Feud: (Webster) - a prolonged quarrel; a lasting conflict between families or clans marked by violent attacks made for revenge. 

Different systems of healing have existed, coexisted and competed with each other since before recorded history. For the past century there has been a bitter feud in Western society between Western allopathic medicine (WAM) and complementary/alternative medicine (CAM). This feud has rivaled, and perhaps exceeded, the acrimony and intensity of the legendary Hatfield and McCoy feud. There are signs that this feud may be coming to an end - and not a moment too soon for the patients caught in the crossfire. 

Since shortly after the turn of the century WAM practitioners have managed to maintain the upper hand in this dispute. This has been achieved by using scientific proof to validate WAM and invalidate CAM. The assumption of scientific proof for WAM has allowed this form of medicine to become institutionalized and legitimized by legislation and insurance reimbursement.. In contrast, CAM has been assumed to be unscientific at best and has consequently been marginalized. However, in response to both scientific evidence and consumer demand, institutional, legislative and insurance support for CAM is on the increase.

Institutional support has come from several prominent medical schools offering courses in CAM as well as the creation of the Office of Alternative Medicine (OAM) at the NIH. At least five states have passed legislation which redefines the "standard of care" for MDs and DOs - thus allowing physicians who incorporate CAM into their practices to do so without jeopardizing their licenses. In fact House Bill 1183 which was presented before the Colorado HEWI committee on Monday, January 27th, 1997 is a local example of legislation attempting to allow physicians to incorporate CAM into their practices without fear of being caught on the wrong side of the Medical Practice Act. 

The HEWI committee hearing of House Bill 1183 was quite a spectacle with well in excess of 100 people showing up in support of the bill and a handful from the Board of Medical Examiners (BME), and the Colorado Medical Society (CMS), present in opposition. Testimony was cut off at almost 10:30 p.m. and the weary committee decided to not decide on the bill until a later date. The opposition objected to the language "objectively reasonable" with respect to the standard of care as too ambiguous and possibly exposing patients to substandard care. Those in favor presented statistics that physicians who incorporate CAM into their practices are disciplined more harshly than other physicians (actions taken against doctors guilty of sexual misconduct 30% of the time, actions taken against doctors guilty of substance abuse 37% of the time and actions against doctors using CAM 80% of the time - Denver Post 1-28-97). 

If the above statistics are accurate they would not be surprising. If the BME defines the standard of care as what they learned in medical school then physicians using CAM are automatically guilty of substandard care. HB 1183 also proposed a non-binding advisory panel composed of physicians with training in and experience with CAM to make recommendations to the BME in cases involving CAM.

Well, to make a long story short, the HEWI committee voted 9:1 on Friday, February 14th to strike all the language in the original bill but to appoint a 15 person study committee to look into this issue and report back before the 1998 legislative session. It was also voted 6:4 to send this to the Appropriations committee to have them vote on funding of the proposed study. The Appropriations committee, in a surprising turn of events, approved an amended version of HB 1183 instead of voting on funding for the proposed study committee.. The CMS then proposed specific language which it felt would allow the use of CAM by physicians without compromising the ability of the BME to adequately discipline physicians who endangered patients with substandard care. Upon acceptance of the CMS wording by the proponents of the bill, CMS opposition was removed, thus clearing the way for passage of HB 1183. Democracy in action! 

So why is this relevant? If physicians can't incorporate CAM into their practices without fear of jeopardizing their licenses CAM will continue to be provided almost entirely without medical supervision. While CAM has many applications in chronic conditions WAM is necessary in acute medical crises. Without medical supervision CAM may be used inappropriately when WAM is called for. Only physicians well versed in WAM are able to accurately identify when WAM is absolutely necessary. Thus any integrated model which combines WAM and CAM must have physician supervision. The legislative changes occurring around the country are a recognition that until now the laws have encouraged fragmentation rather than integration. The Colorado experience in this legislative session is a sign of changing attitudes and one that bodes well for cooperation instead of antagonism. 

On the insurance side more and more insurance plans are offering or considering coverage for CAM therapies which have historically been excluded. Oxford Health Plans, a large managed care insurer on the East coast, has received a lot of press recently for its ambitious CAM practitioner network which can be accessed by paying an additional premium for this option as a rider. Patients can go directly to CAM practitioners without any physician involvement or supervision. While welcoming CAM practitioners into the insurance fold may have many benefits, including gaining market share, the model used by Oxford Health Plans remains fragmented rather than integrated. Nonetheless, this is further evidence of the trend towards integration. 

With the tidal waves of change in health care it is incumbent on the medical profession to quit feuding - both internally amongst ourselves and externally with CAM practitioners. The medical community must show leadership in the integration of WAM and CAM and promote the vital role of medical supervision. To do otherwise is to allow our patients to continue being hurt in the crossfire - and that would be worse than futile.