alternative healing

Complementary and Alternative Medicine Complementary and Alternative Medicine (Adopted 1999, reaffirmed 2004, amended 2005) Increasingly large portions of Americans use complementary and alternative medicine (CAM). A study published in the U.S. Annals of Internal Medicine (2001) showed that 67.6% of respondents had used at least one CAM therapy in their lifetime[1]. According to another recent study in the American Journal of Public Health (2002), 76.7% of respondents had used at least one CAM therapy in their lifetime and continued to use some form of CAM for many years.[2] Although estimates vary as to the exact level of its use, it is evident that patients continue to incorporate CAM modalities into their personal health care plans. [3] Because of the evolving nature of CAM, definitions have and will change over time, making precise calculations of usage problematic. The use of alterative therapies had a dramatic increase in the 1970s, with more modest growth in the 1980s, which has continued throughout the 1990s, and today. This is not localized to one population cohort.[4] Researchers have found that a wide range of individual CAM therapies increased in use over time across all sociodemographic sectors- suggesting the continuing demand for CAM therapies, which will affect health care delivery for the future. In an effort to minimize adverse effects and maximize the usefulness of therapies, research must be evidence-based and providers who treat patients must be facile in discussing benefits and risks.[1] Individuals have used CAM practices for thousands of years and many CAM modalities have great potential for reducing symptoms and complications of disease. However, most patients use CAM regimens without supervision and some therapies may be associated with severe side effects and can even delay or divert patients from proven therapies possibly resulting in death.[5-8] These facts alone mandate that clinicians ask their patients about use of CAM regimens. Likewise, the benefits and side effects of CAM regimens should be a part of every clinician's knowledge base. Involvement of the Federal Government In 1992, the National Institutes of Health (NIH) created the Office of Alternative Medicine (OAM) as a result of a congressional mandate to facilitate the evaluation of the effectiveness of alternative medical treatment modalities. The mandate also provided for a public information clearinghouse and a researchtraining program. The OAM formed ten working groups of international experts who were to formulate recommendations related to future research opportunities and activities at the NIH. 1 Complementary and Alternative Medicine In 1995, their work resulted in the classification of seven broad categories of complementary and alternative medical practices including alternative systems of medical practice; bio electromagnetic applications; diet, nutrition, and lifestyle changes; herbal medicine; manual healing; mind-body control; and pharmacologic and biologic treatments. At that time, CAM was defined as comprising those practices that are not part of the dominant medical system of the country. The U.S. definition would be demonstrated by the availability of a particular practice in hospitals or conventional professional practices, taught in medical schools, and reimbursed or otherwise accessible to the American public.[9] The passage of the 1999 Omnibus appropriations bill established the National Center for Complementary and Alternative Medicine (NCCAM), which provided greater autonomy to initiate research projects. The director is appointed by the Secretary of the Department of Health and Human Services and ultimately resulted in the expansion of clinical research. The NCCAM mission is to explore CAM healing practices through rigorous science, which includes supporting carefully selected studies, as well as designing and conducting clinical trials of CAM therapies.[10] In 2002, the White House Commission on CAM Policy issued its final report. It lists more that 100 recommendations and courses of action for ways to integrate CAM into the health care system. It emphasized information and education as the keys to decision making with regards to use of CAM and suggests the federal government increase its role in the evaluation and implementation of certain forms of CAM. While many recommendations may assist public policy in providing reliable information in the future, the report has been criticized for being too generic and vague. It remains to be seen what impact it will have both short and long-term. [11] Classification of Alternative Therapies Known by a variety of terms - complementary, holistic, alternative, unorthodox, integrative - CAM refers to most treatment practices that are not considered conventional medicine, that is, those that are not widely practiced or accepted by the mainstream medical community. Although the majority of medicine practiced in the U.S. is conventional medicine, worldwide, approximately 70% to 90% of health care is delivered by what would be considered an alternative tradition or practice.[12] Incorporating hundreds of different philosophies and procedures, alternative therapies are usually ideologically based and many are not backed by scientific research that measures safety and effectiveness.[12] CAM as defined by the NCCAM is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. (Conventional medicine is medicine as practiced by holders of MD, DO degrees and by their allied health professionals).[10] The list 2 Complementary and Alternative Medicine of what is considered to be CAM changes as those therapies proven to be safe become adopted into conventional health care. NCCAM has developed fact sheets which define key terms currently used in the field of complementary and alternative medicine and give descriptions of the many modalities and approaches.[13] The ongoing search for scientific evidence to support the safety and efficacy of these many therapies serves to assist patients and health care providers in their decision-making process. As therapies are proven safe and effective they are adopted in to conventional health care defined as Integrative Medicine.[13] Complementary medicine is used together with conventional medicine. An example is aromatherapy to help lessen a patient’s discomfort following surgery. Alternative medicine is used in place of conventional medicine. An example is using a special diet to treat cancer instead of undergoing conventional treatment such as chemotherapy, recommended by a conventional doctor.[13] The NCCAM fact sheet classifies CAM therapies into five categories or domains: • • • Alternative medical systems (homeopathy, naturopathy). Mind Body Interventions (mediation prayer, mental healing). Patient support groups and cognitive behavioral therapy were considered CAM in the past, but are now considered mainstream. Biologically Based Therapies (dietary supplements, herbal products). Consist of substances found in nature such as herbs, foods, and vitamins. Some are often called natural but remain unproven therapy (e.g., shark cartilage to treat cancer). Manipulative and Body Based Methods (chiropractic, osteopathic, massage). Based on manipulation and/or movement of one or more parts of the body. Energy Therapies, which involve the use of energy fields. Biofield therapies are intended to affect energy fields that may surround and penetrate the body (Reiki, qi gong). Bio electromagnetic-based therapies involve unconventional use of electromagnet fields (pulsed fields, magnetic fields).[13] • • Use and Acceptance of Alternative Therapies by Patients Why do patients use alternative medicine? A number of surveys have been conducted over the past several years to determine why patients turn to CAM therapy, and what are the most popular CAM therapies used by these patients. 3 Complementary and Alternative Medicine A study done at the Stanford Center for Research and Disease in the late ‘90s, and published in the JAMA (1998) found the variables affecting use were the following: higher level of education, poorer health status, holistic orientation to health, interest in spirituality and personal growth psychology. The following health problems were the most common complaints: anxiety, back problems, chronic pain and fatigue syndrome, as well as sprains/strains, addictive problem, arthritis and headaches. Dissatisfaction with conventional medicine did not appear to predict the use of alternative medicine, but patients found alternative therapies to be more congruent with their own values, beliefs and orientation towards health and life.[14] In 2001, the U.S. Annals of Internal Medicine published a national survey of patients who use both CAM and conventional therapies. The data did not support the view that the use of CAM in the U.S. reflects dissatisfaction with conventional care. The survey found that 79% of these patients perceived a combination of therapies to be superior to either alone; 70% saw a physician before or concurrent with CAM use. Patients said they felt that CAM therapies were more helpful than conventional care for treatment of headache, neck and back conditions, but considered conventional care to be more helpful than CAM therapy for hypertension.[15] Data from 1999 National Health Interview Survey (NHIS) was reviewed by the National Center for Health Statistics, CDC, in order to measure utilization of CAM by U.S. adults and was published in 2002. Information on 12 types of CAM used in the past 12 months were analyzed. Researchers found that 28.9% of U.S. adults used at least one CAM in the past year. Most commonly used were spiritual healing or prayer (13.7%), herbal medicine (9.6%), and chiropractic (7.6%). [16] In 2002, the American Journal of Public Health published a study of Michigan adults’ use of CAM therapies. Researchers found that 49.7% of respondents had used at least one CAM therapy in the past 12 months. Most frequently used therapies were herbal supplements (20.5%), special diets (12.6%), and chiropractic therapy (12.2%). [2] Researchers have exhaustively explored which demographic groups utilize CAM therapies. In the Journal of the American Medical Association (JAMA, 1998), researchers reported that although the “use of alternative therapies in 1997 was not confined to any narrow segment of society,” they did find that women used alternative therapies more than men and that African Americans tended to use therapies less than other racial groups. The highest incidence of alternative medicine use was in people ages 35-49, and those who used alternative medicine were more likely to be college graduates, have incomes above $50,000 and live in the Western United States.[3] Subsequent research in recent years has generally found demographics in CAM use similar to the 1997 findings.[2, 16, 17] According to a study published 4 Complementary and Alternative Medicine in Medical Care (2001), African Americans and Hispanics are less likely to use CAM. The study also revealed that those in poorer health, who have non-life threatening health problems, mental disorders, musculoskeletal and metabolic disorders tend to be more likely to have visited CAM providers.[17] The 1999 National Health Interview Survey reported that the most prevalent users were women, those aged 35-54 and those with higher educational attainment ( >16 yrs.). Use was higher in white, non Hispanics (30.8 %), than Hispanic (19.9%) and black non Hispanic (24.1%). Use was also higher for those with health insurance. Compared with non users, CAM users were more likely to use conventional medical services in conjunction with CAM therapies. This study also found that overall use of CAM was lower than in previous surveys. [16] The long-term usage trends of CAM therapies in the US was examined in a study published in the U.S. Annals of Internal Medicine (2001) and showed that lifetime use steadily increased with age but also revealed a usage trend by younger respondents. Of those who ever used CAM therapies, nearly half continued to use many years later, which suggests that CAM therapies are not a passing fad by any particular generation. [1] Recent research has reported findings on the trends in CAM use specifically among the senior population. A study published in Gerontology (2002) suggests that there is a higher prevalence of use in the older population. Alarmingly, they may not discuss what they are using with their physician.[18] Another study published in Gerontology Nursing (2003) revealed that the most prevalent motivations for CAM use among seniors were pain relief (54.8%), improved quality of life (45.2%), and maintenance of health and fitness (40.5%). Knowledge of CAM was extremely low across the entire sample, but users knew more than non-users. The most commonly used CAM therapies among seniors were chiropractic (61.9%), herbal medicine (54.8%), massage therapy (35.7%), acupuncture (33.3%). The patients perceived CAM to be extremely beneficial. It is evident that increased education for seniors and health professionals is needed. Practitioners of CAM should try to understand motivations of older patients and be involved in educating them about CAM.[19] Recent research also has focused on CAM use among rural populations. Given these communities’ limited access to conventional medicine, there’s a need for data on those thought to use folk remedies and self care strategies. According to a study of small Illinois communities, published in the Journal Rural Health (2003), two-thirds of respondents reported CAM use in the form of vitamins/megavitamins, chiropractic, relaxation and prayer/faith healing. Rural patients with more medical problems and a higher level of education were more likely to use alternative techniques. Three-fifths of respondents felt that their doctor should discuss alternative medicine and therapies with them. Physician 5 Complementary and Alternative Medicine understanding and communication regarding CAM may be especially important in rural areas, where there is a greater reliance on primary care as the gate keeper.[20] Other new research is providing information regarding CAM use among patients with specific ailments or conditions. According to a study published in the American Heart Journal (2003), use of CAM in cardiovascular (CV) patients was reported at 64%. [21] Nutritional supplements (40%) and megadose vitamins (35%) were the most frequently used CAM therapies among CV patients. Most users sited CV problems as the reason for use. The most common sources of information was a friend or relative (43%), or their usual physician. Researchers also found that 80% claimed they had discussed the use of CAM therapies with their physician. The study also reported that 58% of CV patients who were taking potentially toxic CV Meds (digoxin, warfarin, amiodarone) were taking an oral supplement. Given the high CAM use among CV patients, the physicians caring for these patients need to inquire about CAM therapy use. Moreover, a further study should be performed to evaluate potential benefits and risks of using CAM therapy along with conventional therapy for cardiovascular disease.[21] Use and Acceptance of Alternative Therapies Providers Provider knowledge and attitudes about alternative therapies have also been measured. Yankelovich Partners, Inc. surveyed 300 HMO health care professionals in 1997 regarding their attitudes regarding spirituality and healing. Researchers found that 94% of the HMO professionals believed that personal prayer, meditation, or other spiritual practices can accelerate the medical recovery of ill patients, and 74% believed these practices may have an impact on containing the cost of care. In addition, 83% believed that some practices, such as relaxation and meditation, should be a standard part of formal medical training compared with 80% of the family physicians. [22] A national survey of Family Practitioners, Internists and Pediatrician found than many psycho behavioral and lifestyle CAM therapies appeared to have become accepted by mainstream medicine. Chiropractic and acupuncture appeared to have gained in acceptance, even though the physician had a low level of training in the modality. Those in practice for more than 22 years had the least positive attitudes toward CAM therapies and DO physicians were more open to use. Attitudes toward CAM and training were the best predictors of use. [23] The U.S. Annals of Internal Medicine (2001) published a national survey of patients who use both CAM and conventional therapies. The survey revealed that 63-72% intentionally withheld disclosure of at least one type of CAM from their physician for the following reasons: it wasn’t important (61%), the physician never asked (60%), none of the doctor’s business (31%), doctor would not 6 Complementary and Alternative Medicine understand (20%), thought the doctor wouldn’t approve (14%), and thought the doctor would not continue as their provider (2%).[15] The American Journal of Public Health (2002) reported that nearly half of CAM users surveyed had discussed at least some of their CAM use with their regular medical doctor. The majority (61.3%) had received a recommendation from their doctor for at least some of the CAM therapies they had used.[2] A survey of physicians conducted in Denver, CO and published in Arch Internal Medicine (2002) revealed how physicians discussed CAM with their patients, and what factors influence discussion and referral. Researchers found that 76% of the physician found that their patients used CAM; 59% of those patients were asked about specific treatments; 48% of the physicians recommended CAM; and 24% of the physicians used CAM themselves. Recommendations to patients were most strongly associated with those physicians who themselves used CAM. Notably, few physicians felt comfortable discussing CAM therapy with their patients, and 84% thought they needed to learn more. The survey revealed a significant, unmet need in education of physicians about CAM, and that adequate training would help alleviate the discomfort of discussing CAM with their patients.[24] A recent Texas study of community preceptors’ attitudes toward practices of CAM (2003) also supports the need for more education regarding CAM practices. Results of the study revealed that the CAM concept was relatively well accepted among the physicians and that they welcomed continuing CAM education. However, they reported concerns over the attitudes of their colleagues toward CAM and concerns about CAM therapy in general. They verified that patients expect them to be knowledgeable about therapies and noted some frustration with the lack of opportunity for fact-based CAM continuing education [25] An alarming report in Gerontology (2002) found that physicians tend not to record CAM use in the older patient’s chart, which may lead to unrecognized potentially harmful drug/drug-supplement interactions. Providers should elicit and document information to provide sound medical care and assist in the advancement of knowledge about drug-herb/drug-supplement interactions.[18] Safety of Therapy As the use of complementary and alternative therapies increases, particularly by individuals with chronic medical problems, such as arthritis, depression, diabetes, pulmonary conditions, and HIV infection, more reports are likely to surface regarding their associated risks.[26,27] CAM usage that appears to have the most potential for having a negative effect, such as an untoward 7 Complementary and Alternative Medicine interaction with a traditional medication, include herbal remedies and dietary supplements. Their use has been markedly increased since the discontinuation of regulation by the FDA in 1994.[28]. They are also readily available over-thecounter to consumers and usually are used without professional supervision. In 1994, the Dietary Supplement Health Education Act (DSHEA) was passed. Since then, dietary supplements have fallen under foods not drugs. The FDA does not analyze dietary supplements before they are marketed but monitors research on them and records adverse effects. The burden of proof that a particular supplement is a “significant or unreasonable risk” of illness or injury falls under the Food and Drug Administration (FDA) and often takes a long time, as in the case of ephedra which has been of concern for at least ten years and was taken off the market in 2004.[28] Selected Agents There is a large group of products, generally known as dietary supplements, that encompasses both herbal agents and other botanical substances. Agents that act as cardiac glycosides, for instance, toad venom, foxglove, oleander, and aconitine (larkspur, monkshood) have received the most attention for their negative effects. These agents have been associated with bradycardia and dysrhythmias including complete heart block. Ma huang, another substance with adverse effects, contains ephedra and can cause tachycardia, hypertension, seizures, stroke, and myocardial infarction. This agent is of particular concern in patients who may be taking products that also contain ephedrine, for instance, Rynatuss® thus working synergistically and increasing the adverse effects of Ma huang.[29] In December 2003, the FDA announced its decision to issue a consumer alert regarding dietary supplements containing ephedra. The AMA lobbied hard for a total ban on ephedra in dietary supplements and strongly supported the FDA's decision. Ephedra is found in weight-loss aids, energy booster and performance enhancing supplement for athletes. Seizure, stroke, psychiatric problems, heart attack and death are all recognized risks of ephedra use. A recent RAND study linked ephedra to a host of problems and found little evidence of its effectiveness.[30] The final rule banning ephedra dietary supplements was issued by the FDA in February of 2004. This ban will lead to the removal of dietary supplements containing ephedra from supermarket and drugstore shelves nationwide. This raises the issue of whether other herbal and dietary supplements may also come under increased scrutiny. Herbs have been used for medicinal purposes with effective results since the beginning of time. In fact, many modern drugs, including digitalis, atropine, and narcotic derivatives, have been developed from plants.[31] However, some herbal medicines are harmful under certain conditions, for instance, the long-term use of the herbs, chaparral and comfrey, are associated with hepatotoxicity.[32,33] On the positive side, some complementary therapies, for 8 Complementary and Alternative Medicine instance, relaxation techniques, may require the reduction of the dosages of medications used in traditional therapies, such as insulin, antihypertensives, and analgesics.[34] Response of Organized Medicine In an editorial published in JAMA 1998, the author asserts: "Priority for research funding for alternative medicine should be given to investigations of relevant clinical problems for which well-designed studies have shown encouraging results for alternative therapies, especially for conditions that are common and those for which conventional medicine has not been effective."[35] In the years following this assertion, many medical and governmental agencies have addressed the need for more funding and research of CAM therapies. CAM has received the attention of organized medicine in the past few years with policy statements adopted by the American Medical Association's (AMA) Council on Scientific Affairs and the American Academy of Family Physicians (AAFP). The AMA recommended that 1) well-designed, controlled research should be performed to evaluate the efficacy of alternative therapies; 2) physicians should routinely inquire about the use of CAM by their patients; 3) patients should be counseled on the possible hazards of postponing or stopping conventional medical treatments; and 4) medical schools should present their scientific view of unconventional therapies including their efficacy and safety. This recommendation was reaffirmed by the AMA in 2002.[36] Additionally, in December, 1998, the AMA's House of Delegates approved a resolution to work with the FDA to educate physicians and the public about potential adverse events associated with dietary supplements and herbal remedies. Another resolution was passed to work with Congress to modify the Dietary Supplement Health and Education Act of 1994 to require that current and future dietary supplements and herbal remedies undergo FDA approval for evidence of safety, efficacy, and quality. Standards for packaging and labeling were also implemented, which include adverse events and drug interactions.[37] In September 2002, Dr. Stephen Straus, Director of the National Center for CAM, spoke to the annual AMA Science Reporters conference with regards to several studies showing potential health benefits from several nutritional supplements such as multivitamins and folic acid. Other ongoing studies were reviewed which include Vitamin E and fish oils, antioxidants and zinc in reducing macular degeneration. The issues of safety and the public getting what they pay for were emphasized. “Evidence based research will empower people to make better health decisions and inspire some manufacturers of these products to have their products licensed as drugs rather that dietary supplements.”[38] In 2002, the HOD of the Federation of State Medical Boards of the U.S. adopted as policy “Model Guidelines for the Use of Complementary and 9 Complementary and Alternative Medicine Alternative Therapies in Medical Practice” in order to assure that licensees utilized CAM in a manner consistent with safe and responsible medicine. The policy encourages the medical community to adopt consistent standards to ensure public health and safety. The guidelines educate health care providers on adequate safeguards needed to assure acceptable practice. The definition of CAM used in these guidelines follows the NCCAM, stating that CAM refers to a broad range of healing philosophies, approaches and therapies that conventional medicine does not commonly use, accept, study understand or make available. These therapies may be used alone as an alternative, or in addition to conventional therapies as a complementary or integrative approach.[39] CAM and Medical Education A 1998 survey of 107 PA programs reported that 52% of respondents offered course work on "alternative medicine" in their curriculum.[40] A more recent study, published in 2001, examined how PAs use and perceive CAM. Most PAs surveyed had a positive outlook on CAM therapies, agreeing that such therapies do not have a placebo effect. Nearly half of PAs surveyed use CAM themselves and recommend some form to their patients. However, 80% reported having only a fair or poor level of knowledge, indicating that PAs need to be better informed regarding CAM therapies [41] There is a growing tendency to include CAM therapy both in medical school and physician assistant curriculums. In a 1996-97 AMA survey, only 46 of 125 schools offered CAM topics in required courses. By 1998, 75 of the 125 offered CAM electives or included CAM topics in required courses. A 19992000 survey reported 82 of the schools offered CAM as part of a required course. [42] Although schools are increasingly addressing CAM, researchers have suggested that some schools are still not receptive to teaching CAM as a legitimate field of study. [42] In addition, in some areas adding CAM to the curriculum has been problematic, as an elective tends to marginalize CAM in the minds of students and faculty. Integrating CAM into a course gives some exposure to CAM, but a lack of money, time to prepare, and sometimes outright animosity on the part of faculty make it difficult to address CAM adequately.[42] How to Evaluate CAM Therapies In an effort to increase education and awareness of CAM, the NCCAM encourages individuals who are contemplating beginning a specific therapy to seek out additional information and to talk to their health care provider. It recommends that patients assess the safety and effectiveness of the therapy, examine the practitioner's role when alternative therapy is prescribed, and consider how the service is delivered. In addition, patients should try to determine if the delivery of service adheres to standards for medical safety and care. 10 Complementary and Alternative Medicine Contacting state or local regulatory agencies or health care consumer organizations can be helpful in assessing these aspects. [43] The NCCAM also recommends that patients as well as providers learn about the background, qualifications, and competence of any health care provider practicing CAM, whether it is a physician or another practitioner. Patients should be instructed to contact, if available, local, state, or national agencies that regulate or represent CAM practices. It is also important to be certain that a practitioner is licensed to deliver the services he or she provides.[43] NCCAM is exploring CAM healing practices through clinical trials and medical research which include treatment trials, prevention trials, early detection and screening trial diagnostic trials and quality of life trials. A variety of studies are currently being funded which include acupuncture, herb, dietary supplement and massage. Information is available on the NCCAM web site or through the NCCAM Clearinghouse.[44] Use of CAM in Conventional Medical Practices Clinicians should ask their patients about their use, or desire to use alternative therapies when a history is obtained. The provider should be non threatening nor judgmental and should show interest This will help to identify those patients who have been seeing an alternative therapist, the kinds of alternative medicines being taken, and the patient’s perception of their usefulness, or future plans for use. Similarly, because the patient may elect to continue alternative therapies, in addition to traditional ones being prescribed, it will be useful for the clinician to integrate CAM and their outcomes into traditional therapies as part of the complete biosocial history. It is important once the CAM therapy is identified, that the clinician assist the patient in determining the appropriateness of the modality as well as possible toxicities, side effects and safety of the selected therapy It is also necessary to clarify the patient’s values and beliefs when counseling the patient about the selected CAM therapy[45] Conclusion The trend toward using complementary and alternative therapies continues to increase as more information about their efficacy and safety becomes available. Trends in different therapies have changed, but use of many therapies have persisted over time and are utilized to prevent disease, treat disease and assist with health promotion.[46] Patients look to their primary care providers for guidance and information about the benefits and safety of CAM. This is in part because of the rapid changes in the use and acceptance of CAM. The burden is also on the providers to assist patients in their choices as insurers move towards increasing coverage and as 11 Complementary and Alternative Medicine more and more information becomes available in books, magazine, and the Internet. As the need for training in CAM therapies grows, the AAPA believes there must be cooperative support from many different groups in the medical community: physicians, insurance providers, medical organizations, governmental agencies, and especially medical schools. Formal acceptance of CAM therapies from the entire medical community, as well as increased funding for research, will help counter historical stigmas, and enable providers to obtain adequate training and assist patients in their preferred treatments. In order to provide the best care possible to their patients, PAs need to be knowledgeable about what treatments, including CAM, their patients are currently using or anticipate taking. Even while remedies are undergoing closer scrutiny in clinical trials, many consumers will continue to use - and benefit from alternative therapies that have not undergone rigorous testing. Therefore, information is key, about our patients, their other providers, and ourselves. 12 Complementary and Alternative Medicine References 1. Kessler, RC, Davis, RB, et al Long-Term Trends In Use of Complementary and Alternative Medical Therapies in the US Annals of Internal Medicine 2001 135:4 262-268 2. Rafferty, A, McGee, H, et al Prevalence of complementary and alternative medicine use: State-Specific estimates from the 2001 behavioral risk factor surveillance system. American Journal of Public Health 2002 92:10 1596-1598 3. Eisenberg, DM, Davis, RB, Ettner, L et al. Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. JAMA 1998;280:1569-1575. 4. Eisenberg, DM, Kessler, RC, Foster D, et al. Unconventional medicine in the United States. 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Fontanarosa PB, Lundberg GD, Alternative medicine meets science (editorial) JAMA 1998:280 1618-1619 36. AMA House of Delegates Resolutions CAM 2002 H-480/973 Un conventional Medical care in the US 37. AMA House of Delegates, Resolution 513(I-98). 38. AMA Science News Nutritional Supplements shown to provide valuable heath benefits media briefing 09/21/02 39. Model Guidelines for the Use of Complementary and Alternative Therapies in Medical Practice Approved bye the HOD of the Federation of State Medical Boards of the US as policy April 2002 40. Whitehorse E. Alternative and Complementary Medicine: Does it have a Role in PA Education? A Roundtable. Education Forum. Association of Physician Assistant Programs. Orlando, Florida, October 1998. 41. Houston, E A Bork, CE, Price, JH et al , How physician assistants use and perceive complementary and alternative medicine JAAPA 2001 Jan 14 (1):29-40 42. Wetzel, M S, Kaptchuk, TJ, Haramati, A, Eisenberg, DM, Complementary and alternative medical therapies: Implications for medical education Ann Intern Med 2003:138:191-196 43. NCCAM, National Institutes of Health web site nccan.nih.gov 44. NCCAM Clearinghouse Pub NO: D162 15 Complementary and Alternative Medicine 45. Adams, KE Cohen, MH, Eisenberg, D., Jonsen, AR Ethical considerations of complementary and alternative medical therapies in conventional medical setting. Ann Intern Med 2002:137:660-664 46. Miller, FG, Emanuel, EJ, Rosenstein, DL, Straus, SE Ethical issues concerning research in CAM, JAMA; 2004:291: 599-604 16