Miles Reid, L.Ac., Dipl. Ac., C.H.
MEDICINE AT A CROSSROADS
WESTERN MEDICINE &
TCM:
AN INTEGRATIVE MODEL
FOR THE 21ST CENTURY
Integrative
Medicine: Facts and trends
A paradigm shift in
health care is taking place in the US: the incorporation of complementary
medical modalities into traditional medicine.
Integrative Medicine is a rapidly emerging field that seeks to improve
medical care by combining the best of bio-medicine with mind-body-spirit
approaches to health that have proven efficacy.
This is a crucial time in medicine in the US. Health care
has become too expensive, due in part to advances in medicine itself: as people
live longer, there is a higher incidence of chronic disease. Also we have
become attracted to “technology” medicine: expensive, complex interventions.
Hospitals—even large institutions—are going bankrupt. So managed care has come
in to balance the books, bringing what many described as misery for both
doctors and patients.
Surveys suggest that doctors are as unhappy as patients
about the current state of health care. Doctors want to leave their practices
and patients are turned off from medical care unless it is an absolute
necessity.
(From the physician standpoint, there is a growing trend
towards dissatisfaction fueled by increasing pressure to see more patients in
shorter amounts of time; greater administrative demands, a perceived loss of
control and more complex liability issues. There is a critical mismatch between
the original intention for entering the medical field and the realities of
practice.
A recent study by Spickard, et al. In the Journal of the
American Medical Association (JAMA), mid-career burnout has risen to 76% in a
sample of internal medicine residency. Up to half of the physicians in
California have explored ways to exit from the practice of medicine (according
to Sullivan, M.D.)
This has created an environment in which physicians are more
open to alternative health modalities, and most are eager to expand their
roles. Another, even bigger driving factor is that the public in general is
asking for them with a force that conventional medicine cannot ignore.
CAM is becoming mainstream.
The term CAM (complementary alternative medicine) itself
is somewhat misleading. The word alternative suggests “instead of,” but
integrative medicine seeks to find complements of care, where the total
interaction is more than the sum of its parts.
One important point to stress is that not all of these CAM practices
have been proven effective. Research support for the efficacy of these
therapies varies considerably, and there is a growing interest for solid
research to assess them.
Most conventional medical scientists are unaware of the evidence that
already exists for the safety and efficacy of many CAM treatments. At the same
time, the evidence base for many widely used allopathic treatments is not very
solid.
Research on CAM has exploded in the last 5 years. Created in1993 by a
congressional decree based on public support, the NIH (National Institutes of
Health) CAM office has risen in status. In 1998 it turned into a full-strength
federal agency called the National Center for Complementary and Alternative
Medicine (NCCAM) and quadrupled its annual research budget to $100 million. An
example of their research funding is a recent $1.2 million grant to Bastyr
University in Seattle to train scientists to conduct research in the field of
CAM.
One study documented that up to 95% of the public would utilize CAM
services if proven effective and delivered in a traditional setting.
Nevertheless, for the average healthcare consumer integrative medicine
is still hard to access for the simple reason that qualified practitioners are
few and far between. Demand greatly exceeds supply for physicians trained in
the new paradigm, and training opportunities are limited (Andrew Weil, 2002)
There are a growing number of medical centers and HMO’s that are
incorporating CAM into their patient service lines.
-
More than one third of medical schools in the U.S.
currently offer courses on alternative medicine.
-
-Formal programs in mind-body and integrative
medicine are in place at Harvard, Duke, Stanford, Columbia, the University of
Arizona (under Andrew Weil, M.D.), the University of Massachusetts and UC San
Francisco, among others.
-
At UCLA, Dr. Ka-Kit Hui formed the Center for East
West Medicine in 1993, with the goal of integrating Western medicine and TCM,
and creating a setting where acupuncturists and physicians can work side by
side.
An example of this is a well-known study by Zang-Hee Cho of the University of California, Irvine, where he demonstrated, using fMRI (functional magnetic resonance imaging) that inserting a needle in the acupuncture point GB35 (a point on the outside of the calf) and stimulating the point, caused a marked activation of the visual cortex.
According to author Geoffrey Cowley, what draws people to CAM and
integrative medicine is not a desire for efficiency but a longing to be cared
for. For example, from a patient’s perspective, he says, acupuncture is a
ritual in which a therapist touches us and helps us feel better. By the logic
of scientific medicine, acupuncture is measured as an encounter between a
patient and a needle, and it doesn’t factor in such intangibles as care and
compassion, which count but which can’t be measured by Western medicine’s
current standards. (p. 50)
Supporters of integrative medicine think it will fundamentally change
the way patients are treated. As the director of Duke University Center for
Integrative Medicine Martin Sullivan, M.D. says: “If we can manage to combine
the best of what these two systems have to offer, we’ll be creating a radically
new kind of health care. Many of us, in fact, think that this is what the
medicine of the future will look like.”
According to Ralph Snyderman. M.D., chancellor of Duke
Medical School, the transformation underway could prove as pivotal as the birth
of scientific medicine a century ago. What is at stake is not just the status
of some individual therapies but the whole meaning of health care.
In the long run, the larger mission is to forge a new kind of medicine,
an integrative medicine. The terms complementary and alternative will become
meaningless and we will have one inclusive health system instead of two. All
healing modalities will work in conjunction with the common reference point of
science.
Figure
2: The
Emergence of Integrative Medicine
I. Integrative medicine is
a consumer-driven movement
A- Healthcare consumers are educating themselves
B- Sales of botanicals and other supplements are increasing,
as are visits to
other alternative practitioners
II. Why physicians are
interested in integrative medicine
A- Doctors are growing dissatisfied with their practices
B- Patients are requesting more information on alternative
therapies
III. Aims of integrative
medicine
A- Establish a true partnership between patient and practitioner
B- Revive the art of medicine
1. Develop
and improve listening skills
2.
Communicate clearly and thoroughly
3. Make
appropriate treatment and lifestyle suggestions
4.
Acknowledge patients’ belief systems
C- Change the focus of medicine from disease to healing
D- Emphasize prevention and wellness
Andrew Weil, M.D.
Integrative Medicine: Medicine of the future
Thoughtful
combination of alternative and conventional medicine
Emphasizes
healing and health
Emphasizes
doctor-patient relationship
Looks at the
whole person not just the body
It is the approach that people want; sensible, common-sense medicine
Some Statistical Images
Recent studies support this mainstream emergence: A landmark study from
Harvard Medical School in 1993 by Eisenberg et al, showed that 34% of all U.S.
adults had received at least one unconventional therapy in 1990 and showed that
$13 billion was spent out-of-pocket for CAM therapies each year. By the late
90’s studies estimated this figure at $24 billion, with close to 40% of the
public seeking integrative medicine practitioners, making 425 million visits
per year to this type of health care. Last year, those figures had increased to
$30 billion and 600 million visits, and rising.
Patients are also demanding less aggressive forms of therapy and they
are more and more concerned about the toxicity of pharmaceutical drugs. Adverse
reactions were found to be the sixth leading cause of death, and in 1994, botanicals
were the largest growth area in retail pharmacy.
In the early 1900’s the average life expectancy was 47
years and people died mostly of infectious diseases. In 1990 the life
expectancy had risen to 75 years with the leading causes of death being heart
disease, autoimmune conditions and cancer; these are chronic diseases. More and
more research supports the theory that the reason they are chronic is due to
diet and lifestyle conditions.
Insurance companies have already begun to take note that patients who
use both Western and CAM therapies are healthier by a number of indices, are
more inclined to take preventive responsibility for their health and remain
healthier and productive longer.
A recent survey in
Washington State demonstrated that patients with chronic illness found
conventional bio-medicine to be effective or helpful 46% of the time, while
they found complementary care helpful or effective 89% of the time.
When the use of western medicine is most relevant:
Crisis,
emergencies, severe diseases, trauma, fast moving illnesses, disease involving
vital organs, complicated diseases which amount to 20% of cases.
In 1996, a study by the Maryland Commission on Complementary Medical
Methods found that 46% of the physicians surveyed had made a referral for or
discussed complementary medicine with their patients. (Sullivan, Institute for
Healing in Society and Medicine). The most frequently referred ailments were
allergies, lower back pain, asthma and chemical dependency.
The most
frequently referred CAM therapies were:
Biofeedback
(34%)
Chiropractic
(30%)
Acupuncture (27%)
Nutrition (27%) –
It is interesting to note that nutrition was
considered outside the frame of conventional medicine.
(Sullivan, TCM World, p. 11)
Another similar study by Eisenberg, published in JAMA in 1999 compared
the most common symptoms referred by patients who consulted CAM therapies:
Neck 57%
Back 48%
Headache 32%
Arthritis 27%
Strain/sprain 24%
THE TOP FIVE WERE MUSCLE-SQUELETAL COMPLAINTS
Another study by Long, et al., in 2001 compared the efficacy of CAM
therapies on different symptoms. The best results were obtained for:
1-
Stress/anxiety
2-
Back pain
3-
Insomnia
4-
Muscle-squeletal conditions
The Role of TCM
So think for a moment about the possibilities of TCM
within this emerging model. Chinese medicine is likely to find a growing place
in western medical practice. Since the 1980’s more than 20,000 Americans have
studied TCM in U.S. schools. There is solid research that supports the efficacy
of acupuncture’s therapeutic value, and it is one of the CAM modalities most
suited to grow and become a standard player in the integrative network.
In November 1997, the NIH held a conference to come up with a consensus
statement about acupuncture. This conference was motivated by the need to
establish parameters and promote further research in this area. The NIH
announced acupuncture as a legitimate treatment, which means that a practitioner
of this medicine can file a claim to an HMO or insurance company and qualify
for reimbursement.
As an anecdote, perhaps the most single influential
moment for the development of acupuncture in the U.S. was when then-President
Richard Nixon visited China in 1972. Nixon was accompanied by James Reston,
senior correspondent for the New York Times, who developed acute appendicitis
during the trip and underwent surgery while in Beijing. Upon his return, he
reported in the newspaper that acupuncture had been effective in alleviating
his post-operative pain, which caused many Americans to seek acupuncture
treatments.
The TCM World Foundation organized a landmark conference entitled Building
Bridges of Integration for TCM, in the fall of 2002 in New Jersey.
The purpose was to serve as a forum to explore ways to integrate TCM with the
western medical model.
Another recent event of this nature was the Second World Congress of Integrative
Medicine that took place in Beijing, China, in September of last year,
with 1,500 researchers, medical doctors and acupuncturists from 27 countries.
More than 1,000 research papers evaluating the safety, efficacy and biological
mechanisms of Chinese medicine were presented.
Some examples of effective integrated approaches that emerged were: the
use of acupuncture and tui-na in addition to conventional physical therapy as
an effective alternative to surgery for lumbar herniated discs, and the
administration of Xiao Chai Hu Tang modified for the management of Hepatitis C.
(Acupuncture,
p. 36)
Most of the research showed that Chinese medicine’s strongest area is
actually one of conventional medicine’s weakest: the area of chronic diseases.
These conferences reflect a growing trend among both the biomedical and
TCM communities: that a combination of western medicine and traditional Chinese
medicine gets better results than a single method alone. And this holds true
even more for the treatment of complex diseases.
Results
from a poll *on Acupuncture Today, in 2002-3.
Question: Have you ever referred a patient to a medical doctor or
chiropractor for treatment?
The responses, in a group of 286 acupuncturists, were:
Yes:
78.7%
No: 21.3%
Question: Has a medical doctor or chiropractor ever referred a patient
to you for treatment?
The responses, in a group of 233 acupuncturists, were:
Yes: 73%
No: 27%
The majority of referrals (no specific statistics were reported) were
to chiropractors, who have a longer history of communication and support for
TCM. Clearly, there is still a lot of room for a more fluid referral network
between medical doctors and acupuncturists.
Figure 2
Has a medical doctor
or chiropractor ever referred
a
patient to you for treatment?
Have
you ever referred a patient to a medical doctor
or chiropractor for
treatment ?
Purpose of
integrative medicine:
The fundamental aspects of integrative medicine could be summarized as
follows:
Restoring to medicine its healing orientation. Having patients be aware
of their options, knowing which modalities are effective for different cases.
Shifting the emphasis of the current Western health care system, which
is not really set up as a health care system but as a disease care system.
Doctors are trained to recognize disease, and treat it and, ideally,
cure it, rather than to promote health. Integrative medicine strives to
shift this model to one that supports health, maintains it and enhances it.
Health comes from the old English word “Hal” which means wholeness, soundness,
or spiritual wellness. “Health,” is (defined by the World Health Organization) “a
state of complete physical, mental and social well-being, and not merely the
absence of disease”. To “cure” conversely, refers to doing something that
alleviates a troublesome illness or condition.
Healing does
not equal curing.
To cure hypertension we give a pharmaceutical without healing the
condition. Healing the condition would reduces
stress, improve diet, promote exercise and increase the person’s sense of
community. (Rakel, Integrative Medicine, 2002)
This shift in emphasis, from curing to healing, also implies that healing is
possible even when curing is not.
At present, the trend of medical practice is focused almost entirely on
curing and applies little attention to healing. Integrative medicine believes
that both curing and healing are needed to bring medicine to a new level.
Although a medical system providing healing without curing, like medicine might
have been 400 years ago, is inadequate, a medical system which provides curing
without healing is not sufficient Healing provides an avenue for patients,
specially those with serious chronic and degenerative diseases who cannot be
rendered asymptomatic with full functioning even with the best of care, to find
meaning and purpose in the midst of illness, and to optimize relationships with
family and friends. (Sullivan, TCM World, 2003’)
Success is now defined as helping the patient find an inner peace that
results in a better quality of life, whether the problem can be fixed or not.
Providing both
evidence-based curing and mind-body-spirit healing is medicine at its best
In spite of the high number of visits to CAM
practitioners, most patients do not inform or discuss them with their primary
doctors
What patients want from their health care provider:
-
That they take time to talk to them and explain in
a language that they can understand the nature of their problem
-
That they go over options of treatment with them
-
That they understand the influence and effects of
diet on their health
-
That they understand the influence and effects of
supplements and herbs on their health
-
That they are aware of mind-body interactions and
energetic medicine
Western medicine has, in general, a very negative view of
illness. Integrative medicine regards health and disease as two aspects of the
same whole, much like the concept of yin and yang. For example: a certain
degree of illness is essential during childhood to strengthen and develop the
immune system. Current theories that are gaining support point towards an “excessive”
sanitation that has caused kids to lack a sufficient exposure to allergens,
such as dirt, during their upbringing, which in turn prevents the maturation of
a strong immune system and could account for the epidemic proportions of asthma
in U.S.
A recent survey by Sullivan of 283 North Carolina physicians showed
that 89% felt that spirituality was important to health and 64% felt that it
was important for physicians to address, yet 75% felt that their training did
not prepare them to do so.
Health in body, mind and spirit.
Western medicine is comfortable with the first, somewhat with the
second and not with the third.
Integrative medicine is built upon relationships: It is important for
the doctor to get to know the patient (family, background, how they see
the world, their emotional responses to the environment, their goals and
passions, what makes them feel good or enhanced).
“It is much
more important to know what sort of patient has the disease than what sort of
disease the patient has”
Sir William Osler
Often, the
main motivation for patients to seek CAM is not the treatment itself but the
higher likelihood to get an explanation for the treatment that they will get
and the likelihood to get recommendations for lifestyle and home care.
Perhaps one of the most essential elements of the model
of integrative medicine is that practitioner and patient are partners in the
healing process, rather than the doctor being on a pedestal
imparting his wisdom to the patient. The doctor-patient relationship implies
responsibility on the part of the patient for his or her own healing, and an
exchange of information that will enhance the healing process.
Albert Schweitzer said:
“Every patient carries his own doctor inside. We are at our best when we
give each doctor who resides in each patient the chance to go to work.”
A lot of the care that is part of integrative medicine is comprised of
things that a patient can do on his or her own. The medical practitioner can
give the patient tools and information that they take away with them to enhance
their own health care.
And finally, perhaps the most radical departure from conventional
medicine as traditionally taught in medical schools:
Integrative medicine asks the practitioner to model healing and commit
to his or her own self-exploration. (Tracey Gaudet, M.D., Andrew Weil’s
Integrative Medicine)
A Practice Model
“Cure
sometimes, heal often, support always.”
-Hippocrates
Integrative medicine is based on a partnership
between patient and practitioner within which conventional and alternative
methods are used to stimulate the body’s healing response
In his article “Where Medicine Meets Mind,” Peter Jaret cites a
poignant example that illustrates the need for this new model of medicine:
He describes a patient, Carrie Carlson-Scoglio, who, plagued by
symptoms for much of her life, was diagnosed 11 years ago with fibromyalgia.
After trying alternative treatments such as herbal remedies and homeopathy and
traditional prescription drugs like steroids and anti-inflammatories, she found
an array of conflicting advice. “You get doctors who say that alternative
approaches are nonsense and alternative practitioners who tell you that you’re
being poisoned by the drugs doctors prescribe. After a while, you wonder if any
of them really knows what they’re talking about,” she says.
Jaret quotes Steven Rosenzweig, M.D., director of the Center for
Integrative Medicine at Thomas Jefferson University Hospital in Philadelphia:
“There are still plenty of physicians out there who are uninformed,
uninterested, or even hostile when it comes to CAM approaches. At the same
time, alternative practitioners are often overly suspicious and uninformed
about conventional medicine. And patients are the ones who get caught in the
cross-fire” (page117)
How can we get the taste and experience of an integrative model?
A possible way to introduce this is saying that it is not just putting
under one roof a conventional doctor, an acupuncturist and an aromatherapist
and call it integrative. No! There is nothing integrative about that. Finding
how we can combine each thing, what works and what not, how can each one work
together from different angle on the same patient is a different process.
As the term “Integrative” becomes prestigious, more and more offices
and centers are adopting the name without really being so. A genuine
integrative medicine center should employ trained medical doctors as well as
experts in a variety of alternative disciplines.
Breakdown of
CAM:
1-
Movement Therapies (Feldenkrais, Alexander
Technique)
2-
Manual Therapies (Quiropractic, Osteopathy,
Massage)
3-
Energy Based Medicine (Reiki, Therapeutic Touch)
4-
Systems of Care (TCM, Ayurveda, Homeopathy)
5-
Botanical Medicine (Western, Chinese)
6-
Nutritional Medicine (Diet & Nutrition)
7-
Functional Medicine
8-
Mind-body therapies (Hypnosis, meditation, guided
imagery)
Figure 3
Use western
biomedicine to “put out the fire” Use CAM to nourish and restore balance.
Western:
acute conditions, trauma, sever infections
CAM: chronic
conditions
Treatment Model of Integrative Medicine:
1-
Diet
2-
Lifestyle
3-
Herbs
4-
Supplements
5-
Modalities
6-
Systems of Care
7-
Conventional Care
If a person is already combining conventional and CAM therapies on his
or her own, it’s worth seeking out a center that offers integrative
medicine-especially if it is a chronic condition. That way, there will be a
team of experts supervising the treatments with less risk of adverse reactions.
Most of these centers are associated with teaching hospitals and
academic medical centers, though a small number of private practices are
beginning to integrate themselves.
Every center offers its own selection of alternative therapies. Most
include acupuncture, chiropractic, herbal medicine, massage, nutritional
counseling, meditation, and other stress-reduction techniques. The doctors on
staff tend to be primary care physicians.
In the larger Integrative Medicine clinics, patients are
typically asked to fill out a detailed questionnaire about themselves and their
medical history. Then they meet with a physician for an initial office visit.
Afterward, the team of physicians and alternative practitioners discusses the
case and recommends treatment. The team meets regularly to talk about the
patients’ progress and to fine tune their therapy. In smaller settings, a
variation of this model can suit the individual structure of each place.
The elements of diagnosis and treatment with Integrative
Medicine:
-
Broad
range of data included
-
Western
diagnostic technology
-
CAM
diagnostic paradigms and values
-
Full
spectrum of therapeutic choices
-
Individual
plan for treatment
-
Limits
the mind-body split
Dr. Mary Hardy, Director of Integrative Medicine Group,
Cedars Sinai Hospital
A sample of a health –history intake form:
An Integrative Medicine approach
(From the Program in
Integrative Medicine at the
University of Arizona)
CASE DISCUSSION
TWO EXAMPLES IN PRIVATE PRACTICE
Case One
Patient:
Deborah, female, age 47, from Newport Beach, California
Occupation:
Assistant director, UCLA Medical Center, with a daily schedule of long working
hours, meetings and several hours a day typing in a computer.
Chief complaint: Wrist, elbow and shoulder pain from Carpal Tunnel
Syndrome
Other concomitant complaints:
-General body aches
-Recurrent UTI’s and Pielonephritis
-Recurrent gastroenteritis and vomiting
-Tensional headaches
-Chronic asthma
-Flutter and dizziness
Medical History:
Congenital heart disease with atrial and ventricular
communication corrected with surgery
Heart conductive dysrrythmia resulting in a permanent
pace maker installed at age 19
Chronic systemic hypertension since age 20
Leiomyomas (fibroids) surgery in 90’
Elbow surgery (entrapment syndrome) 99’
Carpal tunnel surgery in the year 00’
Patient is allergic to penicillin and sulfas.
Medications:
Atenolol
Albuterol
Lisinopril
NSAID’s
Periodic antibiotics
Case Two
Patient: Mirta,
female, age 49, from Brazil
Occupation:
Unemployed due to disability
Chief complaint: Generalized upper body pain due to Causalgia (Dystrophy
of Sympathetic Reflexes)
Other concomitant complaints:
- Multiple cervical herniated discs
- Depression, with a history of attempted suicide in 2001
- Insomnia
- Intolerance to heat and cold
- GERD
Medical History:
-Very active until onset of disease in 1998
- Long history of hospitalizations for intravenous pain
medications
- Participated in several research protocols for
management of such neurological conditions
Medications:
Patient came to consultation with a list of 25
prescription drugs that she took daily, including
NSAID’s and Opiates (Fentanyl)
Antidepressants
Sleep inducers
Antacids
Bibliography
-
Cassileth,
Barrie R., Ph.D., The Alternative Medicine Handbook: The Complete Reference guide to
Alternative and Complementary Therapies, New York, New York :
W.W. Norton & Company, 1998.
Cowley, Jeffrey, “The Science of Alternative Medicine,” Newsweek,
Volume CXL, No 23 (December 2, 2002).
-
Diamond,
John, M.D. & Cowden, Lee, M.D., An Alternative Medicine Definitive Guide to Cancer,
Tiburon, California: Future Medicine Publishing, 1997.
-
Gershon,
Michael, M.D., The Second Brain, New York, New York: Harper Collins, 1998.
-
Jaret,
Peter, “Where Medicine Meets Mind,” Health (July-Aug 2001), page 117.
-
Krucoff,
Carol & Mitchell, M.D., Healing Moves, New York, New York: Harmony
Books, 2000.
“Landmark Conference Promotes Integration,” Traditional
Chinese Medicine World, Volume 4, No. 3 (Fall 2002), page 1.
-
Northrup,
Christiane, M.D., Women's Bodies, Women's Wisdom: Creating Physical and Emotional Health
and Healing, New York, New York: Bantam, 1998.
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Oschman,
James L. Energy
Medicine, the Scientific Basis, London, UK: Churchill Livingstone,
2000.
Pert, Candace, Ph. D., Molecules of Emotion, The science
behind mind-body medicine, New York, New York: Simon & Shuster,
1997.
Pressman, Alan H., Ph.D. and Shelley, Dona, M.D., Integrative
Medicine: The Complete Idiot’s Guide, New York, New York: Alpha
Books, 1999.
-
-
-
Remen,
Rachel Naomi, M.D., Kitchen Table Wisdom, stories that heal,
New York, New York: The Berkley Publishing Group, 1996.
-
-
Sullivan,
Martin J., M.D., “Integrative Medicine- Current Trends and Future
Implications,” Traditional Chinese Medicine World, Volume 4, No. 3 (Fall
2002), page 7.
“The Acupuncture Poll,” Acupuncture Today, Volume 4,
No, 1 (January 2003), page 37.
-
Weil, Andrew, M.D. and others. Dr. Andrew
Weil’s Integrative Medicine, Boulder, Colorado: Thorne
Communications, 2000.
“When East Meets West at the Doctor’s Office: Report on
the Second World Congress of Integrative Medicine,” Acupuncture Today, Volume 3,
No. 4 (December 2002), page 36.
Additional Resources
On the
Web
This comprehensive site, operated by American whole Health, has a
useful list of alternative approaches organized by condition. It also has an
A-to-Z reference library on alternative medicine.
The National Center for Complementary and Alternative Medicine (CAM)
offers helpful tips on how to evaluate alternative therapies and therapists, as
well as information about clinical trials of leading alternative approaches.
The American Cancer Society provides critical evaluations of dozens of
alternative therapies for cancer patients, including mind/body approaches.
Contact
Centers
- Duke
University Medical Center’s Center for Integrative Medicine
Durham, NC 919/660-6801
- George Washington University’s Center for Integrative Medicine
Washington, D.C. 202/994-8870
- Memorial Sloan-Kettering Integrative Medicine Service
New York, NY 212/639-8829
-
Thomas Jefferson University Hospital’s Center for
Integrative Medicine,
-
Philadelphia, PA 215/879-5121