The young adult patient had been through a lot in the last few weeks. He had developed numbness and weakness in his lower legs, had been diagnosed with a spinal cord tumor, and was rushed into surgery at Abbott-Northwestern Hospital in Minneapolis to remove it. The operation was successful, but his physical limitations remained. Emotionally devastated, he resisted his prescribed physical therapy for two days.
“So what do you do if you are the physician?” asked Gregory A. Plotnikoff, FACP, an internist at Abbott-Northwestern, when recounting the patient's story. “Do you call a psychiatrist? Suppress the symptoms with a benzodiazepine? Try to persuade or even coerce the patient?”
The physician in this case did none of the above. Instead, she called for an integrative care consultation from the hospital's Institute for Health and Healing, where Dr. Plotnikoff is medical director. The patient was evaluated and treated by an acupuncturist cross-trained in massage and guided imagery, and in less than two hours could fully participate in physical therapy, Dr. Plotnikoff said.
Anecdotes like this are increasingly common, as a growing number of hospitals incorporate complementary and alternative medicine (CAM) into their treatment. It is done through the use of so-called integrative medicine, which blends conventional and nonconventional tactics, rather than using one or the other exclusively. A cancer patient, for example, may get acupuncture to deal with nausea associated with chemotherapy, while a surgical patient may receive a postoperative massage to ease muscles cramped by hours on the operating table.
In a 2005 survey by the American Hospital Association (AHA), 27% of reporting hospitals said they offered at least one type of CAM to patients, up from 8% in 1998. In doing so, these hospitals are meeting a healthy public demand: At least 36% of adults use CAM in a given year, according to the CDC.
“Interest in CAM has been steadily increasing for about 30 years in the outpatient setting, and for about 10 years in the inpatient setting,” said Anne Nedrow, FACP, secretary of the Consortium of Academic Health Centers for Integrative Medicine, a group of 39 centers that supports integrating CAM into clinical care. “We see more and more demand, and less tolerance among patients for those that don't have these services.”
Massage, music lead the way
Complementary and alternative medicine refers to a huge range of treatment, from herbal supplements to yoga. So what, exactly, are hospitals offering?
Non-ingestible therapies like massage and hypnosis tend to be the most popular, because they avoid the possibility of side effects or drug interactions that can occur with herbals and supplements, experts said. They are also generally perceived as having less potential for harm, especially among those who think CAM is a sham, said Brent A. Bauer, FACP, director of the Mayo Clinic's Complementary and Integrative Medicine Program in Rochester, Minn.
“I haven't pressed a lot for things like homeopathy because the research is thinner and it is harder to sway the nonbelievers,” Dr. Bauer said. “I'd rather win the low-hanging fruit and make sure my patients have access to massage or music therapy.”
In fact, massage therapy and music/art therapy are the top two CAM offerings for hospital patients, according to the AHA's survey. Next in popularity comes therapeutic (or healing) touch, which involves a practitioner manipulating what she believes is an energy field around a patient by moving her hands above the body. Other common offerings are guided imagery—wherein a patient envisions a positive outcome to a health procedure—relaxation training and acupuncture.
At Abbott-Northwestern, a wide range of CAM therapies, including aromatherapy, reflexology and Reiki, is available to every patient in the hospital. Yet in many hospitals, inpatient therapies are limited to specific patients, techniques or situations.
“They are usually fairly narrowly focused, as opposed to just having acupuncture and massage freely available on the wards,” said David M. Eisenberg, ACP Member, director of the Osher Research Center at Harvard Medical School and director of integrative medical programs at Brigham and Women's Hospital in Boston.
Columbia University Medical Center in New York offers massage and hypnosis to patients in its cardiothoracic surgery division, largely because of the championing efforts of Mehmet Oz, MD, a cardiac surgeon in the department. Likewise, at Beth Israel Deaconess Medical Center in Boston, radiology patients are offered hypnosis, thanks to the work of Elvira Lang, MD, associate professor of radiology at Harvard Medical School. Dr. Lang has published several large-scale, randomized studies showing hypnosis reduces pain, anxiety and complications during procedures, and has organized a training program for procedure personnel at Beth Israel.
Meanwhile, Wake Forest University Baptist Medical Center in Winston-Salem, N.C., offers massage to all patients, but healing touch is available only to its neurology and pediatric patients, because there happen to be doctors in those departments who are trained in the therapy, said Kathi Kemper, MD, director of the hospital's Program for Holistic and Integrative Medicine.
“For now, CAM is most often provided in hospitals where nurses, physicians or physical therapists have the skills themselves,” said Dr. Nedrow. “There are very few hospitals that have CAM providers come in and provide services, though I think things are moving in that direction.”
Often, CAM clinics that are affiliated with academic medical centers will offer specific therapies to hospitalized patients as part of a clinical trial. The problem, however, is that these trials eventually end, and there is no guarantee the therapies can continue, even if the results are positive.
Such was the case at the University of California-San Francisco. Wolf Mehling, MD, assistant clinical professor at the UCSF Osher Center for Integrative Medicine, conducted a year-long, donor-supported study to test whether acupuncture and massage would help cancer patients manage perioperative symptoms. Despite finding that these patients had less pain and better moods than those who got usual care, the hospital no longer offers the services.
“The insurance carriers won't pay a penny extra for it, so the hospital won't offer it. That's where we are stuck at the moment. Though it helps patients, and may attract more patients, the service is welcome by the hospital only if it doesn't have to pay for it,” Dr. Mehling said.
Another barrier to inpatient CAM is that providers must be credentialed by the hospital, a bureaucratic hoop that some would rather avoid. Payment is also a factor. A few hospitals, like Abbott-Northwestern, are able to offer integrative medicine to patients for free due to philanthropic donations, but this is uncommon, and insurance rarely covers these services for patients.
“Once someone is hospitalized, there is no easy mechanism in place to bill out-of-pocket for a medical service,” said Tracy Gaudet, MD, executive director of Duke University's Center for Integrative Medicine in Durham, N.C.
Outpatient use more common
Though integrative medicine clinics are often located on hospital grounds, they are used mostly on an outpatient basis for chronic conditions. Still, a good chunk of the patients are either about to go into the hospital for elective surgery, or have recently emerged and are still experiencing pain or other symptoms.
“One of our big patient populations in the clinic is people who have had a major health event, like a heart attack or stroke, and have just gotten out of the hospital,” said Dr. Gaudet. “A lot of the work we do was formerly done by nurses, but people are hospitalized for such a short amount of time now that they look elsewhere for help in the healing process.”
Recently, the center helped a man with neck cancer prepare for surgery by making a CD of hypnosis sessions for him to listen to before he went into the operating room. This helped lower his anxiety, Dr. Gaudet said, and he used the CD to fight off nausea after the surgery as well.
“As with all patients, we were very much aligned with his physician and nurses, so that we were an extension of what they determined was the goal and plan for the patient,” Dr. Gaudet said.
Certain medical staff are aware of the services the center offers and actively seek to hook patients up when appropriate, she added, but the majority of doctors don't do this.
“Right now, it is sort of dependent on the patient, physician or nurse knowing we exist,” Dr. Gaudet said. “We don't have it systematized the way we'd like to, where it's standard procedure to inform patients about these integrative options.”
At the UCSF Osher Center, patients sometimes come to Dr. Mehling, a back pain specialist, for a second opinion on whether they need back surgery.
“The patient will get an opinion from the neurosurgeon, then want my opinion. So I'll do another exam and determine either that the situation is so acute the patient needs to have surgery, or that it is OK to try alternative therapy first,” Dr. Mehling said.
Occasionally there is a conflict with a surgeon or physician about one of his recommendations to postpone surgery, but it's fairly rare, he added.
“We'll send emails back and forth, but it always ends up friendly,” Dr. Mehling said. “In the end, it is up to the patient to decide what to do, and we both have to respect that.”
The Center for Integrative Medicine in Philadelphia, located in the center of the Jefferson University Hospital campus, is largely an outpatient clinic. Yet patients come in all the time who are potential candidates for surgery—either because they want to try an alternative therapy first, in hopes of avoiding the knife, or simply to prepare themselves for an operation, said Birgit Rakel, MD, a family physician at the center.
“A patient may come in who needs a hip replacement and ask for an acupuncturist or massage. We make sure he clears it with his other physicians, to see if they are OK with it,” Dr. Rakel said. “But our programs are mostly kind of isolated from the hospitalists; they aren't always aware of us.”
Learning what's offered
At Abbott-Northwestern, the hospitalists on staff “know us, like us and request us,” Dr. Plotnikoff said. Those who are in charge of CAM programs at other hospitals report that hospitalists and other physicians are generally open to integrative medicine, even if they don't always endorse it themselves.
“Because of our approach, which is that we offer another set of tools for dealing with patients, we haven't had conflict,” Dr. Bauer said. “We also do research on the therapies we offer, studying them in the specific settings where they will be used, and can provide data to back our suggestions.”
Opposition to CAM generally centers on the fact that its therapies lack a large body of supportive evidence from randomized controlled trials, and that its use adds costs to the health care system. “I think it matters a great deal that we're adding another layer of costs to our already bloated health care expenditures for nothing more than expensive placebos,” said R. Bausell Barker, PhD, a professor at the University of Maryland School of Nursing and former research director of UM's CAM center from 1999–2004.
Regardless of their personal feelings about CAM therapies, it makes sense for hospitalists to become familiar with the integrative medicine programs offered at their medical facilities, if any, and to regularly ask patients if they have used those services. This includes asking about any alternative medicine providers that the hospital has credentialed to come in and provide services, experts said.
Hospitalists may also want to learn enough about the basics of CAM to be able to comfortably talk to patients who ask about it, Dr. Nedrow said.
“Hospitalists don't need to have CAM skills, just like they don't need to have the skills of various medical subspecialties. But often, the patient is more knowledgeable in this area than the doctor, and that creates an uncomfortable dynamic,” Dr. Nedrow said.
Web sites like the College's Physicians' Information and Education Resource and that of the National Center for Complementary and Alternative Medicine can help hospitalists educate themselves on the basic science and studies related to CAM, experts said. The Web site of the Consortium of Academic Health Centers for Integrative Medicine is also a source for potential local experts whom hospitalists can consult with questions, or refer patients to. (See for a more complete list of sites.)
“It is a basic fundamental skill for doctors: how to guide patients to the best of your ability, how to sow the seeds of change without being dogmatic, pejorative, condescending and dismissive,” Dr. Eisenberg said. “Those are clinical communication skills that aren't tethered to the modality in question. CAM is just another vehicle where they are called into question.”