WAM (Western Allopathic Medicine), as practiced by most MDs and DOs, and CAM (Complementary/Alternative Medicine) have existed predominantly in isolation from each other. The increasing use of CAM by patients, as well as the increased awareness of this by physicians, has sparked a great deal of curiosity and discussion among physicians as to the merits and/or risks of incorporating CAM into medical practice. "Integrative Medicine" is the buzz word being used to describe the rational combining of both WAM and CAM. Unfortunately there are some who misconstrue this to mean that someone practicing integrative medicine can do all things. The result is SPAM (Someone Practicing All Medicine), or as the expression goes, " a Jack of all trades and a master of none." A lack of collaboration with, and appropriate utilization of experts in the various specialties, WAM or CAM, leads to mediocrity and compromised outcomes. 

Of the many studies documenting the widespread use of CAM the most often quoted is that of Eisenberg, et al (NEJM, 1-28-93), which found that 34% of Americans were using CAM. The same study revealed that 83% of the time CAM was used in conjunction with WAM and 72% of the time patients did not tell their physicians. With the potential for unrecognized interactions and contraindications, not to mention therapeutic benefits, it behooves physicians to discuss CAM with their patients. Anything one in three patients are doing should become an important part of the medical history. This may in part explain why CAM was the most requested topic for the 1998 annual CAFP (Colorado Academy of Family Physicians) meeting and why we are seeing more and more articles in mainstream medical journals on CAM. 

There are a burgeoning number of reputable publications dedicated exclusively to coverage of CAM issues from a scientific, medical and even insurance perspective. "St. AnthonyÕs Alternative Medicine Integration & Coverage" (800-632-0123), is a publication which tracks the frenzy of insurance industry activity surrounding CAM. Historically CAM has not been covered by health insurance but this is changing very rapidly. The insurance industry sees an opportunity to expand into a virtually untapped market, a way of expanding market share in existing markets, and the potential for improved clinical outcomes and patient satisfaction as well as lowered costs. Locally, in Colorado, several major insurers are racing each other to see who will be the first to have their credentialed network of CAM providers embraced by the public. There are both advantages and disadvantages to the incorporation of CAM by the insurance industry. A potential advantage, depending on your perspective, is that insurance coverage will make CAM more affordable and accessible to a larger number of patients. A potential disadvantage is that CAM will be subject to the same compromising influences that have battered WAM for quite some time. In fact many excellent CAM practitioners are refusing to participate in some of the insurance networks because they feel the reimbursement is insultingly low - so low that they would have to compromise what they do clinically and see more patients in less time in order to survive financially. Does that sound familiar? That reminds me of a recent article in Medical Economics on how we can be more like Marcus Welby in an office visit lasting only eight minutes (not tongue in cheek)! I I digress. 

So far none of the insurance programs covering CAM adequately address or promote the concept of integration or collaboration. WAM and CAM practitioners are both reimbursed for the services they provide to patients in isolation. Integration of payment does not translate into clinical integration. As Family Practice physicians we are trained to see the big picture and we tend to have a more integrative approach than most other specialties. At the same time we are trained to recognize our personal limitations and to collaborate with experts in other specialties to avoid falling into the SPAM trap. Insurance reimbursement in some cases has actually resulted in different WAM specialties being pitted against each other and reduced professional collaboration to the detriment of both the patients and the medical community. Now add CAM to the mix and imagine what kinds of mayhem might ensue. 

There are six prerequisites for collaboration with other professionals in an integrated model: understanding, respect, communication, pragmatism, commitment and leadership. Understanding the scope of what each member of the team has to offer is essential. Valuing and respecting the contribution of each team member is equally important because it allows everyone to play to their strengths. With ongoing communication between team members understanding and respect increases and without they decrease. Pragmatism allows the philosophical flexibility to accommodate what is in the best interest of the patient. Any practitioner, specialty or healing system which thinks it has all the answers is unable to function collaboratively. With diverse perspectives and training, differences of opinion will be inevitable and it is commitment to the team and the process which prevents it from falling apart. Leadership to both provide direction and resolve problems will multiply the effectiveness of an integrated approach. What insurance company have you ever seen that screens for these types of attributes in creating a network of credentialed providers? It doesn't happen! Trying to create an integrated model out of individuals solely credentialed on the basis of competency in their specialty is absurd. To borrow an old expression, it's like "putting new wine in old skins." Is it any surprise that IPAs and hospital initiated integrated delivery systems are having difficulties when the physicians involved are cynical, disrespectful of each other, uncommunicative, dogmatic and uncommitted? I digress again. 

Integrative medicine is a clear example of how collaboration is necessary to avoid mediocrity. In order to create a collaborative, team approach participants need to be screened for understanding of the big picture, respect, pragmatic flexibility and commitment above and beyond the traditional measures of competency. Communication needs to be fostered and leadership provided. For those Family Practice physicians who choose to expand their knowledge base to include CAM their philosophy and training should prepare them well to be leaders in the evolving field of integrative medicine. They will be able to offer patients the best of both WAM and CAM instead of SPAM.