The responses to "The Futility of Feuding" by both Susan Miller of the Colorado Board of Medical Examiners (CBME) and Dr. Ken Spresser, a respected chiropractor, illustrate the inevitable difficulties encountered when building bridges. On the one hand I must apologize to those who've taken offense at my comments, on the other hand the fact that both sides seem equally offended is encouraging.

There are two central issues that must be addressed when building bridges - improved access and guaranteed safety. The purpose of any bridge is to improve access by providing a path over the obstacles. However, if the bridge is unsafe due to careless engineering and faulty construction, only a few adventurous people will cross the bridge and none will after the bridge collapses and there are casualties. Such a bridge would best never have been built. 

Improved Access

Colorado House Bill 1183 allows physicians to incorporate complementary/alternative medicine (CAM) into their practices without automatically violating the standards of care as defined by the Medical Practice Act. If physicians can incorporate CAM into their practices without fear of professional censure then access to medically supervised CAM will increase. 

The numbers presented by Susan Miller do show that only a small number of physicians using CAM have had encounters with the CBME. Since the number of physicians currently using CAM in their practices is relatively small it seems justifiable to infer that physicians using CAM are not disproportionately sought out by the CBME. However, these same numbers show that the results of encounters with the CBME had a 100% (4/4),adverse outcome for physicians using CAM compared to a 61% (225/368), adverse outcome for physicians not using CAM. Clearly no great statistical conclusions can be drawn from these numbers but it is easy to see how physicians might be a little more nervous about facing the CBME if CAM is part of their practice. House Bill 1183 does not expose the public to physicians practicing sloppy medicine who would use CAM as their plea for immunity from professional censure. 

House Bill 1183 does reduce the fear factor for physicians who would like to incorporate CAM into their practices. Reducing the disincentives (whether real or perceived) for physicians to use CAM will increase the number of physicians willing to help bridge the gap between Western Allopathic Medicine (WAM) and CAM. As Susan Miller pointed out HB 1183 does not enthrone physicians over the CAM kingdom, however it does make it easier to get a green card. 

Safety

Dr. Spresser bristled at the concept of "physician supervised CAM." He correctly observed that physicians should play to their strengths and not dabble in therapies for which they are not adequately trained or qualified. Why should a dabbler have anything to say about how an expert practices their profession? The answer to this objection is that M.D.s and D.O.s are the best qualified professionals in crisis identification and crisis intervention. If you want to build a safe bridge between WAM and CAM it makes sense to have experts in crisis identification and intervention overseeing construction. I'm not saying that CAM is inherently unsafe, in fact in many cases it may be safer than WAM. I am saying that the majority of CAM practitioners are not as well qualified as M.D.s and D.O.s in identifying and handling crises. 

Dr. Spresser tried to assert that chiropractors are the undisputed experts in manual medicine and nutrition. While the vast majority of chiropractors do indeed do a better job with manual medicine than most M.D.s there is a significant minority of D.O.s who are experts at incorporating manual medicine into their practices. It would be presumptuous to think that chiropractors are uniformly better than these D.O.s at manual medicine (or vice versa). On the subject of nutrition, chiropractic training is inconsistent. While there are chiropractors who do become experts in nutrition through elective courses and extra training this does not come automatically with the D.C. degree. Chiropractic training in nutrition is far too variable to make a blanket statement that chiropractors are experts in nutrition.

Integrative vs. Collaborative 

The term "integrative medicine" is being used by many to describe the combination of WAM and CAM. Some practitioners think this means mastering the myriad of therapies available within both WAM and CAM. Such a task would be beyond Herculean - much like one individual trying to build the Golden Gate Bridge without help from anyone else. This type of "integrative" approach attempts to improve access without regard to quality.

On the other hand "collaborative medicine" recognizes the valuable contributions that can be made by expert practitioners of therapies within both WAM and CAM. Using this "collaborative" approach fulfills the essential access and safety criteria needed to build a bridge between WAM and CAM. 

Build It and They Will Come

If we listen to our patients there is no doubt that the bridge between WAM and CAM needs to be built. There are many obstacles that need to be overcome - fear, lack of understanding, professional bias and turf battles to name a few. By reducing the fear factor House Bill 1183 allows physicians to become more involved in the bridge building process. I applaud the Colorado Medical Society and the CBME for removing their opposition to HB 1183 once the wording met with their approval. As the experts in crisis identification and intervention M.D.s and D.O.s must be involved to guarantee the safety of the bridge.

We need experts of every type to build the bridge and not a few people who think they can do everything. Dr. Spresser should be commended for pointing out that improved access to mediocrity cannot compare with quality services performed by experts. The purpose of combining WAM and CAM is not to create SPAM (someone practicing all medicines), but to provide a bridge for those who would choose to use it. Practitioners of WAM or CAM who prefer not to be a part of the bridging process will continue to function autonomously and unimpeded as experts within their respective camps. 

In building the bridge between WAM and CAM it is inevitable that misunderstandings and disagreements will occur. With a spirit of collaboration the misunderstandings and disagreements will be worked out in the best interest of patients. The result will be a bridge that both improves access and guarantees safety. Based on the patient demand for this approach the bridge will be well traveled indeed.