What Are the Implications?

Dr. Michael Costa is in private practice in Boston, Massachusetts. He is a chiropractic provider for the low back pain RCT study being conducted by Dr. Eisenberg, and attended the alternative medicine symposium this past March.

On Sunday March 1st, Dr. David Eisenberg opened the symposium, "Alternative Medicine: Implications for Clinical Practice." Over 700 people crowded the ballroom at the kickoff of a four day meeting featuring an international panel of distinguished researchers and healers. Unfortunately, fewer than a dozen chiropractors were in the room, because what transpired was amazing, inspirational and surprising. The presenters and the audience combined to represent a large number of the clinicians and policy makers who will shape the future of the delivery of health care into the next century. The clear consensus of those present was that the alternative therapies are here to stay and represent the fastest-growing segment in the health care delivery marketplace. The chief concern was how to pick the right alternative practitioners to work with and what kind of a delivery team will be the model within a few years.

Five healing systems were presented in both large meeting and small group forms, including acupuncture, chiropractic, herbal therapies, homeopathy and massage/body work. Each discipline provided its recent research study results, clinical case experiences and some statistics regarding practitioner utilization.

Dr. Eisenberg's research study "Unconventional Medicine in the United States: Prevalence, Costs and Patterns of Use", published in the New England Journal of Medicine in 1993, has propelled a major reassessment of the use of complementary and alternative (CAM) remedies and how mainstream medicine deals with the public and other providers. Revolutionary changes are occurring all over this country in medical schools, hospitals and government offices as these institutions try to catch up with the public's appetite for alternative therapies. The article is also probably the most cited article in the chiropractic literature today.

Dr. Eisenberg gave an overview of his studies of traditional Chinese medicine (TCM) that led up to the research study. Most of the audience was familiar with the study's findings such as: in 1990, the American public spent $13.7 billion on alternative therapies; 70% of the time patients did not tell their medical doctor about using alternative therapy; and that there were more visits to alternative therapy providers than to primary care MDs (425 million vs. 388 million).¹ He also gave a brief overview of his current research projects:

1. Updating the 1990 survey of CAM, including updates of the trends.


2. The Harvard Pilgrim Health Plan, a randomized clinical trial of low back pain comparing conventional care with a choice of chiropractic, acupuncture or massage. This study has begun and is in the pilot stage. Funding includes the National Institutes of Health (NIH) and the Foundation for Chiropractic Education and Research (FCER). The results will be widely used by government agencies and third party payers, as well as consumers, to make decisions about services.


3. Group Health Plan Chronic Low Back Pain Study. A randomized trial comparing the effectiveness of acupuncture and therapeutic massage for chronic low back pain with each other and with the use of self-care materials.

The chiropractic session was presented by Rand Swenson, DC, PhD, MD. Dr. Swenson spoke on the history and development of chiropractic, the many recent research articles that showed the clinical efficacy for acute and chronic spinal pain, as well as a lengthy list of studies on cost effectiveness. He also suggested criteria medical doctors could use to select a chiropractor. He presented data that indicated patients of chiropractors were three times as likely as patients of family physicians to report that they were satisfied with the care they received for low back pain (66% vs 22%, respectively).²

Swenson and Dr. James Barassi led the small group sessions where doctors' individual concerns were addressed. Frequently asked questions related to the types of conditions that chiropractors treat, especially non-neuromusculoskeletal complaints, and concerns about the length of treatment. Doctors Swenson and Barassi fielded these and other questions with calm and measured answers that should increase the willingness of some doctors to try a chiropractic referral.

Dr. Andrew Weil spoke of his experience in starting the nation's first residency program in integrative medicine at the University of Arizona Medical School. He struggled for years to implement the program, but gaining a placement is now highly competitive. There is a long waiting list for patients to enter the clinic. The holistic concept extended to renovating the clinic to feature incandescent lighting, hardwood floors and comfortable furniture in place of fluorescent bulbs, wall-to-wall carpeting and the traditional examination bench. He reports great acceptance from both the medical staff and the patients.

Dr. Weil is trained as a botanist, and his writings and speeches have made him a celebrity in the CAM field. His books are worthwhile as references for anyone who uses nutritional remedies in their practice or personal life. However, he is not a proponent of chiropractic, but an advocate of massage and osteopathic manipulation. « medicine program at Stanford University. Among the many research projects he reported on, two are of particular interest to DC's.

The first project is the "CAM Insurance Coverage: Use by the Public and Delivery/Referral by Physicians Insurance Survey." This is the first formal study of CAM insurance coverage and reimbursement in a sample of 19 major insurance and managed care organizations (MCOs). Results of this study were published in the American Journal of Health Promotion in November/December 1997. Future research includes interviewing an additional 10 insurance and MCOs, as well as tracking the initial 19 and 10 new plans for two years, and tracking upwards of the first 50 major plans to offer CAM coverage in order to determine clinical and cost outcomes as well as future trends.

The second project is the "Survey of CAM Use by Older Persons Enrolled in Blue Shield of California (BSC) Insurance Plan." In 1997, BSC launched a new Medicare supplement plan termed "Shield 65". Among the innovations of Shield 65 are the coverage of: 1. acupuncture; 2. chiropractic and 3. podiatry. Analysis of survey data completed by over 800 enrollees included the following responses:

Overall percent using CAM: 34%

Most frequently used CAM therapies:

Chiropractic: 18%
Herbal medicine 17%
Massage: 13%
Acupuncture: 12%
Naturopathy: 8%

Percent joining Shield 65 plan because it covers:

Acupuncture: 18%
Chiropractic: 24%
Podiatry: 22%

Percent who discussed use of CAM with physician: 38%

Dr. Haskell also reported on the opening of a new complementary clinic under the auspices of UCSF-Stanford, reported to be opened in February 1998. Among the therapies to be offered are hypnosis, biofeedback, acupuncture, nutritional counseling and massage. "The therapies have been chosen because of their proven efficacy and appropriateness to the academic medical setting."³

For many years, chiropractors could dispense advice about nutrition and supplements that patients could not get from their medical doctor or elsewhere. That's all changed. According to Bernadette Marriott, PhD, the director of the NIH Office of Dietary Supplements, soon they will be online with information about« journals. Patients will come into your office with better information and demand better answers.

Other researchers, both from here and abroad, presented findings that reinforce much of what chiropractic has been saying all along. The mind has a profound influence upon the body's state of well-being. Taking time to know the whole person gives better long-term results rather than focusing on symptom relief. And the most important message of all is that the public is choosing to get health care in ways that most medical doctors and hospitals are not yet prepared to provide. The implications for chiropractic are enormous. Change is occurring at a dizzying pace. For a large group of doctors and administrators, the old antagonisms and prejudices are of diminished importance. Chiropractic is popular with the public and now has developed sufficient research to justify its use in some clinical conditions. For doctors of chiropractic interested in cooperating with medical doctors and willing to invest the effort, there will be great opportunities over the next several years.

There are still obstacles to overcome. All of medicine is not waiting with open arms to embrace every chiropractor who comes knocking. Even though there may be doctors of different disciplines wanting to work together, there is so little experience in doing so, we're like at the Wright Brothers' stage of development. Credentialing issues need to be resolved so that medical practices and insurers of all types can provide the integrated services the public wants, and chiropractors have a reasonable chance to participate in that delivery.

Chiropractors still need to keep in mind that many of the leading medical doctors of this movement to an integrated approach are more familiar and comfortable with traditional Chinese medicine than with chiropractic. Many have trained in China or studied acupuncture. One estimate has the number of licensed acupuncturists exceeding licensed chiropractors in 10 years. TCM is not viewed with the same skepticism, and frankly, with its history of over 2500 years, that is not surprising. More chiropractors need to learn to speak the language of medicine, to obtain dual degrees, and to perform the trials and publish the research that will prove the effectiveness of chiropractic.

Of the five systems presented at this conference, chiropractic is by far the largest, best-researched and the most widely accepted by the public. There are growing numbers of medical doctors willing to communicate and even cooperate about patient care. The third-party payers are wary about costs, but see adding chiropractic services as a way to increase market share in the competition for members. For those doctors of chiropractic willing to be part of a team that may include care givers from a variety of disciplines, opportunity awaits.

References

1. Eisenberg D, Kessler RC, et al. "Unconventional" medicine in the United States -- prevalence, costs and patterns of use. N Engl J Med 1993;328:246-252.
2. Cherkin and MacCormack. Western J Med 1989;150:351-5.
3. Haskell WL. In conference notes, "Alternative medicine: implications for clinical practice and state of the science symposium" under the direction of David M. Eisenberg, MD. Harvard Medical School, dept. of cont. ed., Mar 1998.