Complementary & Integrative Medicine in Primary Care

Complementary or Alternative?

Many Americans—more than 30% of adults and about 12% of children—use health care approaches that are not typically part of conventional medical care or that may have origins outside of usual Western practice. Many terms are used to describe these approaches, including “alternative” and “complementary”, but these terms are distinct:

  • If a non-mainstream approach is used together with conventional medicine, it’s considered “complementary”
  • If a non-mainstream approach is used in place of conventional medicine, it’s considered “alternative”
  • An “integrative” approach brings conventional and complementary approaches together in a coordinated way

The remainder of this post will focus on complementary and integrative medicine (CIM). Complementary approaches can be classified by the type of therapy:

  • Nutritional (e.g., special diets, dietary supplements, herbs, and probiotics)
  • Psychological (e.g., mindfulness)
  • Physical (e.g., massage, spinal manipulation)
  • Combinations such as psychological and physical (e.g., yoga, tai chi, acupuncture, dance or art therapies) or psychological and nutritional (e.g., mindful eating)

Common CIM approaches among adults include dietary supplements, deep breathing, yoga, tai chi, qi gong, chiropractic or osteopathic manipulation, meditation, massage, special diets, homeopathy, progressive relaxation, guided imagery, etc.

Creating an Evidence-Based Toolkit

Key points:

  • Be the one to open the conversation (recognizing availability of time and comfort in doing so)
  • Be open-minded in your approach
  • Focus on the integrative aspect of CIM

Creating a Framework:

Some CIM approaches may be less familiar to us. As such, we need a framework in considering these therapies:

  • Do we know what the therapy is?
  • Is it harmful?
  • Is it beneficial? Is this beneficial for something other than the chief complaint?
  • Does it require engagement with a licensed professional?
  • Is our patient at risk of being taken advantage of?
  • Is there a “correct” way to do the therapy? (i.e., Is training required?) 
  • Is the financial cost proportional to the potential benefit?

Assessing Benefit:

The National Center for Complementary and Integrative Health (NCCIH), part of the NIH, is the federal government’s lead agency for scientific research on complementary and integrative health approaches. It conducts research and provides information about complementary health products and practices.

NCCIH has links to a variety of clinical guidelines related to CIM, including

Another great resource to explore CIM literature is through PubMed’s Medical Subject Headings (MeSH), which includes complementary therapies. This category includes a host of subheadings such as acupuncture, cupping therapy, dry needling, homeopathy, mind-body therapies (e.g., aromatherapy, hypnosis, meditation, etc.), sensory therapies, and spiritual therapies, among others.

Other Considerations:

There is no standardized national system for credentialing CIM providers. State governments are responsible for deciding what credentials practitioners must have to work in that state, leading to substantial variety. For instance:

  • Chiropractors: In all 50 states and the District of Columbia, practicing chiropractors must be an accredited Doctor of Chiropractic (D.C.) and must pass special state or NBCE exams.
  • Naturopathic physicians: Only 17 states and the District of Columbia license naturopathic physicians. In general, licensure requires graduating from an accredited 4-year school of naturopathic medicine and passing a postdoctoral board examination.
  • Massage therapists: Most states regulate massage therapists by requiring a license, certification, or registration. Training standards and requirements vary by state, but most states that regulate massage therapists require a minimum of 500 hours of training.

Unfortunately, fraud is common within CIM. Legitimate CIM providers typically have easily available information regarding their education/training, experience, certifications, and licenses; they are open to communicating/coordinating with us as primary care providers and have a track record of telling patients their comfort with a disease/symptom; and they often take insurance.

Cost is another important consideration, raising a number of questions for patients:

  • Is this therapy covered by my insurance?
  • Does it require a prior authorization? prescription? referral?
  • Are there in-network providers?
  • What is the out-of-pocket cost if not covered by insurance? Is sliding-scale available?
  • Do I need to file a claim with my insurance?
  • Can I use my FSA/HAS toward this therapy?
  • Are there any hidden fees?

Take-Home Points!

  • CIM is distinct from alternative medicine, and encompasses a variety of therapies
  • Patients may not readily disclose their use of CIM. As such, we should open the conversation by being open-minded and humble in our exploration of this topic with patients.
  • Utilize available resources, including those through the NCCIH and PubMed, to make evidence-based decisions in discussing CIM

Blog post based on Med-Peds Forum talk by Anu Goel, PGY2

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