicine providers could
progress from our current state of self-determination to bilateral peer
approval and finally bilateral certification
eCAM 20085(4) 411
chiropractors acupuncturists naturopaths and othernon-conventional providersThe tendency to focus narrowly on conventional
providers reflects a familiar cultural centrism consistentwith the dominant position of conventional medicinewithin healthcare (20) Discussion of integrative medicinemust acknowledge the extended group for many reasonsleast of which is accurately estimating the total providerpool We do not want to overlook another factor inmore effectively defining integrative medicine whetherthe integration is simply a matter of the provider havingmore modalities at his disposal or something greater forproviders on both sides of the equation
Who Certifies Integrative MedicinePractitioners
For professional groups identity and responsibility comewith regulation It is therefore crucial to consider theissue of certification in integrative medicine The absenceof a certification scheme means that provider identifica-tion process is self-determined An operational definitionof integrative medicine from the perspective of a regula-tory agent might read as follows integrative medicine isthe practice of any medicine or medicines determined bythe practitioner unbound by regulatory standards withmembership established by the individualIt may be more practical to assert what is not integra-
tive medicine It is not conventional Western medicinealthough many conventionally trained physicianspromote their practices as integrative medicine IndeedNCCAM funds an impressive array of integrativemedicine centers all located at academic medical centersNobody actually knows how many conventional physi-cians identify as integrative to their patients and theircolleagues or more importantly for this discussionwhat criteria they use to determine this designationIntegrative medicine is not acupuncture and Oriental
medicine although many AOM practitioners promotetheir practices as integrative medicine and practition-ers of AOM are often included in integrative clinicsAs with conventional physicians no one knows howmany acupuncturists identify as integrative to theirpatients or colleagues NCCAM which defines AOM asan alternative whole medical system (21) has made a feweducational awards to AOM colleges most in partnershipwith conventional academic medical centers The awardsaim to strengthen traditional approaches to medicaltraining within AOM colleges This can be viewed asa clear step in the direction of trying to standardizeintegrative medicine training by supporting the adoptionof conventional medicine training standards by at leasta few AOM colleges It is expected that graduates ofthese AOM colleges will be more likely to be employedin clinical settings affiliated with conventional medical
systems and will enjoy privileged status when integrativemedicine is finally regulated
Definition Scope of Practice Standards andRegulation
The definition of integrative medicine will become veryimportant as scope of practice issues become moreprominent Defining integrative medicine has as muchto do with regulating practice as with defining educa-tional standards In fact one leads to the other When ascope of practice is modified to include new diagnosticsor therapeutics training programs add content to thecurriculum in the new areas of practice This occursroutinely in conventional medical schools The sameshould hold for AOM schools If integrative medicine isnecessarily bilateral (20) then standards should applybilaterally As things stand currently in the integrativehealthcare arena ie CAM and conventional disciplinesexpectations for standards flow from the larger conven-tional disciplines to the CAM periphery where practiceis less overtly regulated It is axiomatic that exchangeof knowledge production of research and educationalstandards are currently not bilateral Certification ofintegrative medicine providers might follow the develop-mental path from no regulation to self-regulation toco-regulation (Fig 2)We do not challenge the sincerity of the previous
efforts to define integrative medicine We have tried toshow that the definition is malleable and like CAMbefore it depends on the perspective of the definer (22)The markers of definitional change have moved fromobserving the power of consumer economic choiceto spiritual regeneration of a mechanistic medicineto the expansion of choice based on scientific evidenceIn addition to a multitude of new treatment optionsCAM offers conventional medicine a philosophy ofholism (23) lsquonewrsquo ways of looking at the complexphenomena of health and disease (24) and the conceptof inherent healing capacity (vis medicatrix naturae)while conventional medicine offers CAM rigorous meansto scientifically examine these practices and ideas (25)Integrative medicine at its current stage of development
Figure 2 Certification of integrative medicine providers might
follow the developmental path from no regulation to self-regulation
to co-regulation
412 Divining integrative medicine
incorporates the best practices of CAM and conventionalmedicine into a unified treatment plan a goal thatrequires both camps to step into the integrative circle andexamine themselves and each other with an open mindIntegration of medical disciplines will first requiremovement from isolation to collaboration before realintegration occurs (Fig 3)
Regulatory Focus Will Turn to Education
We see integrative medicine as a moving target that willbecome more fixed and stable as sufficient pressures arebrought to bear that demand descriptive clarificationAlthough clinical care is where the practical implicationsof integration first emerge we strongly believe thatresearch and education in integrative medicine willbecome focal points for the negotiation of the morerigorous definition Given its long history of organizedprofessional development and its clinical and economicdominance it is likely that the standards of conventionalmedicine will provide the default criteria How well-prepared are the fields that comprise complementary andalternative medicine especially acupuncture and Orientalmedicine to undergo scrutiny It is time to carefullyexamine this question
References1 Macgregor H Twice as Strong Los Angeles Times August 7 20062 Los Angeles Times Media Center ndash Circulation Retrieved May 7
2007 from httpwwwlatimescomservicesnewspapermediacenterla-mediacenter-circulation07813109story
3 The Bravewell Collaborative ndash Transforming Healthcare RetrievedMay 7 2007 from httpwwwbravewellorgtransforming_healthcarepublic_education
4 The New Medicine viewing audience University of MarylandCenter for Integrative Medicine newsletter Spring 2006
5 Mapping the emergence of integrative medicine a journey towarda new medicine (executive summary short version) ClohesyConsulting April 2003 Retrieved March 30 2007 from httpwwwbravewellorgtransforming_healthcaremapping_the_field
6 Jonas WB Levin JS Essentials of Complementary and AlternativeMedicine Lippincott Williams amp Wilkins 1999
7 Kligler B Lee R Integrative Medicine Principles for PracticeMcGraw-Hill 2004
8 Rakel D Integrative Medicine Philadelphia Saunders 20039 Pizzorno JE Murray MT Textbook of Natural Medicine 3rd edn
Churchill Livingston 200610 Micozzi MS Fundamentals of Complementary and Integrative
Medicine 3rd edn Saunders 200511 Micozzi MS Fundamentals of Complementary and Alternative
Medicine 1st edn Churchill Livingstone 199612 Micozzi MS Fundamentals of Complementary and Alternative
Medicine 2nd edn Churchill Livingstone 200113 American Medical Student Association ndash ICAM Resource Center
Retrieved May 7 2007 from httpwwwamsaorgICAMresourcescfm
14 Hsiao AF Hays RD Ryan GW Coulter ID Andersen RMHardy ML et al A self-report measure of cliniciansrsquo orientationtoward integrative medicine Health Serv Res 200540(5 Pt 1)1553ndash69
15 Bell I Pher C Schwartz GE Grant KL Gaudet TW Rychener DIntegrative medicine and systemic outcomes research Arch InternalMed 2002162133ndash40
16 Atsumi K Kamohara S Bridging conventional medicine andcomplementary and alternative medicine IEEE Eng Med BiolMag 20052430ndash4
17 NCCAM ndash What is CAM Retrieved May 7 2007 from httpnccamnihgovhealthwhatiscam
18 Maizes V Schneider C Bell I Weil A Integrative medicaleducation development and implementation of a comprehensivecurriculum at the University of Arizona Acad Med 200277861ndash3
19 Phelan KE Integrative Medicine Journey Editions 199820 Stumpf S Shapiro S Bilateral integrative medicine obviously
eCAM 2006346ndash5021 NCCAM ndash Whole Medical Systems Retrieved May 7 2007 from
httpnccamnihgovhealthbackgroundswholemedhtm22 Cooper E Complementary and alternative medicine when rigorous
can be science (Editorial) eCAM 200411ndash423 Ghassemi J Finding the evidence in CAM a studentrsquos perspective
eCAM 20052395ndash724 Tan S Tillisch K Mayer E Functional somatic syndromes
emerging biomedical models and traditional Chinese medicineeCAM 2004135ndash40
25 Chiappelli F Prolo P Cajulis O Evidence-based researchin complementary and alternative medicine I History (LectureSeries) eCAM 20052453ndash8
Received May 14 2007 accepted July 9 2007
Figure 3 Integration of medical disciplines could first require movement
from isolation to collaboration before integration
eCAM 20085(4) 413
Submit your manuscripts athttpwwwhindawicom
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Parkinsonrsquos Disease
Evidence-Based Complementary and Alternative Medicine
Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom
He fights to include the most basic herbalformulas in his multi-discipline integrative clinic
An American acupuncturist who becameinvolved with Chinese medicine in the 1950shas been a witness to the history of AOM in theUSA He was among the first to earn anOMD degree (Oriental medicine doctorate) anearly degree requiring 1000 h The currentmasterrsquos degree requires nearly 3000 h Hebelieves physicians could learn enough aboutAOM in 1000 h maybe less given their stronggrounding in organ systems basic anatomy andphysiology He believes traditional Chinese med-icine and conventional Western medicine are veryclosely aligned both allopathic with a centralemphasis on the neurovascular system He refersto his practice as One Medicine
Integrative medicine is as much a prototypical grass-roots populist movement as it is a medical approachthat has sprinted ahead of any simple fixed and lastingdefinition As a descriptive term integrative medicine ismulti-functional and prone to metamorphosis It is fullof nuances that correspond to various factors includingthe background of the author(s) attempting to describe itIntegrative medicine is bound by context and orientationnot fixed by any set of criteria at any level It is worth-while to ask the question how will we understand exactlywhat is integrative medicine
Malleable Definitions
Integrative medicine has gone through several generationsof lsquodefinitionalrsquo changes The greatest change is fromCAM to integrative One of the majormdashand earliest(1999)mdashCAM textbooks was Essentials of CAM editedby Wayne Jonas and Jeffery Levin (6) Although the titlestill reflected the model of CAM the introduction ofevidence-based medicine was prominent One of theintroductory chapters is lsquoHow to Practice Evidence-Based CAMrsquo Two more recent textbooks IntegrativeMedicine by Benjamin Kligler and Roberta Lee (7) andIntegrative Medicine by David Rakel (8) both prefer theterm integrative to CAM The preface in Kligler assertsthis new medicine is lsquorenewing the soul of [conventional]medicinersquo The foreword to Rakel authored byAndrew Weil draws a clear distinction between CAMand integrative medicine Weil distinguishes CAM asmodality-focused especially regarding treatments nottaught in conventional schools of medicine He alsodistinguishes integrative medicine as evidence-basedRakelrsquos integrative approach puts a lsquoholistic understand-ing of the patientrsquo at the center of the interaction (8)This emphasis on the patient continues in the Kliglerand Lee textbook both in the forward also writtenby Andrew Weil and in the preface These similarities
are not surprising as all three authors trained withAndrew WeilThe most important textbook written from a lsquoCAMrsquo
perspective is the Textbook of Natural Medicine edited byPizzorno and Murray (9) both naturopathic physiciansThey do not present the materials as an integrativemedicine textbook even though many naturopathsconsider themselves the prototype integrative physicianIt is presented as a science-based textbook of naturalmedicine in effect an evidence-based practice modelInterestingly the first chapter is lsquoEastern Origins ofIntegrative Medicine and Modern Applicationsrsquo The firstedition was written in 1993 (currently in 3rd edition)One of the earliest physician-edited textbooks on
integrative medicine is the Micozzi series The firstedition was published in 1996 prior to Jonas One caneasily track the nuances driving definitional changewith each new Micozzi text The 2006 third editionof Fundamentals of Complementary and IntegrativeMedicine (10) was titled Fundamentals of Complemen-tary and Alternative Medicine (italics added) in the firsttwo editions The prefaces in each edition illustrate thecontext-laden drivers for arriving at a suitable definitionIn the brief half-page preface to the 1996 first editionCAM is lsquoa classic consumer movement and a currentsocial phenomenon of significant dimensionsrsquo (11) CAMis also metaphysical as the reader is assured his views willexpand regarding how lsquolight time touch sensationenergy and mind enter into health and medicinersquoIn the 2001 second edition (12) CAM is almost
anti-scientific The much longer preface hints at particlephysics and the reductionism of modern Westernmedicine as philosophically opposed to mindndashbodymedicine and naturalistic views of human healthEnergetics is tied to CAM and the brain is offered asa region for lsquoremappingrsquo such that the mechanismsof action of energetics might be revealed As in the firstedition economics earn mention eg the growth ofalternative medicine is based upon what Americanslsquowant and are willing to pay forrsquoIn the third edition CAM shares the limelight with
integrative medicine The movement has become aphenomenon supported by well-established data demon-strating popularity support and growth
Beyond Definitions
For the consumer and many providers the term CAMhas already been supplanted by the term integrativemedicine Integrative medicine may hold more relevancefor a widening range of providers that self-identify withthe new medicine For example the American MedicalStudents Associationrsquos Humanistic Medicine ActionCommittee simply combines the two terms publishingan lsquoICAMrsquo newsletter and hosting an online lsquoICAMrsquo
410 Divining integrative medicine
resource centermdashIntegrative Complementary andAlternative Medicine (13)Defining the concept of integrative medicine is one first
step towards understanding the phenomenon Howevera definition is more likely to emerge from key issuesthat are shaping the future of integrative medicine Theseissues inevitably come to the fore when practice racesahead of regulation They are clinical care researcheducation standards as well as economic opportunitiesWe allude to these topics here with intention to addressthem more substantially in subsequent reports Identifica-tion among integrative medicine providers could progressfrom our current state of self-determination to bilateralpeer approval and finally bilateral certification (Fig 1)There is no unifying conceptual framework (14) of
integrative medicine just as there are no unifying trainingstandards or scope of practice Attempts at one unifyingdefinition are limited by context often seeming speaker-dependent In terms of collaborative medical practice inwhich the patient and doctor are partners integrativemedicine has been described as lsquoa comprehensiveprimary care system that emphasizes wellness and healingof the whole person (bio-psycho-socio-spiritual dimen-sions) as major goals above and beyond suppression ofa specific somatic diseasersquo (15) From the perspectiveof scientific research for example NCCAM (the NationalCenter for Complementary and Alternative Medicineunder the National Institutes of Health) complementaryand alternative medicine includes lsquohealthcare practicesoutside the realm of conventional medicine which are yetto be validated using scientific methodsrsquo (16) Accordingto NCCAM integrative medicine lsquocombines mainstreammedical therapies and CAM therapies for which thereis some high-quality scientific evidence of safety andeffectivenessrsquo (17) A more transcendent view definesintegrative medicine as lsquohealing-oriented medicine thatre-emphasizes the relationship between patient andphysician and integrates the best of complementaryand alternative medicine with the best of conventionalmedicinersquo (18)Practitioners outside conventional medicine often
express concerns about lsquomainstreaming alternativemedicinersquo that will result in alternative practitioners
being lsquorelegated to a subservient position under Western
medical doctors being forced into a paraprofessional
role leaving doctors with the final approval in a power-
based modelrsquo (19) Additional concerns about assimila-
tion include the dilution of CAM therapies and the loss
of diversity within the field(s) However many leaders
believe that continuing movement towards integrative
medicine will encourage transformation of lsquothe entire
system toward the values of holistic person-centered care
without losing access to the science and technology based
cures of conventional medicinersquo (5)The Bravewell Collaborative a philanthropic organiza-
tion which supports an impressive array of developments
in integrative medicine highlights the systemic challenges
inherent to the movement by posing the question
lsquoHow can a highly formalized and large-scale system of
institutions (conventional medicine) and a small-scale
informal system of individual practitioners (CAM)
integrate the best of both to form a better overall
health care systemrsquo (5)Bravewell anticipates two developmental spectra
lsquoexpansion of access to diverse CAM therapiesrsquo and
lsquotransformation of the conventional healthcare systemrsquo
Four possible outcomes to the development of integrative
medicine are suggested (i) high transformation of the
conventional system with high expansion of CAM
wherein lsquoconventional medicine is highly transformed by
IMCAM and CAM therapies are proven and accessiblersquo
(ii) high transformation of the conventional system with
low expansion of CAM wherein lsquoconventional institu-
tions expand their own ideas about prevention public
health and patient educationrsquo thereby starving lsquoresources
and attention from CAM so that its expansion is stalledrsquo
(iii) low transformation of the conventional system with
high expansion of CAM wherein lsquoconventional medici-
ne stays basically the same [while] at the same time
CAMIM research and outcomes-data further define the
value of CAM [and] IM and CAM institutions
flourishrsquo and (iv) low transformation of the conventional
system with low expansion of CAM wherein the
lsquoconventional system does not change and the momentum
for CAMIM stallsrsquo (5)
Who Practices Integrative Medicine
No one really knows As noted most coverage whether
in popular media or scientific literature is focused on
conventional physicians who have integrated aspects of
CAM into their medical practice or who serve as the
head of an lsquointegratedrsquo team of diverse practitioners
from different disciplines Ironically this group is very
likely the smaller cohort among a much larger group of
providers who identify as integrative practitioners or who
operate in self-identified integrative practices including
Figure 1 Identification among integrative medicine providers could
progress from our current state of self-determination to bilateral peer
approval and finally bilateral certification
eCAM 20085(4) 411
chiropractors acupuncturists naturopaths and othernon-conventional providersThe tendency to focus narrowly on conventional
providers reflects a familiar cultural centrism consistentwith the dominant position of conventional medicinewithin healthcare (20) Discussion of integrative medicinemust acknowledge the extended group for many reasonsleast of which is accurately estimating the total providerpool We do not want to overlook another factor inmore effectively defining integrative medicine whetherthe integration is simply a matter of the provider havingmore modalities at his disposal or something greater forproviders on both sides of the equation
Who Certifies Integrative MedicinePractitioners
For professional groups identity and responsibility comewith regulation It is therefore crucial to consider theissue of certification in integrative medicine The absenceof a certification scheme means that provider identifica-tion process is self-determined An operational definitionof integrative medicine from the perspective of a regula-tory agent might read as follows integrative medicine isthe practice of any medicine or medicines determined bythe practitioner unbound by regulatory standards withmembership established by the individualIt may be more practical to assert what is not integra-
tive medicine It is not conventional Western medicinealthough many conventionally trained physicianspromote their practices as integrative medicine IndeedNCCAM funds an impressive array of integrativemedicine centers all located at academic medical centersNobody actually knows how many conventional physi-cians identify as integrative to their patients and theircolleagues or more importantly for this discussionwhat criteria they use to determine this designationIntegrative medicine is not acupuncture and Oriental
medicine although many AOM practitioners promotetheir practices as integrative medicine and practition-ers of AOM are often included in integrative clinicsAs with conventional physicians no one knows howmany acupuncturists identify as integrative to theirpatients or colleagues NCCAM which defines AOM asan alternative whole medical system (21) has made a feweducational awards to AOM colleges most in partnershipwith conventional academic medical centers The awardsaim to strengthen traditional approaches to medicaltraining within AOM colleges This can be viewed asa clear step in the direction of trying to standardizeintegrative medicine training by supporting the adoptionof conventional medicine training standards by at leasta few AOM colleges It is expected that graduates ofthese AOM colleges will be more likely to be employedin clinical settings affiliated with conventional medical
systems and will enjoy privileged status when integrativemedicine is finally regulated
Definition Scope of Practice Standards andRegulation
The definition of integrative medicine will become veryimportant as scope of practice issues become moreprominent Defining integrative medicine has as muchto do with regulating practice as with defining educa-tional standards In fact one leads to the other When ascope of practice is modified to include new diagnosticsor therapeutics training programs add content to thecurriculum in the new areas of practice This occursroutinely in conventional medical schools The sameshould hold for AOM schools If integrative medicine isnecessarily bilateral (20) then standards should applybilaterally As things stand currently in the integrativehealthcare arena ie CAM and conventional disciplinesexpectations for standards flow from the larger conven-tional disciplines to the CAM periphery where practiceis less overtly regulated It is axiomatic that exchangeof knowledge production of research and educationalstandards are currently not bilateral Certification ofintegrative medicine providers might follow the develop-mental path from no regulation to self-regulation toco-regulation (Fig 2)We do not challenge the sincerity of the previous
efforts to define integrative medicine We have tried toshow that the definition is malleable and like CAMbefore it depends on the perspective of the definer (22)The markers of definitional change have moved fromobserving the power of consumer economic choiceto spiritual regeneration of a mechanistic medicineto the expansion of choice based on scientific evidenceIn addition to a multitude of new treatment optionsCAM offers conventional medicine a philosophy ofholism (23) lsquonewrsquo ways of looking at the complexphenomena of health and disease (24) and the conceptof inherent healing capacity (vis medicatrix naturae)while conventional medicine offers CAM rigorous meansto scientifically examine these practices and ideas (25)Integrative medicine at its current stage of development
Figure 2 Certification of integrative medicine providers might
follow the developmental path from no regulation to self-regulation
to co-regulation
412 Divining integrative medicine
incorporates the best practices of CAM and conventionalmedicine into a unified treatment plan a goal thatrequires both camps to step into the integrative circle andexamine themselves and each other with an open mindIntegration of medical disciplines will first requiremovement from isolation to collaboration before realintegration occurs (Fig 3)
Regulatory Focus Will Turn to Education
We see integrative medicine as a moving target that willbecome more fixed and stable as sufficient pressures arebrought to bear that demand descriptive clarificationAlthough clinical care is where the practical implicationsof integration first emerge we strongly believe thatresearch and education in integrative medicine willbecome focal points for the negotiation of the morerigorous definition Given its long history of organizedprofessional development and its clinical and economicdominance it is likely that the standards of conventionalmedicine will provide the default criteria How well-prepared are the fields that comprise complementary andalternative medicine especially acupuncture and Orientalmedicine to undergo scrutiny It is time to carefullyexamine this question
References1 Macgregor H Twice as Strong Los Angeles Times August 7 20062 Los Angeles Times Media Center ndash Circulation Retrieved May 7
2007 from httpwwwlatimescomservicesnewspapermediacenterla-mediacenter-circulation07813109story
3 The Bravewell Collaborative ndash Transforming Healthcare RetrievedMay 7 2007 from httpwwwbravewellorgtransforming_healthcarepublic_education
4 The New Medicine viewing audience University of MarylandCenter for Integrative Medicine newsletter Spring 2006
5 Mapping the emergence of integrative medicine a journey towarda new medicine (executive summary short version) ClohesyConsulting April 2003 Retrieved March 30 2007 from httpwwwbravewellorgtransforming_healthcaremapping_the_field
6 Jonas WB Levin JS Essentials of Complementary and AlternativeMedicine Lippincott Williams amp Wilkins 1999
7 Kligler B Lee R Integrative Medicine Principles for PracticeMcGraw-Hill 2004
8 Rakel D Integrative Medicine Philadelphia Saunders 20039 Pizzorno JE Murray MT Textbook of Natural Medicine 3rd edn
Churchill Livingston 200610 Micozzi MS Fundamentals of Complementary and Integrative
Medicine 3rd edn Saunders 200511 Micozzi MS Fundamentals of Complementary and Alternative
Medicine 1st edn Churchill Livingstone 199612 Micozzi MS Fundamentals of Complementary and Alternative
Medicine 2nd edn Churchill Livingstone 200113 American Medical Student Association ndash ICAM Resource Center
Retrieved May 7 2007 from httpwwwamsaorgICAMresourcescfm
14 Hsiao AF Hays RD Ryan GW Coulter ID Andersen RMHardy ML et al A self-report measure of cliniciansrsquo orientationtoward integrative medicine Health Serv Res 200540(5 Pt 1)1553ndash69
15 Bell I Pher C Schwartz GE Grant KL Gaudet TW Rychener DIntegrative medicine and systemic outcomes research Arch InternalMed 2002162133ndash40
16 Atsumi K Kamohara S Bridging conventional medicine andcomplementary and alternative medicine IEEE Eng Med BiolMag 20052430ndash4
17 NCCAM ndash What is CAM Retrieved May 7 2007 from httpnccamnihgovhealthwhatiscam
18 Maizes V Schneider C Bell I Weil A Integrative medicaleducation development and implementation of a comprehensivecurriculum at the University of Arizona Acad Med 200277861ndash3
19 Phelan KE Integrative Medicine Journey Editions 199820 Stumpf S Shapiro S Bilateral integrative medicine obviously
eCAM 2006346ndash5021 NCCAM ndash Whole Medical Systems Retrieved May 7 2007 from
httpnccamnihgovhealthbackgroundswholemedhtm22 Cooper E Complementary and alternative medicine when rigorous
can be science (Editorial) eCAM 200411ndash423 Ghassemi J Finding the evidence in CAM a studentrsquos perspective
eCAM 20052395ndash724 Tan S Tillisch K Mayer E Functional somatic syndromes
emerging biomedical models and traditional Chinese medicineeCAM 2004135ndash40
25 Chiappelli F Prolo P Cajulis O Evidence-based researchin complementary and alternative medicine I History (LectureSeries) eCAM 20052453ndash8
Received May 14 2007 accepted July 9 2007
Figure 3 Integration of medical disciplines could first require movement
from isolation to collaboration before integration
eCAM 20085(4) 413
Submit your manuscripts athttpwwwhindawicom
Stem CellsInternational
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
MEDIATORSINFLAMMATION
of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Behavioural Neurology
EndocrinologyInternational Journal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Disease Markers
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
BioMed Research International
OncologyJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Oxidative Medicine and Cellular Longevity
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
PPAR Research
The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014
Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Journal of
ObesityJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Computational and Mathematical Methods in Medicine
OphthalmologyJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Diabetes ResearchJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Research and TreatmentAIDS
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Gastroenterology Research and Practice
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Parkinsonrsquos Disease
Evidence-Based Complementary and Alternative Medicine
Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom
resource centermdashIntegrative Complementary andAlternative Medicine (13)Defining the concept of integrative medicine is one first
step towards understanding the phenomenon Howevera definition is more likely to emerge from key issuesthat are shaping the future of integrative medicine Theseissues inevitably come to the fore when practice racesahead of regulation They are clinical care researcheducation standards as well as economic opportunitiesWe allude to these topics here with intention to addressthem more substantially in subsequent reports Identifica-tion among integrative medicine providers could progressfrom our current state of self-determination to bilateralpeer approval and finally bilateral certification (Fig 1)There is no unifying conceptual framework (14) of
integrative medicine just as there are no unifying trainingstandards or scope of practice Attempts at one unifyingdefinition are limited by context often seeming speaker-dependent In terms of collaborative medical practice inwhich the patient and doctor are partners integrativemedicine has been described as lsquoa comprehensiveprimary care system that emphasizes wellness and healingof the whole person (bio-psycho-socio-spiritual dimen-sions) as major goals above and beyond suppression ofa specific somatic diseasersquo (15) From the perspectiveof scientific research for example NCCAM (the NationalCenter for Complementary and Alternative Medicineunder the National Institutes of Health) complementaryand alternative medicine includes lsquohealthcare practicesoutside the realm of conventional medicine which are yetto be validated using scientific methodsrsquo (16) Accordingto NCCAM integrative medicine lsquocombines mainstreammedical therapies and CAM therapies for which thereis some high-quality scientific evidence of safety andeffectivenessrsquo (17) A more transcendent view definesintegrative medicine as lsquohealing-oriented medicine thatre-emphasizes the relationship between patient andphysician and integrates the best of complementaryand alternative medicine with the best of conventionalmedicinersquo (18)Practitioners outside conventional medicine often
express concerns about lsquomainstreaming alternativemedicinersquo that will result in alternative practitioners
being lsquorelegated to a subservient position under Western
medical doctors being forced into a paraprofessional
role leaving doctors with the final approval in a power-
based modelrsquo (19) Additional concerns about assimila-
tion include the dilution of CAM therapies and the loss
of diversity within the field(s) However many leaders
believe that continuing movement towards integrative
medicine will encourage transformation of lsquothe entire
system toward the values of holistic person-centered care
without losing access to the science and technology based
cures of conventional medicinersquo (5)The Bravewell Collaborative a philanthropic organiza-
tion which supports an impressive array of developments
in integrative medicine highlights the systemic challenges
inherent to the movement by posing the question
lsquoHow can a highly formalized and large-scale system of
institutions (conventional medicine) and a small-scale
informal system of individual practitioners (CAM)
integrate the best of both to form a better overall
health care systemrsquo (5)Bravewell anticipates two developmental spectra
lsquoexpansion of access to diverse CAM therapiesrsquo and
lsquotransformation of the conventional healthcare systemrsquo
Four possible outcomes to the development of integrative
medicine are suggested (i) high transformation of the
conventional system with high expansion of CAM
wherein lsquoconventional medicine is highly transformed by
IMCAM and CAM therapies are proven and accessiblersquo
(ii) high transformation of the conventional system with
low expansion of CAM wherein lsquoconventional institu-
tions expand their own ideas about prevention public
health and patient educationrsquo thereby starving lsquoresources
and attention from CAM so that its expansion is stalledrsquo
(iii) low transformation of the conventional system with
high expansion of CAM wherein lsquoconventional medici-
ne stays basically the same [while] at the same time
CAMIM research and outcomes-data further define the
value of CAM [and] IM and CAM institutions
flourishrsquo and (iv) low transformation of the conventional
system with low expansion of CAM wherein the
lsquoconventional system does not change and the momentum
for CAMIM stallsrsquo (5)
Who Practices Integrative Medicine
No one really knows As noted most coverage whether
in popular media or scientific literature is focused on
conventional physicians who have integrated aspects of
CAM into their medical practice or who serve as the
head of an lsquointegratedrsquo team of diverse practitioners
from different disciplines Ironically this group is very
likely the smaller cohort among a much larger group of
providers who identify as integrative practitioners or who
operate in self-identified integrative practices including
Figure 1 Identification among integrative medicine providers could
progress from our current state of self-determination to bilateral peer
approval and finally bilateral certification
eCAM 20085(4) 411
chiropractors acupuncturists naturopaths and othernon-conventional providersThe tendency to focus narrowly on conventional
providers reflects a familiar cultural centrism consistentwith the dominant position of conventional medicinewithin healthcare (20) Discussion of integrative medicinemust acknowledge the extended group for many reasonsleast of which is accurately estimating the total providerpool We do not want to overlook another factor inmore effectively defining integrative medicine whetherthe integration is simply a matter of the provider havingmore modalities at his disposal or something greater forproviders on both sides of the equation
Who Certifies Integrative MedicinePractitioners
For professional groups identity and responsibility comewith regulation It is therefore crucial to consider theissue of certification in integrative medicine The absenceof a certification scheme means that provider identifica-tion process is self-determined An operational definitionof integrative medicine from the perspective of a regula-tory agent might read as follows integrative medicine isthe practice of any medicine or medicines determined bythe practitioner unbound by regulatory standards withmembership established by the individualIt may be more practical to assert what is not integra-
tive medicine It is not conventional Western medicinealthough many conventionally trained physicianspromote their practices as integrative medicine IndeedNCCAM funds an impressive array of integrativemedicine centers all located at academic medical centersNobody actually knows how many conventional physi-cians identify as integrative to their patients and theircolleagues or more importantly for this discussionwhat criteria they use to determine this designationIntegrative medicine is not acupuncture and Oriental
medicine although many AOM practitioners promotetheir practices as integrative medicine and practition-ers of AOM are often included in integrative clinicsAs with conventional physicians no one knows howmany acupuncturists identify as integrative to theirpatients or colleagues NCCAM which defines AOM asan alternative whole medical system (21) has made a feweducational awards to AOM colleges most in partnershipwith conventional academic medical centers The awardsaim to strengthen traditional approaches to medicaltraining within AOM colleges This can be viewed asa clear step in the direction of trying to standardizeintegrative medicine training by supporting the adoptionof conventional medicine training standards by at leasta few AOM colleges It is expected that graduates ofthese AOM colleges will be more likely to be employedin clinical settings affiliated with conventional medical
systems and will enjoy privileged status when integrativemedicine is finally regulated
Definition Scope of Practice Standards andRegulation
The definition of integrative medicine will become veryimportant as scope of practice issues become moreprominent Defining integrative medicine has as muchto do with regulating practice as with defining educa-tional standards In fact one leads to the other When ascope of practice is modified to include new diagnosticsor therapeutics training programs add content to thecurriculum in the new areas of practice This occursroutinely in conventional medical schools The sameshould hold for AOM schools If integrative medicine isnecessarily bilateral (20) then standards should applybilaterally As things stand currently in the integrativehealthcare arena ie CAM and conventional disciplinesexpectations for standards flow from the larger conven-tional disciplines to the CAM periphery where practiceis less overtly regulated It is axiomatic that exchangeof knowledge production of research and educationalstandards are currently not bilateral Certification ofintegrative medicine providers might follow the develop-mental path from no regulation to self-regulation toco-regulation (Fig 2)We do not challenge the sincerity of the previous
efforts to define integrative medicine We have tried toshow that the definition is malleable and like CAMbefore it depends on the perspective of the definer (22)The markers of definitional change have moved fromobserving the power of consumer economic choiceto spiritual regeneration of a mechanistic medicineto the expansion of choice based on scientific evidenceIn addition to a multitude of new treatment optionsCAM offers conventional medicine a philosophy ofholism (23) lsquonewrsquo ways of looking at the complexphenomena of health and disease (24) and the conceptof inherent healing capacity (vis medicatrix naturae)while conventional medicine offers CAM rigorous meansto scientifically examine these practices and ideas (25)Integrative medicine at its current stage of development
Figure 2 Certification of integrative medicine providers might
follow the developmental path from no regulation to self-regulation
to co-regulation
412 Divining integrative medicine
incorporates the best practices of CAM and conventionalmedicine into a unified treatment plan a goal thatrequires both camps to step into the integrative circle andexamine themselves and each other with an open mindIntegration of medical disciplines will first requiremovement from isolation to collaboration before realintegration occurs (Fig 3)
Regulatory Focus Will Turn to Education
We see integrative medicine as a moving target that willbecome more fixed and stable as sufficient pressures arebrought to bear that demand descriptive clarificationAlthough clinical care is where the practical implicationsof integration first emerge we strongly believe thatresearch and education in integrative medicine willbecome focal points for the negotiation of the morerigorous definition Given its long history of organizedprofessional development and its clinical and economicdominance it is likely that the standards of conventionalmedicine will provide the default criteria How well-prepared are the fields that comprise complementary andalternative medicine especially acupuncture and Orientalmedicine to undergo scrutiny It is time to carefullyexamine this question
References1 Macgregor H Twice as Strong Los Angeles Times August 7 20062 Los Angeles Times Media Center ndash Circulation Retrieved May 7
2007 from httpwwwlatimescomservicesnewspapermediacenterla-mediacenter-circulation07813109story
3 The Bravewell Collaborative ndash Transforming Healthcare RetrievedMay 7 2007 from httpwwwbravewellorgtransforming_healthcarepublic_education
4 The New Medicine viewing audience University of MarylandCenter for Integrative Medicine newsletter Spring 2006
5 Mapping the emergence of integrative medicine a journey towarda new medicine (executive summary short version) ClohesyConsulting April 2003 Retrieved March 30 2007 from httpwwwbravewellorgtransforming_healthcaremapping_the_field
6 Jonas WB Levin JS Essentials of Complementary and AlternativeMedicine Lippincott Williams amp Wilkins 1999
7 Kligler B Lee R Integrative Medicine Principles for PracticeMcGraw-Hill 2004
8 Rakel D Integrative Medicine Philadelphia Saunders 20039 Pizzorno JE Murray MT Textbook of Natural Medicine 3rd edn
Churchill Livingston 200610 Micozzi MS Fundamentals of Complementary and Integrative
Medicine 3rd edn Saunders 200511 Micozzi MS Fundamentals of Complementary and Alternative
Medicine 1st edn Churchill Livingstone 199612 Micozzi MS Fundamentals of Complementary and Alternative
Medicine 2nd edn Churchill Livingstone 200113 American Medical Student Association ndash ICAM Resource Center
Retrieved May 7 2007 from httpwwwamsaorgICAMresourcescfm
14 Hsiao AF Hays RD Ryan GW Coulter ID Andersen RMHardy ML et al A self-report measure of cliniciansrsquo orientationtoward integrative medicine Health Serv Res 200540(5 Pt 1)1553ndash69
15 Bell I Pher C Schwartz GE Grant KL Gaudet TW Rychener DIntegrative medicine and systemic outcomes research Arch InternalMed 2002162133ndash40
16 Atsumi K Kamohara S Bridging conventional medicine andcomplementary and alternative medicine IEEE Eng Med BiolMag 20052430ndash4
17 NCCAM ndash What is CAM Retrieved May 7 2007 from httpnccamnihgovhealthwhatiscam
18 Maizes V Schneider C Bell I Weil A Integrative medicaleducation development and implementation of a comprehensivecurriculum at the University of Arizona Acad Med 200277861ndash3
19 Phelan KE Integrative Medicine Journey Editions 199820 Stumpf S Shapiro S Bilateral integrative medicine obviously
eCAM 2006346ndash5021 NCCAM ndash Whole Medical Systems Retrieved May 7 2007 from
httpnccamnihgovhealthbackgroundswholemedhtm22 Cooper E Complementary and alternative medicine when rigorous
can be science (Editorial) eCAM 200411ndash423 Ghassemi J Finding the evidence in CAM a studentrsquos perspective
eCAM 20052395ndash724 Tan S Tillisch K Mayer E Functional somatic syndromes
emerging biomedical models and traditional Chinese medicineeCAM 2004135ndash40
25 Chiappelli F Prolo P Cajulis O Evidence-based researchin complementary and alternative medicine I History (LectureSeries) eCAM 20052453ndash8
Received May 14 2007 accepted July 9 2007
Figure 3 Integration of medical disciplines could first require movement
from isolation to collaboration before integration
eCAM 20085(4) 413
Submit your manuscripts athttpwwwhindawicom
Stem CellsInternational
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
MEDIATORSINFLAMMATION
of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Behavioural Neurology
EndocrinologyInternational Journal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Disease Markers
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
BioMed Research International
OncologyJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Oxidative Medicine and Cellular Longevity
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
PPAR Research
The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014
Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Journal of
ObesityJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Computational and Mathematical Methods in Medicine
OphthalmologyJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Diabetes ResearchJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Research and TreatmentAIDS
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Gastroenterology Research and Practice
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Parkinsonrsquos Disease
Evidence-Based Complementary and Alternative Medicine
Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom
chiropractors acupuncturists naturopaths and othernon-conventional providersThe tendency to focus narrowly on conventional
providers reflects a familiar cultural centrism consistentwith the dominant position of conventional medicinewithin healthcare (20) Discussion of integrative medicinemust acknowledge the extended group for many reasonsleast of which is accurately estimating the total providerpool We do not want to overlook another factor inmore effectively defining integrative medicine whetherthe integration is simply a matter of the provider havingmore modalities at his disposal or something greater forproviders on both sides of the equation
Who Certifies Integrative MedicinePractitioners
For professional groups identity and responsibility comewith regulation It is therefore crucial to consider theissue of certification in integrative medicine The absenceof a certification scheme means that provider identifica-tion process is self-determined An operational definitionof integrative medicine from the perspective of a regula-tory agent might read as follows integrative medicine isthe practice of any medicine or medicines determined bythe practitioner unbound by regulatory standards withmembership established by the individualIt may be more practical to assert what is not integra-
tive medicine It is not conventional Western medicinealthough many conventionally trained physicianspromote their practices as integrative medicine IndeedNCCAM funds an impressive array of integrativemedicine centers all located at academic medical centersNobody actually knows how many conventional physi-cians identify as integrative to their patients and theircolleagues or more importantly for this discussionwhat criteria they use to determine this designationIntegrative medicine is not acupuncture and Oriental
medicine although many AOM practitioners promotetheir practices as integrative medicine and practition-ers of AOM are often included in integrative clinicsAs with conventional physicians no one knows howmany acupuncturists identify as integrative to theirpatients or colleagues NCCAM which defines AOM asan alternative whole medical system (21) has made a feweducational awards to AOM colleges most in partnershipwith conventional academic medical centers The awardsaim to strengthen traditional approaches to medicaltraining within AOM colleges This can be viewed asa clear step in the direction of trying to standardizeintegrative medicine training by supporting the adoptionof conventional medicine training standards by at leasta few AOM colleges It is expected that graduates ofthese AOM colleges will be more likely to be employedin clinical settings affiliated with conventional medical
systems and will enjoy privileged status when integrativemedicine is finally regulated
Definition Scope of Practice Standards andRegulation
The definition of integrative medicine will become veryimportant as scope of practice issues become moreprominent Defining integrative medicine has as muchto do with regulating practice as with defining educa-tional standards In fact one leads to the other When ascope of practice is modified to include new diagnosticsor therapeutics training programs add content to thecurriculum in the new areas of practice This occursroutinely in conventional medical schools The sameshould hold for AOM schools If integrative medicine isnecessarily bilateral (20) then standards should applybilaterally As things stand currently in the integrativehealthcare arena ie CAM and conventional disciplinesexpectations for standards flow from the larger conven-tional disciplines to the CAM periphery where practiceis less overtly regulated It is axiomatic that exchangeof knowledge production of research and educationalstandards are currently not bilateral Certification ofintegrative medicine providers might follow the develop-mental path from no regulation to self-regulation toco-regulation (Fig 2)We do not challenge the sincerity of the previous
efforts to define integrative medicine We have tried toshow that the definition is malleable and like CAMbefore it depends on the perspective of the definer (22)The markers of definitional change have moved fromobserving the power of consumer economic choiceto spiritual regeneration of a mechanistic medicineto the expansion of choice based on scientific evidenceIn addition to a multitude of new treatment optionsCAM offers conventional medicine a philosophy ofholism (23) lsquonewrsquo ways of looking at the complexphenomena of health and disease (24) and the conceptof inherent healing capacity (vis medicatrix naturae)while conventional medicine offers CAM rigorous meansto scientifically examine these practices and ideas (25)Integrative medicine at its current stage of development
Figure 2 Certification of integrative medicine providers might
follow the developmental path from no regulation to self-regulation
to co-regulation
412 Divining integrative medicine
incorporates the best practices of CAM and conventionalmedicine into a unified treatment plan a goal thatrequires both camps to step into the integrative circle andexamine themselves and each other with an open mindIntegration of medical disciplines will first requiremovement from isolation to collaboration before realintegration occurs (Fig 3)
Regulatory Focus Will Turn to Education
We see integrative medicine as a moving target that willbecome more fixed and stable as sufficient pressures arebrought to bear that demand descriptive clarificationAlthough clinical care is where the practical implicationsof integration first emerge we strongly believe thatresearch and education in integrative medicine willbecome focal points for the negotiation of the morerigorous definition Given its long history of organizedprofessional development and its clinical and economicdominance it is likely that the standards of conventionalmedicine will provide the default criteria How well-prepared are the fields that comprise complementary andalternative medicine especially acupuncture and Orientalmedicine to undergo scrutiny It is time to carefullyexamine this question
References1 Macgregor H Twice as Strong Los Angeles Times August 7 20062 Los Angeles Times Media Center ndash Circulation Retrieved May 7
2007 from httpwwwlatimescomservicesnewspapermediacenterla-mediacenter-circulation07813109story
3 The Bravewell Collaborative ndash Transforming Healthcare RetrievedMay 7 2007 from httpwwwbravewellorgtransforming_healthcarepublic_education
4 The New Medicine viewing audience University of MarylandCenter for Integrative Medicine newsletter Spring 2006
5 Mapping the emergence of integrative medicine a journey towarda new medicine (executive summary short version) ClohesyConsulting April 2003 Retrieved March 30 2007 from httpwwwbravewellorgtransforming_healthcaremapping_the_field
6 Jonas WB Levin JS Essentials of Complementary and AlternativeMedicine Lippincott Williams amp Wilkins 1999
7 Kligler B Lee R Integrative Medicine Principles for PracticeMcGraw-Hill 2004
8 Rakel D Integrative Medicine Philadelphia Saunders 20039 Pizzorno JE Murray MT Textbook of Natural Medicine 3rd edn
Churchill Livingston 200610 Micozzi MS Fundamentals of Complementary and Integrative
Medicine 3rd edn Saunders 200511 Micozzi MS Fundamentals of Complementary and Alternative
Medicine 1st edn Churchill Livingstone 199612 Micozzi MS Fundamentals of Complementary and Alternative
Medicine 2nd edn Churchill Livingstone 200113 American Medical Student Association ndash ICAM Resource Center
Retrieved May 7 2007 from httpwwwamsaorgICAMresourcescfm
14 Hsiao AF Hays RD Ryan GW Coulter ID Andersen RMHardy ML et al A self-report measure of cliniciansrsquo orientationtoward integrative medicine Health Serv Res 200540(5 Pt 1)1553ndash69
15 Bell I Pher C Schwartz GE Grant KL Gaudet TW Rychener DIntegrative medicine and systemic outcomes research Arch InternalMed 2002162133ndash40
16 Atsumi K Kamohara S Bridging conventional medicine andcomplementary and alternative medicine IEEE Eng Med BiolMag 20052430ndash4
17 NCCAM ndash What is CAM Retrieved May 7 2007 from httpnccamnihgovhealthwhatiscam
18 Maizes V Schneider C Bell I Weil A Integrative medicaleducation development and implementation of a comprehensivecurriculum at the University of Arizona Acad Med 200277861ndash3
19 Phelan KE Integrative Medicine Journey Editions 199820 Stumpf S Shapiro S Bilateral integrative medicine obviously
eCAM 2006346ndash5021 NCCAM ndash Whole Medical Systems Retrieved May 7 2007 from
httpnccamnihgovhealthbackgroundswholemedhtm22 Cooper E Complementary and alternative medicine when rigorous
can be science (Editorial) eCAM 200411ndash423 Ghassemi J Finding the evidence in CAM a studentrsquos perspective
eCAM 20052395ndash724 Tan S Tillisch K Mayer E Functional somatic syndromes
emerging biomedical models and traditional Chinese medicineeCAM 2004135ndash40
25 Chiappelli F Prolo P Cajulis O Evidence-based researchin complementary and alternative medicine I History (LectureSeries) eCAM 20052453ndash8
Received May 14 2007 accepted July 9 2007
Figure 3 Integration of medical disciplines could first require movement
from isolation to collaboration before integration
eCAM 20085(4) 413
Submit your manuscripts athttpwwwhindawicom
Stem CellsInternational
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
MEDIATORSINFLAMMATION
of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Behavioural Neurology
EndocrinologyInternational Journal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Disease Markers
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
BioMed Research International
OncologyJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Oxidative Medicine and Cellular Longevity
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
PPAR Research
The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014
Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Journal of
ObesityJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Computational and Mathematical Methods in Medicine
OphthalmologyJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Diabetes ResearchJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Research and TreatmentAIDS
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Gastroenterology Research and Practice
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Parkinsonrsquos Disease
Evidence-Based Complementary and Alternative Medicine
Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom
incorporates the best practices of CAM and conventionalmedicine into a unified treatment plan a goal thatrequires both camps to step into the integrative circle andexamine themselves and each other with an open mindIntegration of medical disciplines will first requiremovement from isolation to collaboration before realintegration occurs (Fig 3)
Regulatory Focus Will Turn to Education
We see integrative medicine as a moving target that willbecome more fixed and stable as sufficient pressures arebrought to bear that demand descriptive clarificationAlthough clinical care is where the practical implicationsof integration first emerge we strongly believe thatresearch and education in integrative medicine willbecome focal points for the negotiation of the morerigorous definition Given its long history of organizedprofessional development and its clinical and economicdominance it is likely that the standards of conventionalmedicine will provide the default criteria How well-prepared are the fields that comprise complementary andalternative medicine especially acupuncture and Orientalmedicine to undergo scrutiny It is time to carefullyexamine this question
References1 Macgregor H Twice as Strong Los Angeles Times August 7 20062 Los Angeles Times Media Center ndash Circulation Retrieved May 7
2007 from httpwwwlatimescomservicesnewspapermediacenterla-mediacenter-circulation07813109story
3 The Bravewell Collaborative ndash Transforming Healthcare RetrievedMay 7 2007 from httpwwwbravewellorgtransforming_healthcarepublic_education
4 The New Medicine viewing audience University of MarylandCenter for Integrative Medicine newsletter Spring 2006
5 Mapping the emergence of integrative medicine a journey towarda new medicine (executive summary short version) ClohesyConsulting April 2003 Retrieved March 30 2007 from httpwwwbravewellorgtransforming_healthcaremapping_the_field
6 Jonas WB Levin JS Essentials of Complementary and AlternativeMedicine Lippincott Williams amp Wilkins 1999
7 Kligler B Lee R Integrative Medicine Principles for PracticeMcGraw-Hill 2004
8 Rakel D Integrative Medicine Philadelphia Saunders 20039 Pizzorno JE Murray MT Textbook of Natural Medicine 3rd edn
Churchill Livingston 200610 Micozzi MS Fundamentals of Complementary and Integrative
Medicine 3rd edn Saunders 200511 Micozzi MS Fundamentals of Complementary and Alternative
Medicine 1st edn Churchill Livingstone 199612 Micozzi MS Fundamentals of Complementary and Alternative
Medicine 2nd edn Churchill Livingstone 200113 American Medical Student Association ndash ICAM Resource Center
Retrieved May 7 2007 from httpwwwamsaorgICAMresourcescfm
14 Hsiao AF Hays RD Ryan GW Coulter ID Andersen RMHardy ML et al A self-report measure of cliniciansrsquo orientationtoward integrative medicine Health Serv Res 200540(5 Pt 1)1553ndash69
15 Bell I Pher C Schwartz GE Grant KL Gaudet TW Rychener DIntegrative medicine and systemic outcomes research Arch InternalMed 2002162133ndash40
16 Atsumi K Kamohara S Bridging conventional medicine andcomplementary and alternative medicine IEEE Eng Med BiolMag 20052430ndash4
17 NCCAM ndash What is CAM Retrieved May 7 2007 from httpnccamnihgovhealthwhatiscam
18 Maizes V Schneider C Bell I Weil A Integrative medicaleducation development and implementation of a comprehensivecurriculum at the University of Arizona Acad Med 200277861ndash3
19 Phelan KE Integrative Medicine Journey Editions 199820 Stumpf S Shapiro S Bilateral integrative medicine obviously
eCAM 2006346ndash5021 NCCAM ndash Whole Medical Systems Retrieved May 7 2007 from
httpnccamnihgovhealthbackgroundswholemedhtm22 Cooper E Complementary and alternative medicine when rigorous
can be science (Editorial) eCAM 200411ndash423 Ghassemi J Finding the evidence in CAM a studentrsquos perspective
eCAM 20052395ndash724 Tan S Tillisch K Mayer E Functional somatic syndromes
emerging biomedical models and traditional Chinese medicineeCAM 2004135ndash40
25 Chiappelli F Prolo P Cajulis O Evidence-based researchin complementary and alternative medicine I History (LectureSeries) eCAM 20052453ndash8
Received May 14 2007 accepted July 9 2007
Figure 3 Integration of medical disciplines could first require movement
from isolation to collaboration before integration
eCAM 20085(4) 413
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Submit your manuscripts athttpwwwhindawicom
Stem CellsInternational
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
MEDIATORSINFLAMMATION
of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Behavioural Neurology
EndocrinologyInternational Journal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Disease Markers
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
BioMed Research International
OncologyJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Oxidative Medicine and Cellular Longevity
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
PPAR Research
The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014
Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Journal of
ObesityJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Computational and Mathematical Methods in Medicine
OphthalmologyJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Diabetes ResearchJournal of
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Research and TreatmentAIDS
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Gastroenterology Research and Practice
Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014
Parkinsonrsquos Disease
Evidence-Based Complementary and Alternative Medicine
Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom