Report of Working Group on Complementary/Alternative Medicine

From The University of Pennsylvania Health System

Report of Working Group on Complementary/Alternative Medicine

Fueled by popular demand, interest is currently high in relating unconventional forms of therapy, variously designated as complementary or alternative or both (CAM), to conventional "Western scientific medicine." In many academic medical centers, CAM has been insinuated into teaching and practice from the periphery with few ventures into traditional research that can withstand Western scientific criteria. Approximately two years ago, in order to face up squarely to this issue, Dr. William N. Kelley, CEO and Dean of the University of Pennsylvania Medical Center commissioned a "Working Group" to look into, and to recommend if and how, so-called "alternative" or "complementary" medicine might relate to the traditional programs in education, research and practice at the University of Pennsylvania. As the Working Group went about its business, it received many inquires about the process and the results.

The following is a summary of the Conclusions and Recommendations of the Working Group. On October 11, 1999, after passing critical review by the various Chairs, Institute Directors and the CEO/Dean, the Conclusions and Recommendations have begun to be implemented.

The Membership of the Working Group

The Working Group on the Role of Alternative Medicine at Penn (click here for list of members) was designed to be equally balanced; strong proponents for complementary and alternative methods on the one hand, and on the other, defenders of clinical investigation and the "Western scientific method." At first, the two groups lived on opposite sides of the table. After a few of the monthly sessions and better understanding of the differing perspectives, distinction between the two sides became increasingly blurred.

The Monthly Meetings

Monthly meetings began on June 5, 1998. Minutes were kept and forwarded to the CEO/Dean. At first, the agendas were general, seeking common ground and understanding. About halfway through its life span, the Working Group focused increasingly on the reports of the Focus Groups.

The Focus Groups

Three separate subgroups were created for clinical practice, research and education. Since the original membership was too sparse to be subdivided and deal effectively with the three topics, the Chair of each group was authorized to enlarge the group by adding a few experts in the area to be covered.

The members added to each group also appear at the end of this paper.

The Retreat

Part of the original design was to present the findings and recommendations of the Working Group to a critical audience of faculty, administration (University as well as Medical School) and practitioners drawn from the University of Pennsylvania Health System. In addition, several nationally prominent leaders in health care policy were invited as discussants and Dr. June Osborn, president, Josiah Macy, Jr. Foundation was invited to provide the final summing-up and critique. The Conclusions and Recommendations that follow were well received and the CEO/Dean suggested that plans be drawn for review by the appropriate standing committees of faculty and administration.

The Situation at Penn

As part of this process, inventory was taken of the current practice of CAM in the University of Pennsylvania Health System (UPHS). Questionnaires were sent to 1,500 physicians in the UPHS. The questionnaires were directed to identify: 1) physicians who personally practiced complementary/alternative medicine, and perceived needs, 2) physicians who referred patients for unconventional therapies either inside or outside of the UPHS and 3) patient self-referrals. The results are shown graphically in the table at right. The questionnaires identified virtually no research in progress that would pass critical review by a scientifically oriented Western medical journal or NIH study section.

Conclusions and Recommendations

The Conclusions and Recommendations fall into four categories: General, Clinical Practice, Education and Research.

I. General

1. Conclusion--The Commitment to Scientific Medicine
The Academic Medical Center must continue to practice scientific (evidence-based) medicine.: 1. Recommendation; Traditional approaches for evaluating traditional Western medicine will be applied to unconventional and unproven therapies considered for inclusion in the practice of conventional medicine.
2. Conclusion--Response to the Charge
Certain unconventional therapies, currently lumped together under the rubric of "Alternative/Complementary" medicine, should be evaluated with respect to incorporation into the programs of the UPHS. Each should be evaluated separately with respect to its potential clinical, research and educational role(s).: 2. Recommendation; An appropriate administrative structure to undertake such appraisals should be created.
3. Conclusion--Definitions and Terminology
The term "alternative medicine" is ambiguous, encompassing a wide variety of unconventional (and generally unproven therapies), which differ greatly in potential for harm, efficacy and cost-effectiveness. None of the so-called "alternative therapies" provides an alternative to conventional medicine.
Systems of unconventional medicine, such as homeopathy or Ayurveda, may be topics for research and education but not for clinical practice unless they satisfy criteria for scientific medicine.: 3. Recommendation; The designation "complementary" is preferable to "alternative" for unconventional therapies that are to be evaluated with respect to clinical practice, research and education in the UPHS.
4. Conclusion--Working Group to Steering Committee
Until now, the Office of the Associate Dean for Program Development has collaborated with the Office of the CEO/Dean, in defining the role of complementary therapies in the Academic Medical Center and Health System. Plans should be made for implementation of the recommendations of the Working Group.: 4. Recommendation; The Working Group should be modified to constitute a Steering Committee to facilitate evaluation and implementation. The Steering Committee will be concerned with program development, serve as advisory to Medical Affairs, Human Resources, Legal Affairs, Heads of Departments, Centers and Institutes and similar entities. The Associate Dean for Program Development will serve as Chair of the Steering Committee. The Steering Committee, which will include experts in complementary therapies, will evaluate proposals referred to it.

II. Clinical Practice

5. Conclusion--Categorizing So-Called "Complementary" Therapies
While recognizing consumer-driven demand for unconventional therapies, the Academic Medical Center should not be pressured into uncritical adoption of such practices. Instead, each proposed therapy should be evaluated for its readiness for clinical practice, research and/or education.: 5. Recommendation; In evaluating the use of complementary therapies, distinctions should be drawn between harmless therapies and potentially hazardous therapies.

6. Conclusion--Apply Existing Mechanisms for Individual Privileges
The process for evaluating a proposed therapy should be basically the same for complementary therapies as for conventional therapies except for the addition of the Steering Committee as a review group.: 6. Recommendation; The offices of Medical Affairs, Human Resources and Legal Affairs should perform the same functions for assessing competency in the various complementary therapies as for conventional medicine. Complementary therapies practiced in the UPHS should undergo review in accord with policies and guidelines developed by these offices. The Steering Committee will serve in an advisory capacity to these offices.

7. Conclusion--Expert Advice
The offices of Medical Affairs, Human Resources and Legal Affairs have had little, if any, experience in setting guidelines and standards of competency in complementary therapies.: 7. Recommendation; Once the Steering Committee is established, it should serve as a deliberative and advisory group to these offices.

8. Conclusion--A Virtual Center
It would be ill-advised to attempt to concentrate complementary therapies under one roof. However, concentrations of therapies could be offered at different sites.: 8. Recommendation; Complementary medicine should be organized as a "virtual center" so that standardized practices could be accomplished at the different inter-linked sites.

9. Conclusion--Dissemination of Information
As complementary therapies are introduced into the UPHS, information about their availability should be provided to patients, physicians and other interested parties.: 9. Recommendation; The UPHS should initiate a continuing educational program for all concerned about the availability of complementary therapies. For this purpose, printed materials, the Penn Web page and PennNet would be useful. Marketing can play an important role in dissemination of information.

III. Education

10. Conclusion--Educational Needs
Medical students, house staff and practicing physicians are not well-informed about complementary therapies. Need exists to educate physicians about the nature and content of unconventional therapies that their patients are using and to instruct them to be critical in their use.: 10. Recommendation; Instruction about complementary therapies should be part of the medical curriculum and available as electives. Instruction should also be available for house staff and practicing physicians.

IV. Research

11. Conclusion--Proven or Research
Research into unconventional medicine should follow the same guiding principles and scientific criteria as those for conventional medicine.: 11. Recommendation; The same criteria and guidelines should be used for unconventional and conventional (scientific) therapies. Unproven therapies may constitute opportunities for research.

12. Conclusion--Encourage Research
The Academic Medical Center provides ample opportunity for research in complementary medicine. On the one hand, is the large number of practicing physicians to participate in clinical outcomes trials; on the other, are the clinical and basic science departments, to explore mechanisms.: 12. Recommendation; The Steering Committee should encourage research in complementary therapies. Advantage should be taken of opportunities provided by the new "Center for Complementary and Alternative Medicine" of the National Institutes of Health, which is affording funds for such research.

13. Conclusion--Research Training
As a rule, practitioners of unconventional therapies have had little training or experience in research. The University affords ample opportunities in research training.: 13. Recommendation; The UPHS should encourage research into selected unconventional therapies. In doing so, advantage should be taken of the many opportunities for such training in clinical and basic science departments, in the Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, in other components of the University, e.g. The Leonard Davis Institute, the Wharton School, and in various offices engaged in health services research.
14. Conclusion--Seed Money
There is a critical shortage of faculty at Penn interested in, or trained in, research into complementary medicine. This shortage affects multiple departments and centers and affects the ability of the institution to attract research funding. This shortage exists despite the remarkable capabilities of the institution, e.g., the Center for Clinical Epidemiology and Biostatistics, the Department of Biostatistics and Epidemiology, basic science departments, the Leonard Davis Institute, to train personnel and to pursue research.: 14. Recommendation; Seed money is needed to initiate the program. One approach is by a cooperative venture involving the UPHS and interested departments and centers, to develop research and practice along interdepartmental, interdisciplinary lines.

Working Group

A.P. Fishman, M.D. Chair Patrick LaRiccia, M.D.

Michael Baime, M.D. Gail Morrison, M.D.

Michelle Battistini, M.D. Sandra A. Norman, Ph.D.

Stanley Baum, M.D. Richard G. Petty, M.D.

Marjorie A. Bowman, M.D., M.P.A. Brian L. Strom, M.D., M.P.H.

Mr. Peter L. DeAngelis, Jr. Richard L. Tannen, M.D.

Ms. Gail Di Giambattista John M. Templeton, M.D.

Jack Ende, M.D. Linton Whitaker, M.D.

John H. Glick, M.D. Paul Root Wolpe, Ph.D.

Clinical Practices Focus Group

A.P. Fishman, M.D. Chair Ms. Gail Di Giambattista

Michelle Battistini, M.D. Jack Ende, M.D.

Michael Baime, M.D. John H. Glick, M.D.

Stanley Baum, M.D. Patrick J. LaRiccia, M.D.

Marjorie A. Bowman, M.D. Richard G. Petty, M.D.

Michael Cirigliano, M.D. Paul Root Wolpe, Ph.D.

Mr. Peter L. De Angelis, Jr.

Education Focus Group

Gail Morrison, M.D., Chair Lisa Hark, Ph.D., R.D.

Michael Baime, M.D., in absentia Priya Kumar, M.S.III

Marjorie Bowman, M.D., M.P.A. Lorna Lynn, M.D. in absentia

Michael Cirigliano, M.D. Joseph Pace, M.S. IV

Wayne Diamond, N.D. Richard Petty, M.D.

Joshua Frank, M.S. II Lynn Seng, M.S.Ed.

MaryLou Galantino, PT, Ph.D. Anthony Sun, M.D.

Research Focus Group

Brian Strom, M.D., M.P.H., Chair J. Richard Landis, Ph.D.

David Asch, M.D. Barbara Medoff-Cooper, Ph.D.

Marjorie Bowman, M.D. Richard Petty, M.D.

John Farrar, M.D. Richard Tannen, M.D.

Almanac, Vol. 46, No. 13, November 23/30, 1999

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