Acupuncture has been a health profession in the U.S. since the 1980s and is accepted as safe. The NIH panel on CAM estimated that “acupuncture is used by millions of Americans,” and expressed hope that “where there are state health insurance plans, and for populations served by Medicare or Medicaid, expansion of coverage to include appropriate acupuncture services would also help remove financial barriers to access.”
Studies have reported efficacy of acupuncture for various conditions, including asthma, digestive symptoms, back pain, and osteoarthritis. Stress management techniques like yoga, meditation and biofeedback, have shown efficacy in the treatment of asthma, insomnia, depression, hypertension and immune functions. CAM treatments have shown to result in a “broad range of outcomes, from physical and emotional change to benefits involving lifestyle, outlook, and attitude towards health.”
Sixty-two percent of Americans from all income levels used CAM in 2003. In 1997, Americans spent $21.2 billion out-of-pocket for CAM services, and they used CAM providers almost 60% more often than primary-care physicians. Americans want their physicians to be more involved in CAM care, and 50% of physicians in North America agree that they should be knowledgeable about CAM. The Institute of Medicine has recommended that schools of medicine and health professions include CAM instructions for patient education and referrals.
In the light of these changes, boards of trustees must ask themselves the following questions: Would offering CAM in medical institutions make patient care more comprehensive? Safer? More dignified? More affordable? Would it promote patients' autonomy and informed consent? If the answer is yes, the boards must act to exercise their leadership in promoting collaboration between physicians and CAM providers through education, fellowships and referral networks.
The extent to which boards will welcome CAM practitioners in their institutions will depend on the mission and the type of care provided. A hospital that focuses on orthopedic surgery will have different considerations than a center providing general care. A center in an affluent neighborhood may consider different CAM modalities than a center in the inner city. The Management and the Medical staff will determine CAM therapies most appropriate for the type of services the institution provides, in accordance with the board's goals related to the quality of care and fiscal responsibility.
The following issues may be considered by the boards that look toward expanding their care to include CAM:
Boards may look at the quality of care and patient safety in an expanded way, which will consider the amounts of drugs for pain management, reduction of stress levels, psychological outlook, or patients' cultural and spiritual needs—markers not always considered by scientific medicine. The inconsistency of the CAM research outcomes may present some challenge, however, with the help from the experts, CAM safety can be determined in a clear and measurable way.
Boards must not be tempted to micromanage the implementation of CAM therapies and leave the implementation of safety related to the CAM devices, sterilization or safety education for CAM practitioners to the clinical staff and the management.
Boards need to distinguish between general beliefs and the facts about CAM therapies. They need to understand CAM efficacy, research methodologies and epistemological differences between CAM therapies and biomedicine. They must make sure that hospital privileges for CAM practitioners are not granted solely on the subjective judgments of medical staff.
Boards must both remain true to the mission by providing quality care and ensure fiscal soundness and profitability for the developments and future investments. While it is the purview of the management to decide how the money will be spent for the implementation of CAM practices, it is the duty of boards to anticipate financial problems, monitor budgets and evaluate if CAM therapies are providing quality of care, as defined by boards.
Community, with its environment and natural resources, is one of the medical institution's stakeholders. It is the board's fiduciary duty to promote values of self-care and care for others. Boards must assess the cost of biomedical care to the environment, and they provide leadership in promoting environmentally friendly CAM therapies whenever safe and effective.
Clearly, the Boards of Trustees of medical institutions have fiduciary duties to provide health care that is effective, safe, least-invasive, and preventive. In order to fulfill this duty, Boards must provide vision and leadership to bring their institution toward expanded healthcare in a safe and fiscally responsible manner.
B. Basia Kielczynska
AcupuncturistIntegrative Medicine DepartmentBeth Israel Medical CenterNew York
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