Volume 16 Number 3, SPRING 1999

complementary my dear watson

A tour of this new medical clinic reveals its nonstandard nature. The most telling detail, perhaps: In two rooms, soft, luxuriously padded, reclining chairs await patients.

The physicians at the Complementary Medicine Clinic provide the comfy chairs for their patients because they know that relaxing the body and the mind not only pleases, it promotes healing. Patients sit in the chairs to alter their state of consciousness through hypnosis or to heighten their awareness and control over autonomic functions like skin temperature and heart rate with a technique called biofeedback. The patients learn, under the guidance of medical doctors and clinical psychologists, to reduce severe pain and anxiety.

In other treatment rooms, patients relax on massage tables for therapeutic massage to relieve stress, increase flexibility and boost athletic performance. The massage tables also come in handy for giving acupuncture, a therapy in which finger-length, flexible needles are inserted into the skin at precise points to stimulate healing and decrease pain and inflammation.

The largest room at the clinic is used for support group meetings aimed at improving the quality of life and even increasing the length of life for women with breast cancer. The room also is used for classes on mindfulness meditation -- the practice of living in the present moment -- to help patients better cope with stress-related maladies.

While the therapies offered at this UCSF Stanford Health Care clinic are hardly conventional, all of them are backed by solid scientific study and provided by proven practitioners, including faculty members. Indeed, several therapies, including cancer group therapy and acupuncture, were already available on a limited basis through Stanford Hospital and its clinics before the Complementary Medicine Clinic opened in April 1998, expanding those services and adding new ones.

The clinic's core mission is to help people draw on their physical and psychological resources for healing the stress, pain and anxiety resulting from medical illnesses and the treatment of those illnesses. Whether ancient or modern, Eastern or Western, these therapies evoke the healing power of both body and mind, and thus complement conventional medical care. They shine strongly in areas where mainstream medicine only flickers: relieving physical pain, anxiety and stress-related problems, including the psychological trauma of coping with a serious illness.

In recent years, half a dozen major academic medical centers, including Harvard and the University of Maryland, have begun alternative medicine clinics, usually specializing in one technique. Stanford's clinic seems to be unique in offering a broad range of services: acupuncture, biofeedback, alternative medicine counseling, individual counseling, hypnosis, massage, mindfulness meditation, support groups for cancer and chronic illness, and yoga (see sidebar, page 24).

"It's a real statement about where medicine is going," says Mark Abramson, DDS, who teaches mindfulness meditation at the clinic.

Opening a clinic with such services at a prominent medical center -- where technology and skepticism reign -- highlights the growing acceptance and popularity of scientifically based alternative practices. There are two basic reasons for this acceptance. First, there is a growing body of scientific evidence that some alternative methods work well. Second, the research also shows that these therapies fill a gap in care.

"Stanford has a well-deserved reputation for high-tech medicine. It has less of a reputation in helping people cope with the emotional and social aspects of illness," says David Spiegel, MD, the clinic's medical director. The clinic helps address this, he says.

Spiegel, a professor of psychiatry and behavioral sciences, has a worldwide reputation for rigorously and open-mindedly investigating the interaction between mind and body. He published a landmark study in 1989 reporting that women with terminal breast cancer who attended psychosocial group therapy sessions lived twice as long as their peers without a group. The women in a group also experienced better moods and had less pain.

"There's now a grudging acceptance on the part of the medical community that some alternative therapies may work and that there's a need for them," he says. "Ten years ago, the knee-jerk reaction of the medical community was that alternative medicine is awful, terrible and dangerous because it pulls people away from regular treatment," Spiegel recounts. "But the studies say that people don't use it as an alternative, they use it as a complement to mainstream treatment."

Thus the name of the clinic: "We're called 'complementary' because we go hand-in-hand with mainstream medicine. We're not alternative, which is either-or," says the clinic's manager, registered nurse RoseAnn Kushner.

The clinic is also a return to the roots of medicine, when physicians were healers, not "providers." Medicine is an art, as well as a science, contends Spiegel. "If we don't use compassion and reclaim the role of healer, we will be turned into a bunch of body mechanics," he says.

He says his medical center colleagues are primarily positive about the clinic. A few faculty are even working with the Complementary Medicine Clinic to bring its techniques to their own clinics and departments. But Spiegel says that the medical community is rightfully still cautious about alternative therapies.

"There are some charlatans, some people who oversell, and some things in the alternative category that are useless or potentially harmful," he says. "It's unfortunate. I've had patients who took the shark cartilage route; it has no effect on cancer."

As director of the Clinical Cancer Center at Stanford, Charlotte Jacobs, MD, knows about the false promises that mislead vulnerable patients. That's why she has encouraged the Complementary Medicine Clinic since its inception, knowing it can genuinely and safely help her patients.

"In a nutshell, it's providing a much-needed service that patients who have serious illnesses are seeking," she says. "Patients seek complementary treatment because it gives them a way of participating in their own well-being. In the past, and even now, patients will seek sources of alternative medicine from Web sites and other places. We often don't know the credentials or professionalism of the sources, so we're absolutely delighted that Spiegel started this service at Stanford."

The fact that Stanford runs the clinic reassures physicians and patients alike that the clinic's practitioners and techniques are legitimate and removes the uncertainty of choosing from the Yellow Pages.

"From the beginning the clinic has had a research- and science-driven menu of services, which is why patients and referring doctors can be assured of high quality and responsible care," says Kenneth R. Pelletier, PhD, a clinical associate professor of medicine. He worked with Spiegel and an outside consulting group to develop the clinic's business plan, and he now sits on the clinic's faculty advisory board.

As alternative therapies seep into mainstream medical practice and classrooms, the line between mainstream and alternative medicine is beginning to bleed. Alternative has been defined as therapies generally not taught at medical schools or practiced in hospitals. Spiegel, however, thinks the label "alternative" isn't very useful once a therapy has been proven to work. "My goal is that eventually the scientifically based therapies will become recognized as good medicine," Spiegel says.

The strict scientific scrutiny of alternative therapies has grown immensely this decade. Amazed and alarmed by the popularity of alternative practices, the National Institutes of Health in 1992 founded the Office of Alternative Medicine to separate the wheat from the chaff. NIH's alternative medicine office supports everything from reviews of the scientific literature to controlled, randomized, double-blind clinical trials, the gold standard of medical science. The NIH office has funded 13 research centers at medical institutions across the country, including one at Stanford (see sidebar, page 23). Even Congress finds alternative medicine more interesting lately: Last fall it bumped up the NIH alternative medicine office's status and power by turning it into the National Center for Complementary and Alternative Medicine, and it increased the budget from $20 million to $50 million a year. In 1992, the office started out with just $2 million a year.

Medical schools have started to teach the therapies that pass rigorous study. An American Medical Association poll of the country's 125 medical schools found that 75 offered courses in alternative medicine in 1997, compared with only 46 schools less than two years before.

The science is just starting to catch up with popular opinion. In this decade, Americans have flocked to alternative medicine. A survey published in the Nov. 11, 1998, issue of the Journal of the American Medical Association found that visits to alternative practitioners increased by 47 percent from 1990 to 1997, with a total of 629 million visits in 1997. That exceeds the number of visits to primary care physicians. The survey, headed by David M. Eisenberg, MD, of Beth Israel Deaconess Medical Center in Boston, was a follow-up to one he conducted in 1990, when one in three adult Americans used at least 1 of 16 kinds of alternative therapy. In 1997, 4 out of 10 used alternative medicine and spent a total of $27 billion of their own money on it. The survey also found that people used alternatives most frequently for chronic conditions such as anxiety, back problems, depression and headaches.

"People are voting with their feet and pocketbooks," says Spiegel. "They are saying we want something more than a technician. Patients want a human being."

The new clinic is getting some of that foot traffic. Its stream of patients has grown steadily, with 250 total visits a month as of January. Three-quarters of the clinic's patients are women, perhaps because women are more willing to get help for their problems, suggests Spiegel.

Clinic manager Kushner notes that about half of the patients come needing treatment for pain stemming from cancer, chronic illness, headaches, inflammatory processes or injuries. Acupuncture, biofeedback, hypnosis and meditation can help these patients.

Another quarter of the clinic's patients come for cancer-related problems like anxiety about medical procedures and nausea from treatments. Hypnosis helps patients with these two conditions. And group therapy sessions offered by the clinic help patients with cancer and chronic illnesses improve the quality of their lives.

The clinic also provides care for people suffering from psychiatric conditions including anxiety, depression, sleep problems and stress. The most useful modalities in this area are biofeedback, hypnosis, meditation and individual counseling, Kushner says.

The practitioners agree that the therapies' effectiveness varies from person to person. Some people fall into a hypnotic state more readily than others, for example. One of the clinic's missions is to take note of what works for which people. "We want to advance research on what works and what doesn't," says Spiegel. Two of the clinic's practitioners, acupuncturist Michael Fredericson, MD, and psychologist Ian Wickramasekera, PhD, are studying whether patients who are more receptive to suggestion are better candidates for acupuncture, as they are for hypnosis, and what autonomic nervous system changes are correlated with acupuncture therapy.

Almost all clinic patients are under the regular care of a physician; about 30 percent have come to the clinic on referral from their doctors, Kushner says. If the patient is willing, the clinic communicates with the patient's physician about treatment and progress. The clinic screens patients to make sure their needs fit within the clinic's services. Patients with medical needs that have not been addressed are referred back to their clinicians, Kushner says.

Acupuncture is the clinic's most utilized service, primarily because it's the modality most often covered by insurance companies, says Kushner, who estimates acupuncture is paid for by insurance companies 70 percent of the time. The clinic is in the process of adding a third acupuncturist to meet the demand. About 20 percent of all patients pay for their own treatments because insurance won't cover it, Kushner says.

Even though patients and some insurance companies are paying for treatments, the clinic has yet to break even. It has had trouble collecting from insurance companies, compounding the problem of low reimbursement payments from them, Spiegel says. And to anyone who wonders whether the clinic was started to cash in on a trend, Spiegel flatly says, "Show me the money. We're responding to a medical need. We're not making big bucks."

While not currently profitable, the clinic does cater to the growing interest in unconventional medicine. Peter Van Etten, CEO of UCSF Stanford Health Care, approached Spiegel four years ago about setting up a complementary clinic. "He's got a good feel for the future," Spiegel says. They did a business plan, used focus groups and polled the faculty on who had skills to offer and which services should be provided.

The timing was good for Robert C. Robbins, MD, a heart surgeon and assistant professor of cardiothoracic surgery. Last year he went to Van Etten to ask for a stress-management program for his patients. Van Etten told him his request would be met in a few months, with the opening of the Complementary Medicine Clinic.

Robbins wants his patients to take an intense, short course on mindfulness meditation before they arrive for their often stressful cardiac appointments, procedures and surgeries. He is working to develop a good protocol with Abramson, the meditation instructor.

"My goal is to be able to recommend it for all of our patients," says Robbins. Stanford sees about 1,000 cardiothoracic surgery patients every year.

"Transplant patients in particular are ideal candidates for using stress-management strategies because they have long illnesses, a lot of medical care after surgery, and the demands of a transplant and major heart surgery are very anxiety producing," he says.

People undergoing cardiac catheterization to diagnose chest pain are also in serious need of stress management. They remain awake during the stressful procedure. And the test result is often a shock. "At the end of the procedure, patients are often informed that they need coronary artery bypass surgery within days," Robbins says. "Teaching patients stress-reduction techniques prior to cardiac catheterization would benefit them both during and after the procedure."

Robbins points to a small number of studies that suggest using mindfulness meditation reduces the amount of anesthetic needed during surgery, the amount of pain medication needed after surgery and the time needed to recover.

The studies on alternative medicine are bearing out patients' and doctors' beliefs that the body is not the only player in medical dramas.

"I have frequently observed that patients with a positive outlook before surgery tend to do better," Robbins says. "I've always thought that there was something more than voodoo involved in the mind-body approach to treating somatic diseases."

The clinic can be reached at 650-498-5566. SM