Chapter 50: Complementary & Alternative Medicine

According to the World Health Organization, between 65% and 80% of the world’s health care services are classified as traditional medicine. These practices become relabeled as complementary, alternative, or unconventional medicine when they are used in Western countries. In April 1995, a panel of experts, convened at the National Institutes of Health (NIH), defined complementary and alternative medicine (CAM) as “a broad domain of healing resources that encompasses all health systems, modalities, practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period.” Similar definitions have been used since then by other organizations. Surveys of CAM use by the public and health professionals have defined it as those practices used for the prevention and treatment of disease that are not an integral part of conventional care, and are neither taught widely in medical schools nor generally available in hospitals. Table 50-1 lists the major types and domains of complementary and alternative medicine, while recognizing that there can be some overlap, adapted from the National Center for Complementary and Alternative Medicine (NCCAM) at NIH.

A. Use of Complementary and Alternative Medicine

Practices that lie outside the mainstream of “official” or current conventional medicine have always been an important part of the public’s management of their personal health. Complementary, alternative, and unconventional medicine has become increasingly popular in the United States. Two identical surveys of unconventional medicine use in the United States, done in 1990 and 1996, showed a 45% increase in use of CAM by the public. Visits to CAM practitioners increased from 400 million to >600 million per year. The amount spent on these practices rose from $14 billion to $27 billion—most of it not reimbursed. Recent data from the National Health Interview Survey (NHIS) have increased this estimate to $33.9 billion. Professional organizations are now beginning the “integration” of these practices into mainstream medicine. In 2007, the number of those using CAM was similar between 1997 and 2002, and rose in 2007 (36.5%, 36.0% and 38.3%; respectively P = .21). The greatest relative increase in single CAM use was seen for deep breathing (12.1%, 11.6%, and 12.7 respectively) and meditation (3.7%, 7.6%, and 9.4% respectively).

The public uses these practices for both minor and major problems. Multiple surveys have now been conducted on populations with cancer, human immunodeficiency virus (HIV), children, minorities, and women on CAM use. Rates of use are significant in all these populations. For example, >50% of women surveyed have been found to explore and use CAM both for themselves and as healthcare decision makers for their family. A recent national survey showed that 12% of children use CAM regularly. More than 68% of patients with cancer or HIV will use unconventional practices at some point during the course of their illness. Immigrant populations often use traditional medicines that they experienced in their country of origin and not commonly used in the West.

As the public’s use of CAM has grown, so, too, has the call to action of our research institutions and training centers. Will CAM treatments offer hope as we grapple with the growing burden of chronic illness and rising costs currently stressing our health systems? Are new educational and research training paradigms needed? Such efforts have emerged and are evolving. For example, the budget of the Office of Alternative Medicine at the US National Institutes of Health rose from $5 million to the present $123.1 million in 10 years and changed from a coordination office to a large government agency: the National Center for Complementary and Alternative Medicine (NCCAM). The NCCAM 2012–enacted Congressional budget was $128,299,000. The 2013 Congressional budget request is $127,930,000, a reduction of <1% from fiscal year 2012. During fiscal year 2012, 248 research grants and 5 research centers were funded by the NCCAM. Since the early 1990s, more than 2500 research projects have been funded by NCCAM.

Our current medical and health professions students are the future. How are they learning about the potential healing power and possible pitfalls of CAM? Currently >95 of the nation’s 125 medical schools require their medical students to enroll in either required or elective CAM coursework. A significant development in residency training, lead by family medicine educators, is the Integrative Medicine in Residency (IMR) national curriculum project. Launched in 2008 via eight pilot sites, the IMR was the first time that integrative medicine education became a required component of graduate medical education. IMR has been successfully disseminated to 42 residencies, including family medicine, internal medicine, and pediatrics (http://integrativemedicine.arizona.edu/education/imr.html). An increasing percentage of hospitals have developed complementary and integrative medicine programs offering both in- and outpatient services. Some health management organizations have “expanded” benefits packages that include specific alternative practitioners and services with a reimbursement option. A recent survey of CAM use in the US hospitals showed that 37% of hospitals offer CAM services. The majority of all services are offered on an outpatient basis, with massage therapy (54%), acupuncture (35%), and relaxation training (27%) among the most popular. On an inpatient basis, the top modalities offered are pet therapy (46%), massage therapy (40%), and music/art therapy (30%).

As the interface of CAM and conventional medicine grew, there emerged the concept of integrative medicine as a way to bridge the best of both worlds. The Consortium of Academic Health Centers for Integrative Medicine has defined integrative medicine (IM) as the practice of medicine that reaffirms the importance of the relationship between practitioner and patient; focuses on the whole person; is informed by evidence; and makes use of all appropriate approaches, healthcare professionals, and disciplines to achieve optimal health and healing. The application of integrative medicine can be defined as the purposeful, coordinative application of appropriate preventive and treatment modalities that support and stimulate the patient’s inherent healing and self-recovery capacities. As such, these treatments are derived from various practices and healthcare systems from around the world. Thus, the term integrative medicine encompasses concepts from various healing philosophies, such as person-centered care, humanistic medicine, holistic healthcare, and the medical home.

Complementary and alternative medicine, and more specifically integrative medicine, is finding an important and growing place in American medical practice. Indeed, its significance is demonstrated by the newly formed American Board of Integrative Medicine^® (ABOIM) under the auspices of the American Board of Physician Specialties (ABPS) (http://www.abpsus.org/integrative-medicine). Undoubtedly, these philosophies and practices will continue to be debated informally among medical staff and physicians and formally in peer-reviewed publicaitons, as well as medical societies, academies, and organizations. More importantly, the individual Western-trained medical physician will continue to be the primary arbitrator and counselor for the patient through the time-honored fundamentals of the therapeutic alliance; that is, compassion coupled with trust, integrity, and empathy; concern coupled with caring and active listening; competence coupled with skill, intellect, and common sense; and communication coupled with availability, continuity, and follow-through.

B. Conventional Physician Use of CAM in Practice

Family physicians are frequently faced with questions about CAM. Some also refer patients for CAM treatment and, to a lesser extent, provide CAM services. A review of 25 surveys of conventional physician referral and use of CAM found that 43% of physicians had referred patients for acupuncture, 40% for chiropractic services, and 21% for massage. The majority believed in the efficacy of these three practices. Rates of use of CAM practices ranged from 9% (homeopathy) to 19% (chiropractic and massage). National surveys have confirmed that many physicians refer for and fewer incorporate CAM practices into their professional practice. However, as CAM and IM physician training and fellowships programs (eg, AzCIM’s IMF: http://integrativemedicine.arizona.edu/education/fellowship/index.html and the ABOIM’s listing of current IM fellowships: http://www.abpsus.org/integrative-medicine-fellowships) continue to grow, so will the direct incorporation of CAM and IM into clinical care.

C. Risks of CAM

The amount of research on CAM systems and practices is relatively small compared with that on conventional medicine. There are >1000 times more citations on conventional cancer treatments in the National Library of Medicine’s bibliographic database, MEDLINE, than on alternative cancer treatments. With increasing public use of CAM, inadequate communication between patients and physicians about it, and few studies on the safety and efficacy of most CAM treatments, risks are increased for misuse and harm. In response to inadequate communication about CAM use, NIH launched the “time to talk” campaign to increase awareness (http://nccam.nih.gov/timetotalk/forpatients.htm?nav=gsa). Many practices, such as acupuncture, homeopathy, and meditation, are low-risk but require practitioner competence to avoid inappropriate use. Botanical preparations can be toxic and produce herb-drug interactions. Contamination and poor quality control also exist with these products, especially those harvested, produced, and shipped from Asia and India.

D. Potential Benefits of CAM

Both CAM and IM practices have value for the way we manage health and disease. In botanical medicine, for example, there is research showing the benefit of herbal products such as ginkgo biloba for improving conditions due to circulation problems (although not Alzheimer disease), Butterbur for migraine prophylaxis and other herbal preparations, and the prevention of heart disease with garlic. A number of placebo-controlled trials have been performed showing that Hypericum (St. John’s wort) is effective in the treatment of mild to moderate depression. Additional studies report that Hypericum is as effective as some conventional antidepressants but produces fewer side effects and costs less. However, the quality of too many of these trials does not reach the standards set for drug research in this country. Thus, physicians need to have and apply basic skills in the evaluation of clinical literature.

What is the role of the family physician in the management of CAM? The goal is to help patients make informed choices about CAM as they do in conventional medicine. Specifically, physicians must continue to apply the ethical principle of beneficence and autonomy and play the role of patient advocate—a professional should protect, permit, promote, and partner with patients about CAM practices as appropriate.

A. Protecting Patients from Risks of CAM

Many practices, such as acupuncture, biofeedback, homeopathy, and meditation, are low- risk if delivered by competent practitioners. However, if used in place of more effective treatments, CAM may result in harm. The practitioners who apply these modalities should be qualified to help patients avoid inappropriate use. Many herbal preparations contain powerful pharmacologic substances with direct toxicity and herb-drug interactions. Contamination and poor quality control occur more often than with conventional drugs, especially if preparations are obtained from overseas. The family physician can help distinguish between CAM practices with little or no risk of direct toxicity (eg, homeopathy, acupuncture) and those with greater risk of toxicity (eg, megavitamins and herbal supplements). Physicians should be especially cautious about those products that can produce toxicity, work with patients to ensure that they do not abandon proven care, and alert patients to signs of possible fraud or abuse. “Secret” formulas, cures for multiple conditions, slick advertising for mail order products, pyramid marketing schemes, and any recommendation to abandon conventional medicine are “red flags” and should be suspect.

B. Permitting Use of Nonspecific Therapies

Spontaneous healing and placebo effects account for the improvement seen in many illnesses. The medical literature does contain essays and polemics that attempt to separate and often denigrate these factors from those that are considered identifiable, tangible, specific aspects of a therapy. The clinician, however, is interested in how to combine both specific and nonspecific factors for maximum benefit. Many CAM systems emphasize high-touch, personalized approaches for the management of chronic disease and the crises associated with acute illness. The physician can permit the integration of selected CAM approaches that are not harmful or expensive, that may enhance these nonspecific factors.

C. Promoting CAM Use

Proven therapies that are safe and effective should be available to the public. As research continues, more CAM practices will be found to be effective. Gradually, physicians and patients will have more options for management of disease. In arthritis, for example, there are studies suggesting improvements with homeopathy, acupuncture, vitamin and nutritional supplements, botanical products, diet therapies, mind-body approaches, and manipulation. A similar collection of studies exists for other conditions such as heart disease, depression, asthma, and addictions. The Cochrane Collaboration conducts systematic reviews (SRs) of randomized controlled trials (RCTs) on both conventional and complementary medicine and is an excellent source for evidence-based evaluation of such studies. Other groups such as RAND, AHRQ, EPIC, and Samueli Institute also conduct such reviews. Samueli Institute has developed a streamlined but effective way to do these reviews called the rapid evidence assessment of the literature. As research accumulates, rational therapeutic options can be developed in these areas.

As CAM information is presented in peer-reviewed professional journals, the challenge will be to implement its coordinated application via integrative medicine strategies within clinical teams into holistic care models in hospitals, offices, clinics, and other care venues. The availability of pluralistic care delivery with onsite, certified, and licensed CAM practitioners will require the training of physicians who will guide the appropriate selection of modalities using indication and evaluation methods related to safety and efficacy. In fact, an increasing number of team-based care and group visits will be required to accomplish this. Although the physician may be the cornerstone of this team, optimal care will require collaboration among all members with honest communication, generous listening, a shared commitment to treating the whole person, integrated care plans, and appropriate referral when necessary.

D. Partnering with Patients about CAM Use

Over 60% of patients who use CAM practices do not reveal this information to their conventional physicians. Thus, there is a major communication gap between physicians and the public about CAM. Patients use alternative practices for various reasons: their culture or social network, dissatisfaction with the results of their conventional care, or an attraction to CAM philosophies and health beliefs. The overwhelming majority of patients use CAM practices as an adjunct to conventional medicine. Fewer than 5% use CAM exclusively. Patients who use alternative medicine do not foster antiscience or anti–conventional medicine sentiments or represent a disproportionate number of the uneducated, poor, seriously ill, or neurotic. Patients often do not understand the role of science in medicine and will accept anecdotal evidence or slick marketing as sufficient justification for use. The family physician can play a role in examining the research base of these medical claims and partner with patients to incorporate more evidence into their healthcare decisions. Quality research on CAM practices provide this evidence, and the physician can help bridge this gap with patients.

Other social factors have also influenced the emergence of CAM. These include rising rates of chronic disease, increasing access to health information, growing “computerization” of medical decision making, declining faith that science will benefit personal health, and increasing interest in spirituality. In addition, both the public and health professionals are increasingly concerned about side effects, errors, and the escalating costs of conventional care. Physicians and scientists who ignore CAM only broaden the communication gap between the public and the profession that serves them. Thus, as patient advocates, physicians will best meet their patients’ needs by learning about these practices and openly engaging in dialogue.

We all need good evidence to make medical decisions. Evidence comes in a variety of forms, and what may be good for one purpose may not be good for another. The term evidence-based medicine (EBM) has become a synonym for “good” medicine recently, and is often used to support and deny the value of complementary medicine. EBM uses the “hierarchy of evidence” (Figure 50-1). In this hierarchy, SRs are seen as the “best” evidence, then individual RCTs, then nonrandomized trials, then observational studies, and finally case series. All efforts are focused on approximating evidence at the top of the pyramid, and lower levels are considered inferior. Clinical experiments on causal links between an intervention and outcomes become the gold standard when this model is used.

All family physicians have seen patients who recover from disease because of complex factors, many of which are not additive and cannot be isolated in controlled experiments. Under these circumstances, observational data from clinical practice may provide the best evidence rather than controlled trials. Patients’ illnesses are the human experience of the disease—the manifestation of the patient’s beliefs, fears, and expectations. As such, they are complex, and holistic phenomena cannot be reduced to single, objective measures. Often highly subjective judgments about life quality may be the best information with which to make a decision. Such experiences may be captured only with qualitative research, not with scans or blood tests. Often the meaning that patients infer regarding their illness and recovery is the “best” evidence for medical decisions.

Sometimes the “best” evidence comes from laboratory tests. For example, the most crucial evidence for management of St. John’s wort in patients on immunosuppressive medications originates from a laboratory finding that it accelerates drug metabolism via cytochrome P450. Arranging evidence in a hierarchy obscures the fact that the “best” evidence may be neither related to cause and effect, nor objective, nor clinical.

We suggest that family physicians not use an evidence hierarchy but rather build an evidence “house” (Figure 50-2). On the left side of this house is evidence for causal attributions, for mechanisms of action, and for “proof.” If physicians confine themselves to the left side of the house, they will never know about the relevance of a treatment for patients or what happens in the real world of clinical practice. They will also not know whether proven treatments can be generalized to populations such as the ones they see or the healthcare delivery system in which they practice. The “rooms” on the right side of the house provide evidence about patient relevance and usefulness, in practices both proven and unproven.

How evidence is approached has ethical implications. Different groups prefer different types of evidence. Regulatory authorities are most interested in RCTs or SRs (left side), which may never be done because of the logistics of time, cost, and access. Healthcare practitioners usually want to know the likelihood of benefit or harm from a treatment (right side). Patients are intensely interested in stories and descriptions of cures (right side). Rationalists want to know how things work and so need laboratory evidence (left side). If one type of evidence is selected to the exclusion of others, science will not allow for full public input into clinical decisions. A livable house needs both a kitchen and a bathroom and places to sleep and play. Each type of evidence has different functions and value, and all types need to be of high quality.

Fortunately, most treatment decisions need information only on whether a practice has a specific effect and on the magnitude of that effect in practice. This is evidence from randomized controlled trials and outcomes research, respectively. An evidence-based practice would then involve clinical expertise, informed patient communication, and quality research. This presumes that the physician has good clinical and communication skills. Medical training and experience address these, but evaluation of the CAM research evidence may not be something that physicians feel fully prepared to undertake. Obtaining research, selecting appropriate research for clinical situations, and then evaluating the quality of that research in CAM are essential for a fully evidence-based practice that addresses these topics.

A. Finding and Selecting Good Information

Where can the family physician obtain research on CAM? A number of groups have collated and produced CAM-specific databases (Cochrane Collaboration, Evidence Based Medicine Reviews, Samueli Institute, and Natural Standard). Table 50-2 lists some good sources of clinical information on CAM and what they provide. When searching these databases, look for the following key terms: (1) meta-analyses, (2) RCTs, and (3) observational or prospective outcomes data. Although there are many other types of studies, it is necessary to be cautious about using these for problem-oriented decision making in practice. If no research information is found from the databases listed, it is likely that there is little relevant evidence for the practice on that clinical condition. A search for this information need not take up a lot of time. A trained research assistant or librarian can often do the search, streamlining time spent on this process. Many librarians, especially those at health centers and hospitals, are now receiving training in literature searching methodology and growing awareness and expertise in CAM databases. After a literature search, the physician can be confident in knowing the quantity of evidence on the therapy (Figure 50-3). Patients are usually grateful for this effort as they will come to their physician in the hopes of obtaining science-based information they can trust.

B. Risks and Types of Evidence for Practice

If there are studies on a specific type of CAM practice, then the risk of toxicity and the cost of the therapy indicate which types of data are needed. Low-risk practices include OTC homeopathic medications, acupuncture and gentle massage or manipulation, meditation, relaxation and biofeedback, other mind-body methods, and vitamin and mineral supplementation below toxic doses. Low-cost therapies involving self-care are also often low-risk. High-risk practices include herbal therapies, high-dosage vitamins and minerals, colonics, and intravenous administration of substances. Some otherwise harmless therapies can produce considerable cost if they require major lifestyle changes. Herbal therapies can produce serious adverse effects secondary to their impact on cell function, including enzymatic reactions or contamination with toxic materials. Because patients frequently take herbal products along with calculated dose prescription medications, physicians should specifically inquire about their use. High-risk or high-cost practices and products require RCT data.

Under some circumstances, observational (outcomes) data are more important, and in other circumstances RCT data are more important. Outcomes research provides the probability of an effect and the absolute magnitude of effects in the context of normal clinical care. It is more similar to clinical practice and usually involves a wide variety of patients and variations of care to fit the patient’s circumstances. It does not provide information on whether a treatment is specific or better than another treatment.

With low-risk practices, the physician wants to know the probability of benefit from the therapy. Quality observational data from practices are preferable to RCT data if the data are collected from actual practice populations similar to those of the practitioner. This may be sufficient evidence for making clinical decisions. Often, it will be the only useful information available for chronic conditions. For example, if quality outcome studies report a 75% probability of improving allergic rhinitis using a nontoxic, low-cost, homeopathic remedy, this information can assist in deciding on its use.

For high-risk, high-cost interventions, the physician should use randomized controlled trials (or meta-analyses of those trials). RCTs address the relative benefit of one therapy over another (or no therapy). RCTs can determine whether the treatment is the cause of improvement and how much the treatment adds to either no treatment or placebo treatment. RCTs provide relative (not absolute) information effects between a CAM and control practice. They are difficult to do properly for more than short periods and difficult if the therapy being tested is complex and individualized or if there are marked patient preferences. In addition, RCTs remove any choice about therapy and, if blinded, blunt expectations—both of which affect outcomes. Placebo-controlled RCT differences are dependent largely on the control group, which requires careful selection and management. Strong patient preferences for CAM, differing cultural groups, and informed consent may also alter RCT results. RCTs are more important if we need to know more about specific benefit-harm comparisons, such as with high-risk, high-cost interventions. Recently comparative effectiveness research (CER) has emerged as an important goal and set of methods. CER may be a valuable addition to CAM research, allowing whole systems of care to be compared to other different systems.

The more a CAM practice addresses chronic disease and depends on self-care (eg, meditation, yoga, biofeedback), or involves a complex system (eg, classical homeopathy, traditional Chinese medicine, Unani-Tibb), the more local, observational data are important. The more a CAM practice involves high-risk or high-cost interventions, the more essential RCT data become.

C. Evaluating Study Quality

Once data are found and the preferred type of study is selected, the practitioner should apply some minimum quality criteria to these studies. Three items can be quickly checked: (1) blind and random allocation of subjects to comparison groups (in RCTs) or blind outcome assessments (in observational research), (2) the clinical relevance and reliability of the outcome measures, and (3) the number of subjects that could be fully analyzed at the end of the study compared to the number entered. These same minimum quality criteria apply to RCTs or observational studies, except that blinded, random allocation to treatment and comparison groups does not apply in the latter. However, evaluation of effects before/after treatment can be blinded to the treatment given in any study. Detailed descriptions of patients, interventions, and dropouts are hallmarks of a quality outcomes trial.

Finally, one can ask if the probability of benefits reported in the outcomes study is worth the inconvenience, risk of side effects, and costs of the treatment and, in addition, whether confidence intervals were reported. Confidence intervals are the range of minimum to maximum effects expected in 95% of similar studies. If confidence intervals are narrow, the physician can be confident that similar results will occur with other patients. If confidence intervals are broad, the chance of obtaining those effects from treatment in other patients will be less predictable.

If the quality screening questions reveal marked quality flaws in the studies retrieved, the evidence in the study is insufficient and should not be used as a basis for clinical decisions.

D. The Population Studied

Even if good evidence is found for a practice, physicians should determine whether the population in the studies is similar to the patient being seen. Although this matching is largely subjective, the physician can compare five areas. Specifically, determine whether the study was done (1) in a primary, secondary, or tertiary referral center; (2) in a Western, Eastern, developing, or industrialized country; and (3) with diagnostic criteria similar to the patient (eg, the same criteria were used to diagnose osteoarthritis or congestive heart failure). Also, determine whether the age (4) and gender(s) (5) of the study population were similar. If the study population is not similar to the patient being seen, then the data, even though valid, cannot be applied to the situation. The study country may be especially important for some CAM practices. For example, data on use of acupuncture to treat chronic pain may come from China. Pain perception and reporting is different in China from that in the United States. Results from a study done in one country may not be applicable in another. If the study and clinic population match, an appropriate body of evidence for moving forward with a therapeutic trial exists.

E. Balancing Beliefs

Belief in the treatment by the physician and the patient needs to be explicitly considered in CAM. In conventional medicine, both patient and physician accept the plausibility of treatment. Belief has long been known to affect outcome. Strong belief enhances positive outcomes, and weak belief interferes with them. A physician may feel that a CAM practice has incredibly low plausibility although the patient may have a strong belief in the therapy. This “prior probability” (or belief) by the physician and patient should be considered in the decision to allow or not allow the patient to use a treatment. If physician and patient have similar beliefs, then a decision is easily made. Sometimes, however, the patient has a strong belief in the therapy, but the physician finds it unbelievable. In such situations, the physician should work with the patient to decide the best action—including referral elsewhere as an option.

F. Alternative Diagnoses

Some diagnoses are not very useful for management of a patient’s illness. If the family physician’s conventional diagnosis is not helping a patient, the clinician may want to consider an evaluation by an alternative system. Chinese medicine uses energy diagnosis, for example, and homeopathy has a remedy classification system. Sometimes, obtaining an assessment from a practitioner experienced in a CAM system may prove useful. For example, a 51-year-old woman with several years of idiopathic urticaria had obtained no relief from several conventional physicians. A homeopathic assessment showed that she might benefit from the remedy Mercurius 200C (mercurius virax). She was given several small doses and the urticaria cleared.

The physician should also be alert to practitioners who pursue CAM diagnoses that are not useful. A complicated CAM evaluation and treatment with little effect might be managed simply and effectively by conventional medicine. For example, a 57-year-old man with cardiovascular disease and recurrent bouts of angina was treated by a CAM practitioner for 3 years with special diets and nutritional supplements without help. Consultation with a conventional practitioner shows that he had myxedema. A thyroid supplement cleared his angina rapidly. In cases in which the diagnostic approach of the medical system fails, a professional consultation may be needed. In situations in which the alternative system’s diagnostic and treatment approach is clear, a limited therapeutic trial with specific treatment goals and follow-up can be attempted. Of course, quality products and qualified practitioners must be located. In situations of serious disease, such as cancer, desperate patients may seek out CAM treatments. Under these circumstances, good training and clinical experience and protection of patients from harm (even from themselves) should prevail.

Evidence-based medicine can be applied to complementary and alternative medicine. Table 50-3 summarizes questions for CAM management. Although evidence-based CAM may initially seem like a large task, appropriate data-driven clinical decisions can be made with CAM as with all medical care.

American medicine continues to evolve in its focus, capabilities, technology, and demands. Our population is aging, and with that comes more chronic disease. By definition, chronic disease cannot be cured—patients may suffer with disability, diminished function, emotional challenges, economic burden, and overall challenges to quality of life. Conventional medicine is failing to provide the necessary and required care that these patients deserve. Although cure is not always the physician’s primary goal, the provision of individualized, person-centered care suffused with empathy and compassion remains the foundation of all medical practice. The knowledgeable use of integrative medicine, combining the best of CAM and conventional therapies, will empower patients to participate in a process of healing with their physician by engaging in their inherent healing capacities, expectation, hope, understanding, and belief that well-being can and will manifest.

Special thanks to Cindy Crawford and Viviane Enslein in helping collecting background information and preparing the manuscript.