Does Integrative Medicine Really Work?

Sixteen years after Northwestern Memorial became one of the first U.S. hospitals to offer conventional and alternative medicines, questions remain about the latter treatments’ efficacy.

Illustration by Tim Foley

Illustration: Tim Foley

Approach a certain address on Huron Street a few blocks from Lake Michigan, and past the receptionist area you enter a world of gently curving feng shui–approved walls painted in soothing tones of light green and yellow. A recording of flute music plays quietly in the background. Doors are adorned with signs that say things like “Nature,” “Harmony,” “Peace,” and “Believe.”

A high-end spa? The site of a Buddhist retreat? Nope: the offices of Northwestern Integrative Medicine.

Backed by one of the nation’s best hospitals, Northwestern Memorial, this health center is as unconventional as it looks. It dishes out a combination of modern medicine and complementary and alternative medicine (CAM), which includes acupuncture, biofeedback, massage, Reiki, and Chinese herbal remedies. (For descriptions, see “What It May Cost You.”) “Many alternative therapies have immense benefit for patients,” says Melinda Ring, a stylish board-certified internist and Reiki master who has been Northwestern’s integrative medical director for the past six years.

What’s really immense is the demand for unconventional treatments. According to 2007 data (the most recent available) from the Centers for Disease Control and Prevention, 38 percent of adults turned to CAM that year, spending nearly $34 billion. No surprise, then, that the percentage of U.S. hospitals offering such treatments has zoomed: from 14 percent in 2000 to 42 percent in 2010, according to the American Hospital Association. In the Chicago area, integrative medicine is also offered by Rush University Medical Center and NorthShore University HealthSystem, among others.

There’s just one problem: Most alternative treatments haven’t been scientifically proven to work. At least not yet. So health insurers, which demand evidence of efficacy, refuse to cover most of them.

The hope was that hospitals and others would fix the lack of proof by conducting rigorous clinical trials. In 1992, the National Institutes of Health created the Office of Alternative Medicine (now the Center for Complementary and Alternative Medicine) to conduct and fund just such research. Two decades later, few of the treatments studied look to perform much better than placebos.

Yet hospitals seem loath to curb what have become big crowd pleasers. The situation raises important questions about what role medical institutions should play in the prevention and treatment of disease. Hospitals are supposed to deliver care that works, say critics such as Paul Offit, head of the Division of Infectious Diseases at Children’s Hospital of Philadelphia and author of the buzzed-about new book Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine. Isn’t that the point?

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Americans’ growing demand for a more holistic approach to health care is easy to understand. Modern medicine is geared toward treating illness when it occurs, patching people up and sending them on their way. But that’s not necessarily the best way to manage chronic conditions such as arthritis, sinusitis, and fibromyalgia, as Deepak Chopra, Andrew Weil, and other progressive doctors started pointing out a couple of decades ago. What’s more, thanks to increasing pressure on physicians to move quickly from patient to patient, many began spending less time talking to people about ways they can get healthier by reducing stress, exercising, or eating better.

Around this time, says Daniel Derman, president of the Northwestern Memorial Physicians Group, “we were approached by one of our doctors who said, ‘[Integrative medicine] is a passion of mine I’d like to pursue.’ ”

That doctor was Theri Raby, a charismatic internist who had trained in both Western and alternative medicine and who championed the idea that integrating them could better care for “the whole person.”

In 1997, Derman’s group greenlighted what was initially called the Center for Integrative Medicine at Northwestern Memorial Hospital, with Raby at the helm. (She left in 2008 to start a separate for-profit practice called the Raby Institute at Northwestern.) Lots of consumers of modern medicine were seeking out alternative treatments anyway, the thinking went, so why not offer them both under one roof? “The use of [alternative] therapies is so much higher than what [patients report] to their doctors,” Derman explains. “[With an integrative center] we have an outlet for people so they don’t have to go elsewhere.”

Such practical considerations were influencing hospital bigwigs around the country too. According to a 2010 survey by a unit of the American Hospital Association and the Samueli Institute, a think tank that funds alternative medicine research, administrators—not doctors—were the main forces behind opening integrative medicine centers. The most frequently cited reason? Patient demand.

The danger of that rationale is that doctors can become like waiters in a restaurant, says Offit. “I don’t think we should just give [people] what they want because they want it. They’re not patrons. They’re patients.”

Also unenthusiastic about the trend were many conventional doctors, including Thomas Green, chief of pediatrics at Lurie Children’s Hospital. “When we talk about things like homeopathic medicine or chiropractic or whatever, we’re largely talking about proposals for treatment to families and children that have not been proven to be efficacious and have oftentimes failed in comparison to conventional means,” he says. “We don’t want to cross a line where we don’t know the balance of risks and benefits.”

David Gorski, a surgeon at Detroit’s Barbara Ann Karmanos Cancer Institute who edits the blog Science-Based Medicine, became perhaps the bluntest critic of all. Gorski calls alternative medicine “pseudo science,” acupuncture “the gateway quackery,” and naturopathy “a hodgepodge of the somewhat reasonable and the pure nonsense.” He says, “I think that the lack of a need to have to collect insurance and the ability to charge whatever the market will bear are very tempting [to hospitals].”

Gorski has no objection to people getting a massage, for example, if it makes them feel better. “Just don’t call it medicine.”

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As the years passed, study after study was showing showed that certain alternative treatments don’t, in fact, work significantly better than dummy pills. Saw palmetto, used in herbal medicine to help men with urologic problems? Research by Kevin McVary, one of the first doctors at Northwestern’s integrative center (he’s now chairman of urology at Southern Illinois University), revealed that it did no better than a placebo in lowering prostate-specific antigens or improving urinary tract symptoms. Likewise, “we could not demonstrate that ginkgo was helpful to slow cognitive decline,” says Josephine Briggs, director of the National Center for Complementary and Alternative Medicine. “We could not demonstrate that Silybum marianum [milk thistle] is a successful treatment for liver disease.”

She adds, “We are full believers in science-based medicine. . . . Ideally, public health dollars should be spent on things that work.”

So what alternative treatments have been scientifically proved to work by a substantial body of methodologically sound, peer-reviewed studies that demonstrate results statistically superior to placebos? Pretty much the only one that all sides can agree on is acupuncture, and then only to treat chronic pain or certain kinds of nausea. (Smaller groups of studies have shown that biofeedback can be effective for some conditions and that massage can help relieve labor pain.)

Yet even acupuncture, Offit believes, makes some patients feel better thanks to the placebo effect: Some treatments work simply because patients believe they will. He notes that acupuncture was created by the ancient Chinese, who did not have special insight into the human anatomy. “They thought there were 365 parts of the body because there were 365 days a year. The reason there were 12 needles is there are 12 rivers in China. . . . You can argue that [acupuncture’s effectiveness] has nothing to do with your ‘vital energy tree’ but everything to do with the perception you’re getting better. And that belief is important. You can learn to release your own endorphins. That’s great. Conventional healers don’t realize how powerful placebo medicine can be.”

When asked to respond to criticism that some treatments she prescribes are little more than hocus-pocus, Ring does not answer the question directly. “The issue of whether CAM therapies are just placebo raises the question as to not just how significant are the effects of the treatment, but as importantly, are we using the right tool to study the effect?” she said in an e-mail.

OK, but should hospitals offer services that are not scientifically proven? Ring doesn’t see the harm: “The potential risk of someone engaging in meditation or energy healing, as long as they do so alongside needed Western medical treatments, is extremely low.”

As for alternative supplements, “we have different genetic makeups,” she argues. “Our ability to metabolize and detoxify both medications and supplements varies from person to person. There are so many reasons why an individual might respond even though a study is negative [on a supplement’s effectiveness].”

Kevin Berry, vice president of military medical research at the Samueli Institute, also stresses individual responses. “It’s not necessarily a finding in your blood sample” that pinpoints whether a treatment is effective, he says. “It’s how it works for the person and how they perceive that they’re doing.”

It may sound odd to judge a medical approach on patient perception rather than on health outcomes. But according to the 2010 AHA/Samueli survey, that has become the most common standard by which institutions evaluate the success of integrative medicine programs.

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Despite the naysayers, a push by integrative medicine doctors for greater legitimacy in the health establishment has borne fruit. In June, one of the national bodies that award board certification—the American Board of Physician Specialties—announced that it will begin accrediting integrative doctors next year. The American Board of Medical Specialties, a more prestigious group, still does not certify integrative medicine. But “it’s still a big deal,” Ring says.

What’s more, last year the American Medical Association quietly dropped this line from its official policy: “There is little evidence to confirm the safety or efficacy of most alternative therapies.” An AMA spokesperson declined to comment.

Even formerly unsupportive physicians are coming around now, according to Leslie Mendoza Temple, the medical director of NorthShore’s integrative medicine program. They may have been “the last to accept us,” she says. But these days, “anyone who hasn’t [accepted IM] isn’t really speaking up about it.”

Meanwhile, Northwestern Integrative Medicine has become an unqualified success. In October, it will host a trifecta of national conferences: the annual meeting of the Consortium of Academic Health Centers for Integrative Medicine, the National Student Conference in Integrative Medicine, and the International Congress for Clinicians in Complementary and Integrative Medicine. And it’s in the midst of conducting several studies on the efficacy of approaches such as reflexology, yoga, and meditation, including one partially funded by the American Cancer Society.

Derman says that NIM’s revenues grew 33 percent from 2009 to 2012, though he declines to give a dollar figure. Ring says: “We are not a liability to the hospital.” (While about half of all U.S. hospitals, including Northwestern Memorial, are nonprofits, IRS rules do not prohibit them from taking in more money than they spend. Northwestern’s net income—revenue minus expenses—was $270 million in 2011, more than any other hospital in the area, according to Crain’s Chicago Business.)

Speaking of money: While nearly three-quarters of NIM’s patients are women, and its prices for alternative treatments can add up (see “What It May Cost You,” on the next page), Ring dispels any notion that NIM caters primarily to affluent spa lovers. “I wish you could have seen our waiting room this morning,” she says. “It was all ages, all races, all socioeconomic factors.”

Thanks in part to $2 million in donations to NIM over the past five years, Ring says, subsidized services are available to patients who cannot otherwise afford them. A gift from the philanthropist Abra Prentice Wilkin covers free acupuncture and massage for Northwestern’s chemotherapy patients. “Even for people who have to pay out of pocket for supplements,” Ring says, “[costs] may be less than the copay for medication or surgery.”

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With 10,000 patients last year and a projected 1,000 more in 2013, NIM is rapidly outgrowing its current 10,000-square-foot digs, despite recently opening an outpost in Lincoln Park. Ring says she plans to expand to a to-be-determined location in 2014. She might be wise to retain the gentle earth tones and flute music. “Welcoming and peaceful and serene” is how Gabriela
Cleveland, a 52-year-old lawyer and longtime patient, describes NIM’s offices.

Even some people for whom acupuncture didn’t work—such as Linda Difino, 50, who turned to it earlier this year in an effort to minimize the side effects of chemotherapy—wind up enjoying what NIM has to offer. “She wasn’t in a hurry,” Difino says of her acupuncturist. “She was very genuine and caring. We talked.”

Such anecdotes suggest that what people are craving may not be the treatments themselves so much as the soothing atmosphere and extra time that integrative practitioners tend to provide. “There has to be another way [for conventional medicine] to bring back the personal touch and more attentiveness to patients,” Gorski laments.

If it can’t, integrative medicine—the issue of scientific proof notwithstanding—looks unlikely to lose steam.

NEXT: What It May Cost You »

 

What It May Cost You

There’s no skeptic like a health insurer. Here are 10 treatments or approaches often used by integrative doctors, what Northwestern Integrative Medicine (Chicago’s leading practice) typically charges for each, and whether Cigna (the largest health insurer with clear, consistent guidelines) covers them in its standard policies.

TREATMENT WHAT IT IS COST1 COVERED?2
Acupressure Using finger pressure to stimulate specific points along the body to enhance energy flow, thereby relieving pain or treating disease $90 for a 30-
to 60-minute session
No. According to four different studies, acupressure showed “no statistically significant effects” versus placebo.
Acupuncture Like acupressure, but with needles inserted into the skin $90 for a 30-
to 45-minute session
Yes, but only to treat certain kinds of pain, nausea, and vomiting: “Peer-reviewed scientific literature” shows effectiveness for those conditions.3
Ayurveda Ancient Indian approach that focuses on restoring the body’s balance through lifestyle changes, including diet, and herbal remedies E.g., $112 for one hour of Ayurvedic massage No. “Considered
experimental, investigational,
or unproven.”
Biofeedback Electronically monitoring basic bodily functions (e.g., breathing, blood pressure) and teaching the patient to control them $204 for a session Yes, but only “for the treatment of constipation, urinary incontinence, and migraine and tension headaches.” 4
Chinese herbal
medicine
Prescribing any of dozens of herbs (e.g., black cohosh, ginkgo, milk thistle) to treat various ailments Price varies No. For instance, research
on ginkgo “for cognitive impairment and dementia . . . [resulted in] overall no significant differences.”
Homeopathy Giving tiny amounts of substances that in larger doses would cause the very health problem from which the patient suffers $75 for a 30-
to 60-minute appointment
No. In studies, “firm conclusions about the safety and efficacy of homeopathy” could not be made.
Massage Kneading the body’s soft tissues or the internal muscular viscera to relieve tension and pain and improve function $112 for one hour No. “Considered experimental, investigational, or unproven.”
Meditation Guiding the patient to quietly focus the mind to relax and promote health $250 for six one-hour group sessions No. “Considered experimental, investigational, or unproven.”
Naturopathy Prescribing natural treatments (e.g., hydrotherapy, joint manipulation, nutritional supplements, herbs) to promote healing $105 for a 30- to 45-minute appointment No. For instance, studies on how naturopathy may affect endometriosis pain “were of poor methodological quality.”
Reiki Putting hands on or just above the body while channeling energy to heal the patient’s spirit—and, as a result, the body $112 for one hour No. “A definitive conclusion regarding the effectiveness of Reiki could not be established.”

NOTES: 1. AVERAGE CHARGE AT NORTHWESTERN INTEGRATIVE MEDICINE. 2. BY CIGNA’S STANDARD POLICY. 3. IF DEEMED MEDICALLY NECESSARY FOR NAUSEA AND VOMITING ASSOCIATED WITH PREGNANCY, CHEMOTHERAPY, OR RECENT SURGERY; MIGRAINE OR TENSION HEADACHE; PAIN IN THE NECK, LOW BACK, OR AN OSTEOARTHRITIC KNEE; OR POSTOPERATIVE DENTAL PAIN. 4. ONLY IF PERFORMED BY A LICENSED HEALTH CARE PROFESSIONAL AS MEDICALLY NECESSARY FOR THESE CONDITIONS; EEG BIOFEEDBACK EXCLUDED. SOURCES: CIGNA; NORTHWESTERN INTEGRATIVE MEDICINE
 

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