I read with keen interest the April 2001 issue of Trustee magazine, the publication that goes to the trustees of all hospitals across the country. Trustee is a well-respected journal, and many directors of hospitals across the country are influenced by the articles they read. I was particularly interested and intrigued by the article by Laurie Larson, "Natural Selection: Weaving Complementary Medicine into Your Health System." I know you will not be shocked to learn that it's off target on a solution or approach to integration, as the core concepts in the article are flawed. The article, however, is important because it raises a subject that only 10 years ago would have been taboo in any hospital medical publication, much less in Trustee.
Being a trustee at our local hospital for more than a decade has provided insight and appreciation for the day-to-day problems encountered with running an institution like a hospital, whether it is for profit or nonprofit. The rigid mindset of the medical staff, and sometimes of the administration, is often cast in the concrete of medical tradition, and is reflected in many decisions made by hospital boards. On a personal note, it was 20 years (from the early 60s to the late 70s) before I could get a urinalysis or blood chemistry performed at my local hospital on my orders. Today, laboratory and diagnostic services are no longer national or local issues, largely resolved by the tincture of time and the element of economics. The new "buzz" discussions are focused on how to incorporate, or should I say, "integrate," complementary and alternative medicine (CAM) services into medical and hospital practices, often without addressing the "chiropractic problem," as I metaphorically term it.
The Trustee article, while discussing the subject of CAM in hospitals, only succeeded in reinforcing and perpetuating a mindset and attitude that will ensure the demise of any truly emerging integrated system. I say this not to present a hostile or adversarial position to that of the author or those individuals interviewed for the article, but rather to point out the weakness in continuing to suggest that CAM be included, as does Donald Novey,MD, medical director of the Center for Complementary Medicine at Lutheran General Hospital in Park Ridge, Illinois. He suggests that CAM be packaged properly as "an additional tool in the physician's toolbox." He further explains, "We're providing modalities, not creating a culture." This very concept of incorporating CAM as an adjunct, not as a discipline, is the converse of what is attempted by the "integration" of CAM.
Admittedly, as a doctor of chiropractic, I am sensitive to chiropractic issues, and I find it interesting and curious that Samuel Benjamin,MD, director of the Center for Complementary and Alternative Medicine at State University of New York, suggests that the most commonly used CAM therapies are "herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy." Where is his mention of chiropractic? In every study of CAM therapies, chiropractic is always the most widely used, respected, accepted and demanded service. Yet in this article to hospital trustees and other influential health care decision makers, the word chiropractic is only used two times, and, at best, as an afterthought. Could this be the remnant of long-standing bias from a physician who appears to be "cutting-edge" by operating an integrated, center? Is it integrated or is it simply medical at the "core" with lots of CAM ornaments to demonstrate a cutting-edge appearance?
The CAM movement and integration are destined to fail simply because the effort endeavors to add on various CAM therapies/procedures to the medical and hospital settings as if they were ornaments on the medical Christmas tree. At the core of the health care debate is how medical care (or should I say "health care"?) will be delivered in the future, and as important, who will lead the process.
The entire concept of health care in the U.S. must be altered and radically reformed if it is truly to benefit from a paradigm shift from a medical "crisis intervention" model to a "health and wellness" model espoused by most CAM providers. It is this very philosophy or approach to health that needs to be debated before a decision is made to utilize the medical Christmas tree concept as the basis for the model. Simply attempting to hang CAM ornaments upon a flawed model, and believing that the tree will continue to serve the purpose, is not going to solve the core issues relative to CAM or health care reform.
The concept of integration does not necessarily mandate that the current medical model emerge as the "best" or "most appropriate" for the delivery of all health care. Essentially, a paradigm shift in thinking is required, not unlike today's military model, which was historically based upon aggression of a hostile country. The battle in the old model would be a ground war with many soldiers in hand-to-hand combat. Today's new military model is altered to a peacetime readiness with sophisticated computerized weapons of mass destruction capable of being launched from hundreds of miles away by a single soldier. This is a total paradigm shift in thinking, preparedness, and implementation. Is one wrong or the other right? No, times have changed, necessitating a new model for consideration. It is the same issue confronting health care delivery. How we communicate has gone from the Pony Express to e-mail. Models change, and change is often difficult to assimilate, acknowledge, and ultimately accept.
It will be a difficult challenge for the entrenched medical system that has enjoyed a virtual monopoly over health care for a hundred years to be called to the table not to "chair the meeting," but to be an equal participant in a new discussion. How do we truly integrate the best of what has now been discovered as effective alternative medicine models? The biggest challenge to those in charge of altering the system is to remove the medical model from the position of dominance to the role of equal participant.
The article in Trustee only serves to provide fodder to fuel the demand for CAM, but does nothing to truly establish the fundamental basis for a new health care delivery system that is badly in need of revision. This is not an indictment of medicine, nor is this article meant to be hostile to the medical system. There is simply no way that America can exist without the marvelous crisis intervention that the current medical/surgical model provides. However, the Institute of Medicine (IOM), in releasing statistics on medical care, recognizes the flaws in the system and is demanding reform. Other consumer advocates recognize that the medical system as we know it is not the complete answer to health care, but rather only a portion of the total health care program. No one is suggesting that medicine needs to be eliminated, but rather that the medical model does not provide the basis for a health care system of the future. The new system must incorporate differing disciplines and models that offer counter-solutions and philosophies to the current medical model, and "integration with integrity" is required rather than "integration by ornamentation."
For CAM to be truly recognized for the value it can and does provide, the federal government must be encouraged to appropriate money earmarked to convene high-level discussion conferences to discuss health care reform. The conferences should not be dominated by one group over another, but with the imprimatur of the government, the conference should convene with independent objective arbiters. This conference will make decisions and hold discussions, which may or may not be welcomed by the entrenched models, but everyone will be heard and given appropriate consideration.
Despite the hoopla surrounding the desire to promote CAM services, the real motivation is couched in two fundamental objectives:
Money: Hospitals and physicians have had an economic turndown because of managed care initiatives. They are looking for sources of revenue to augment declining profits. The economic driver is why prestigious institutions that only a few years ago held CAM practitioners and procedures in low regard are now willing to revisit the CAM craze. The underlying motivation, unfortunately, is not deeply rooted in providing better or improved health care, but in increasing revenue, while being perceived as on the "cutting edge."
Public Relations: Everyone is jumping on the proverbial CAM bandwagon with the knowledge that the baby boomers will dominate the political and social landscape for several decades to come. This generation is demanding CAM services for a variety of reasons. Boomers recognize that they will be living longer than their parents, understand the weakness of the paternalistic medical model, and are unwilling to kneel at the altar of medicine. They have economic and political savvy and are unafraid to exercise that power. They are also technologically advanced and have the power to demand CAM services, patient-centered care and a health model that incorporates reimbursement for wellness and maintenance (not simply a model that fosters high dollars for crisis intervention). I point this out to highlight an honest assessment of why this is happening, despite what the "spin doctors" may attempt to feed the general public.
Trustee saw fit to include an article on CAM, but I am afraid that the information in the article was truly a "fluff" piece with the appropriate "spin" to appear to be in the vanguard, while protecting the medical model ingrained in the hospital/medical/pharmacological complex. Perhaps there should be an article in a future issue of Trustee outlining why CAM integration in hospitals conveniently eliminates chiropractic from its discussion. Chiropractic is a profession licensed in all 50 states, having considerable research to back the profession's claims, having an educational and organizational infrastructure to support the profession, and yet it is overlooked. Could a discussion of software be complete if Microsoft, an integral part of the industry, were not in the discussion? Yet CAM is discussed and chiropractic is not mentioned.
Most CAM procedures, and more specifically chiropractic, have undergone decades of adverse, hostile, and illegal activity designed to "contain and eliminate" them. Chiropractic has endured the most unlawful, menacing, intimidating campaign ever endured by any professional health care group. The medical monopoly and hostility are still active, alive and well, and as the learned judge in the AMA lawsuit so appropriately stated, "the lingering effects of the conspiracy will last for decades." It is precisely for these reasons that CAM, or perhaps better stated, "health care disciplines not under the control of medicine," needs to be given an equal seat, voice and vote at the new health care decision-making table.
In closing, treating all CAM disciplines, theories and procedures as merely ornaments on the medical tree will not create a solution to the health care crisis facing our nation, and is a discredit to all nonmedical professions currently termed CAM. Recently, the CAM label has been challenged. Perhaps all health care should be termed "best practices" for whatever health care is delivered. The "ornament" treatment will only serve to postpone the inevitable demise of the current model, while frantically attempting to make it look different. Imagine the crew of the Titanic rearranging the deck chairs as the ship listed.
Louis Sportelli,DC
Palmerton, Pennsylvania
