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1998 / Vol 2, No 2

Comments from the Journal EditorsAbstracts from articles published in other journals
Clinical articles on the practice of Permanente medicinePermenente Medical History
Poetry, Art, Musings from Permanente clinicians
Nonclinical articles on external issuesOriginal ResearchArticles from a Systems perspective
Book Reviews lighter side of medicineLetters to the editor












Complementary and Alternative Medicine Comes to Kaiser Permanente | to pdf >>
by Lydia S. Segal, MD


This edition's Systems Challenge puts an extremely important and yet highly controversial issue on the table for discussion. Few topics evoke such a diverse, emotional response among Permanente physicians and other providers than that of the application of alternative medicine. We all agree that we need to ask the question about the medical appropriateness of each modality. However, there are other questions. With several managed care organizations offering alternative therapies, is it a strategic question as to whether we need to redesign our benefit plans to remain competitive? As leaders in health care delivery, Permanente clinicians clearly need to get involved in the dialogue and strive to understand the value of these "new" modalities and integrate them into our practices when appropriate. As advocates for our members, proven quality must be our foremost concern before we attach our "Permanente" label of approval to any alternative modality. Studies are needed; debate and dialogue within the Permanente Community is needed. I believe that this System Challenge will encourage such a dialogue.
- Lee Jacobs, MD, Associate Editor

Acupuncture, chiropractic, massage therapy, and herbal medicine: these are some of the forms of alternative medicine that are starting to make inroads into Kaiser Permanente (KP). Dissatisfaction with conventional medicine in treating some chronic conditions and a move toward wellness are driving both patient and provider to seek broader treatment modalities than are currently offered in allopathic, traditional medicine. Different regions of KP are independently creating alternative medicine offerings in response to member and provider demands.

Complementary and alternative medicine (CAM) first became recognized as a major player in health care delivery when David Eisenberg et al published their 1993 New England Journal of Medicine study.1 This landmark article demonstrated that one-third of his survey population used some form of CAM treatment, spending 13.8 billion dollars--mostly out of pocket--during the study year. This figure exceeded the total amount spent on inpatient hospitalizations for the same period. KP members demonstrate the same usage patterns discovered by Eisenberg et al: somewhere between 20 and 33% of members are either interested or are actively using some form of CAM therapy. This has been validated in three different internal studies over the past several years (Gordon in Northern California [unpublished material], Whitlock2 in the Northwest, and the Starr Member Satisfaction Study in Mid-Atlantic3). The recently released KP Consumer Segmentation Report4 from National Communications, Marketing, and Sales Development found that about 20% of those surveyed (non-Kaiser Permanente members) would be interested in joining a health plan that covered alternative methods, suggesting that Kaiser Permanente members are no different then the general population in their interests and usage patterns. Regional differences exist as to which CAM modality is most popular.

Complementary and Alternative Medicine Defined
So, what is alternative medicine? The NIH Office of Alternative Medicine defines a broad range of healing philosophies, approaches, and therapies as those forms of medicine not traditionally taught in medical school.5 These modalities may be used alone, often referred to as alternative, or in combination with other alternative therapies or with traditional allopathic therapies, often referred to as complementary or integrative. CAM modalities generally include manual therapies (osteopathic, chiropractic, and therapeutic massage), acupuncture and acupressure, mind/body medicine (eg, meditation, guided imagery, stress reduction), biofeedback and hypnosis, nutritional therapies (supplements, diets), herbs, homeopathy, movement (yoga, tai chi), and self-help groups. For a more detailed description, see Marie Mulligan's (Kaiser Permanente, Santa Rosa, CA.) excellent review below.

The Provider Perspective
Provider resistance is slowly changing as a growing body of scientific evidence becomes available. For example, in November 1997 an NIH consensus panel made recommendations on the use of acupuncture based on a review of articles which they determined merit scientific credibility.6 These included treatment for nausea and vomiting after chemotherapy, nausea due to pregnancy, and postoperative dental pain. Other conditions such as headaches and back pain were considered likely to be helped with acupuncture, but the data were insufficient for a full endorsement. Proponents suggested that the acupuncture process probably releases endogenous opioids, whereas skeptics felt results were solely due to the placebo effect. However, the NIH consensus statement added validity to acupuncture, making it more acceptable to some of those providers who had been previously hesitant.

Aside from many providers still being reluctant to use these modalities, many are unaware which therapies might offer benefit to patients. In some markets where new benefits include CAM modalities, educational seminars are often being offered to providers.

Lastly, providers may be unaware that their patients are seeking care in the CAM arena, because many patients do not tell them. In her 1997 study, Gordon found that only approximately 25% of providers asked their patients if they used some form of complementary and alternative medicine. She also noted that 20% of patients who used CAM modalities did not tell their provider. This lack of communication between patient and provider can easily create therapeutic dilemmas when patients are using a CAM modality of which their provider is unaware.

The Patients Who Use CAM
Traditional high-technology Western medicine excels in the treatment of acute illness and injury, whereas CAM's strong hand is in treating the following three populations of patients, who tend to be the highest utilizers of CAM:

  • The chronically ill
  • The chronic pain patient
  • The patient seeking wellness/prevention

The dichotomy between CAM and traditional Western medicine is starting, however, to merge into a field currently coined Integrative Medicine. Here the best of both modalities are used together. As an example, low back pain patients use acupuncture or chiropractic care along with their NSAIDs. In another example, headache patients can use lower doses of their medications because these patients are trained in meditation.

Kaiser Permanente Across the Country
Table 1 is a partial listing of KP providers from different Regions who are active in research, education, and health care delivery. Many have chronic pain programs that act as a springboard in providing CAM services. Many Health Education Programs in different Regions also provide "wellness" classes in such fields as yoga, tai chi, and meditation.

After speaking with numerous providers within KP, and CAM providers outside the Program, I would make the following recommendations:

  1. Internalize services where possible.
  2. Provide an integrated format so providers of different types can evaluate patients as a team. The language barrier is much greater between an acupuncturist and an internist than between an orthopedic surgeon and an internist.
  3. Include mental health/behavioral medicine and self-help group models to empower patients' awareness of their ability to manage their own health.
  4. Create an interregional task force/network for providers to create best practices in this newly emerging field (see sidebar at the conclusion of this article). Include on the task force interested health plan administrators who would strengthen our position in the marketplace and provide a basis for coordinated care.

We need to continue exploring methods of integrating the most valuable aspects of complementary and alternative medicine into our operations. A collaborative effort between the Medical Group and the Health Plan both nationally and locally will demonstrate Kaiser Permanente as taking a lead in change in the ever-evolving world of health care.

1. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional Medicine in the United States: Prevalence, costs, and patterns of use. NEJM 1993;328(4):246-252.
2. Whitlock E, Russell A. "1995 Current Membership Study" Center for Health Research, Portland Oregon.
3. Segal LS, Evans DL. "1997 Starr Member Satisfaction Survey Results of the Mid Atlantic Region" Permanente Medical Group, Mid-Atlantic Region.
4. Swanson K. "Consumer Segmentation Report" National Marketing, Sales and Business Development, Dec. 1997, Oakland CA.
5. National Institute of Health Office of Alternative Medicine. June 1996, General Information Package: Statement on Alternative Medicine, .
7. NIH Consensus Statement on Acupuncture, November 1997 3-5;15(5). In press. Also available on the NIH-OAM website.

Guide to Alternative Medical Practices and Alternative Medical Systems

By Marie Mulligan, MD; Kaiser Permanente Medical Center, Santa Rosa, California

Alternative Systems of Medical Practice
Acupuncture involves stimulating specific anatomic points in the body for therapeutic purposes by using acupuncture needles, moxa, impulses of electromagnetic energy, friction, suction, or pressure. Acupuncture is used to regulate the flow of chi to restore health, and is part of the therapeutic armamentarium of traditional Chinese medicine.

Traditional Chinese Medicine
This is a complete medical system which has diagnosed, treated, and prevented illnesses for over 23 centuries. There are 4 basic branches to Chinese medicine: herbalism, food cures, acupuncture, and manipulative therapies. Herbalism and food cures are part of the system of internal medicine. Acupuncture and manipulative therapies are included in the system of external medicine. Diagnosis involves observation, history taking, palpation of radial pulses, observation of the tongue, and palpation of sensitive body parts.

This is India's natural system of medicine which has been practiced for over 5,000 years. Ayurveda provides a complete, integrated approach to the treatment and prevention of illness by dealing with imbalance and stress in the individual's consciousness, attending to diet and digestive issues, using breath and movement therapies including pranayama and yoga, and using numerous herbal and mineral medicines.

Homeopathic Medicine
Homeopathy is based on the work of Samuel Hahnemann, a German doctor who founded this healing system in the 18th century. Homeopathic substances are medicines that when used in large doses will produce symptoms in a healthy person that will cure these identical symptoms in a sick person. Additionally, homeopathic medicines are diluted to concentrations that are sometimes lower than avogadro's number. Critics of homeopathy contend that such extreme dilutions are beyond the point at which any active molecules can be found in the medicine. However, homeopathic practitioners suggest that there may be energetic reasons why these remedies may be effective. Homeopathic medicine is practiced worldwide, especially in Europe, Asia, and Latin America.

Naturopathic Medicine
Naturopathic medicine is an American health care profession that is nearly 100 years old. It incorporates use of herbal or botanical medicine, home
opathy, and chiropractic. Naturopathic providers are in many ways the family practitioners or generalists of Western alternative medicine. Naturopaths attempt to assist the body's innate healing properties, without the use of pharmaceutical medicines whenever possible.

Environmental Medicine
Environmental medicine is a very controversial alternative modality. It is an extension of conventional western medicine. Practitioners are MDs who believe that many common foods and chemicals trigger the onset of acute and chronic illness, even when the exposure is at low levels. They frequently work with diet, especially elimination diets, and use megavitamin therapy, including megadoses of vitamin C. They also use a variety of other nonconventional pharmaceutical and biological treatments, including chelation therapy.

Christian Science
People involved in Christian Science healing are usually members of the Christian Science Church. Prayer and attitudinal healing are the main focus in this system.

Anthroposophical Medicine
Anthroposophical medicine is an extension of conventional Western medicine, with its roots in the philosophy of Rudolph Steiner. Herbal medicine and homeopathy are also incorporated into this system.

Mind/Body Medicine
Meditation is a practice for relaxing the body and mind that involves focusing the attention on different objects. Concentration practices can involve focusing on a sound, a repeated word or mantra, visual image, or body sensation. Mindfulness meditation involves attending to the sensations of breathing to cultivate concentration and calming of body and mind. Once some relaxation has occurred and some concentration has been developed, the person then directs their attention to whatever thought or emotion might arise with a nonjudgmental attitude. Various meditation techniques have been demonstrated to be useful in treating stress-related disorders.

Many areas are covered by psychoeducation, including couples communication classes and parenting classes. One of the most powerful areas includes cognitive therapy for treating mild to moderate depression. The person identifies negative automatic thoughts and retrains their mind to reinforce true and helpful thoughts. This technique has been demonstrated to be effective in treating mild to moderate depression and to reduce relapse rates.

There are many schools of psychotherapy. Each addresses a person's emotional and mental health, which in turn can affect physical wellbeing and capacity for self care. Conventional psychotherapy uses a variety of psychologic methods, including psychoanalysis, suggestion, persuasion, and education. All of these therapies can be undertaken either in a group or individual setting.

Yoga has its origins in India. It is a 5,000-year-old practice that includes ethical precepts, dietary prescriptions, physical exercise, and breath work. Yogic meditation has been shown to reduce anxiety levels and to be helpful in treating stress related disorders.

Tai Chi, Chi Goin
Both of these modalities involve movement, breath work, and directing the attention. They arose out of the 4,000-year-old Chinese system of healing and, like yoga, have been found to be useful in the treatment of stress related disorders.

Imagery has been popularized by the Simontons. It is a mental process using thought representing a sensory quality, which can be visual, aural, tactile, olfactory, proprioceptive, and kinesthetic. Imagery has been shown to successfully treat nausea and vomiting associated with chemotherapy and is also successful in treating stress related disorders.

Prayer and Mental Healing
There are several types of prayer. Healing can happen either in the presence of the person being healed, or from a distance. This can involve directed prayer requesting a specific outcome, or nondirected prayer requesting the best possible outcome. Some suggest that this second kind of prayer may be more effective in generating positive outcomes.

Dance, Art, Music, and Movement Therapy
There are many schools of dance, art, music and movement therapy. They are all a means for the patient to foster self awareness, reconcile emotional conflicts, and express unspoken or unconscious concerns about either emotional or physical problems.

Biofeedback uses a variety of monitoring instruments to feedback to the patient physiologic information about which they are normally unaware. It is basically an educational device for patients to gain more control over their psychophysiologic responses to stress.

Hypnotherapy includes the induction of trance states and the use of therapeutic suggestion. Increased relaxation, rapport, internal focus, and receptivity to ego-syntonic suggestions are hallmarks of therapeutic trance states. Hypnosis can be done with groups or individually. It has been shown to be helpful in treating stress-related disorders.

Manual Healing Methods
Chiropractic is concerned with investigating the relationship between structure and function of the human body to restore and preserve health, with an emphasis primarily on the spine and nervous system. Manual procedures and interventions are used to the exclusion of surgical and chemotherapeutic procedures. Recent research suggests that chiropractic treatment can be useful in treating acute low back pain.

Osteopathic Manipulation
Of note is that the majority of osteopathic physicians are involved in primary care. They receive 2,000-3,000 hours of hands-on training in manipulative modalities as part of their education. Classically, osteopaths have focused more on soft tissue problems than chiropractors do.

There are numerous methods of massage therapy. Massage consists of a group of manual techniques to apply fixed or movable pressure to the body. Massage therapists are licensed in 19 states, including California.

Body Work
There are many modalities of body work. Feldenkrais, developed by Moishe Feldenkrais, focuses on sensory motor awareness and teaches patients to both hold their bodies in more healthful postures and to move in new and healthful ways. Somatics is an extension of Feldenkrais developed by Thomas Hanna. The Somatics Institute is located in Novato, California. Its goal is to move the person from amnesia of sensory motor input to an awareness of sensory motor input, which allows the person to have a greater choice in reducing the wear and tear on the body over time.

Rolfing was developed by Ida Rolf and involves deep body work. It works with fascial layers to bring about what is described as "structural integration."

Rosen Body Work
Rosen body work was developed by Marian Rosen, a physical therapist. Her institute is located in Berkeley. The goal of this very gentle body work is to help the person be in touch with the authentic self. The person experiences emotional relief by contacting and releasing emotional contractions held in the body.

Touch for Health
Touch for Health is quite popular among nurses in this country. It can involve touching the person directly or holding the hands out a short distance from the body. It is used primarily for stress reduction.

Reflexology is a body work system that involves massage of the feet with the intention to affect not only the feet, but other parts of the body. It has been shown to be helpful for stress-related disorders.

Physical Therapy
Physical therapy is an example of a modality which has moved into the mainstream. It involves a variety of methods, including hands-on therapy and the use of physical modalities, eg, ultrasound. It is often used to assist injured patients to regain function and to increase their comfort level.

Pharmaceutical "Botanical Medicine"
Botanical and Herbal Treatments
All cultures have a long history of folk medicine traditions. Currently in the West, there is a resurgence of interest in identifying the biologically active agents from botanical sources to treat a variety of conditions; for example, garlic oil for treatment of mild hypertension. The German FDA regulates the use of herbs, and the German Commission E monographs delineate the safety, efficacy, indications, and dosing of herbs. These monographs will be available in English in early 1996.

Nutritional Dietary Therapies
There are a variety of nutritional dietary therapies. The best known include: the very-low-fat diets, including Pritikin, McDougal, and Dean Ornish programs; supplements, including vitamins, plant extracts, and antioxidants. One of the most widely publicized supplement includes melatonin, currently available over the counter and used for jet lag, among other indications.

Aromatherapy is the use of aromatic oils for a variety of conditions and, most often for stress reduction. It is popular among many British nurses to help increase the comfort level of many patients.

Chelation Therapy
Chelation therapy is primarily used by physicians who practice environmental medicine. They use either parenteral or oral chelating agents to treat chronic degenerative conditions. Chelation therapy is shown to be safe; however, its efficacy is hotly disputed.

Community-Based Practices
Native American Indian Healing
Native American Indian healing is a community-based system that uses certain rituals and practices, including sweating and purging (usually done in a sweat lodge), use of herbal medicines, and certain shamanic practices.

Latin American Healers (Curanderos)
Curanderos use a system of folk medicine that includes a model for classifying food, drugs, activity, and illnesses, usually based on whether a condition is hot, cold, dry, or moist. Currently there are no formal effectiveness studies done on this system.

Southeast Asian Folk Medicine
An example of Southeast Asian folk medicine: In Cambodia there are folk healers called kru khmer who are highly respected members of an aristocratic class. They use coining, cupping, herb teas, sauna, and massage to facilitate healing. They are usually trained through apprenticeship. Almost without exception, these healers are older men.


Creation of an Interregional Task Force on Alternative Medicine
A number of people have expressed an interest in developing an interregional task force/network to communicate on issues of benefits, service delivery, and education for providers and for patients. If you are interested in learning, teaching or exchanging ideas, please con-tact Lydia Segal, MD at (703) 536-1487, or via e-mail at









To Spring 1998 Table of Contents >>


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