Jacobs/Grundling CAM Guide for American College of Physicians Sets Standard for Internists
Written by John Weeks
Jacobs/Grundling CAM Guide for American College of Physicians Sets Standard for Internists
Summary:The American College of Physicians, representing the nation's internists, turned to integrative medicine leader Bradly Jacobs, MD, MPH to take the lead in their textbook on complementary and alternative medicine. The book, An ACP Evidence-Based Guide to Complementary and Alternative Medicine, lives up to its billing To evaluate evidence, the editors use, uniquely for this field, the GRADE Working Group method, also favored by the WHO, the Cochrane Collaboration and others. Appropriately, the editors also introduce readers to some of the challenges regarding evidence for these fields. While the chapters are provided almost entirely by MD authors, the co-editors include a substantive appendix on "Systems of Practice" for which they took consultation from leading members of complementary healthcare disciplines. The success of the text, excellent for its audience, may be a plebiscite on whether medical doctors, and internists in particular, believe it's finally time to pay attention.
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Jacobs served on the faculty and developed the integrative medicine clinic for what is now the Osher Center for Integrative Medicine at the University of California San Francisco. As a researcher, Jacobs developed a resume in the field of yoga, for which he has personal passion and practice. In the dot.com era, he worked with some natural products-related initiatives, honing his knowledge of the literature and also a skill set which later brought him a senior medical position with Steve Case's online Revolution Health. Jacobes currently serves as integrative medicine leader at Cavallo Point Lodge. Most notable is Jacobs' role as a long-time Integrator adviser.
The 450 page Guide that Jacobs and his co-editor, Katherine Grundling, MD produced for the organization representing the nation's internists has been greeted with positive reviews by the intended audience. Brian Berman, MD, who heads up the Cochrane Collaboration's complementary medicine section states that "finally we have a comprehensive, evidence-based textbook." In a forward, Ralph Snyderman, MD, most recently the chair of the planning committee for the Institute of Medicine's National Summit on Integrative Medicine and the Health of the Public, calls the book "a valuable and essential compendium."
Text uses the GRADE system for evaluating clinical evidence
A useful characteristic of the book for busy clinicians is the inclusion of "Evidence Summary" tables with each of the roughly two dozen chapters. The areas in which readers are offered guidance for each therapeutic intervention reviewed are "Confidence of the Estimate on Effectiveness," "Magnitude of Effect," "Safety" and "Clinical Recommendation." Guidance is based on scales described in an introductory section.
The editors chose to apply GRADE Working Group criteria to establish these guides. GRADE is an acronym for Grade of Recommendations Assessment, Development and Evaluation, a working group which began in 2000 as "an effort to develop a common, sensible and transparent
approach to grading quality of evidence and strength of recommendations." The process is presently adopted or used by WHO, QUORUM and the Cochrane Collaboration, among other organizations.
Lessons for readers on the challenges of evidence for these fields
To their credit, the editors do not engage the evidence game without introducing their readers to some of the cultural-scientific context in which evidence is, or is not, offered. Six pages are devoted to the "Unique Challenges to Conducting Research in the Field of CAM."
The half-dozen subheadings in this section include such critically important themes as "the intervention is typically composed of multiple treatments" and "the challenge of creating standardized interventions makes it difficult to replicate clinical trial protocols and clinical practice." Appropriately, they inform those conventional clinicians whose reading of evidence maps is shaped almost entirely by drug trials that they are entering a different country.
A method for respecting not just therapies but whole systems and practices
The book follows the patterns in most such texts which target medical doctor readers by using almost entirely medical doctors as writers. Of the 26 chapter authors and co-editors, all are MDs except one DO, one MA, and an MS, RD. None are from the distinctly licensed complementary healthcare fields. Jacobs weighed in directly on this topic in an earlier Integrator forum stimulated by a review of David Rakel, MD's Integrative Medicine (Your Comments: Bradly Jacobs, MD, MPH & Christy Lee Engel, ND, LAc on Rakel's Integrative Medicine, July 16, 2008). Jacobs wrote:
"One must consider how does one best
communicate and convince conventionally oriented MDs to consider an integrative
approach to patient care? I would argue that you are more likely to
consider something different from what you are accustomed to/trained in if you
hear it from ‘one of your own’."
One outcome - the medium being the message - is that readers
will not be given a chance to meet members of licensed complementary
healthcare disciplines as individuals respected enough to be contributors of chapters.
The editors offer a respectful step toward mediating the absence of CAM authors by an appendix Systems and Practices.
The editors offer a respectful step toward mediating the absence of authors from the complementary healthcare disciplines by an appendix called "Systems and Practices." This substantial, 15-page segment effectively introduces readers to the important difference between, for instance, "acupuncture" as the use of needles as a therapy and the use of a licensed representative of the "acupuncture and Oriental medicine (AOM)" system of practice.
To the credit of the co-editors, they directly contacted the Academic Consortium for Complementary and Alternative Health Care for reviewers of their draft sections. The co-editors took substantive changes from the members of these disciplines for the sections on Ayurvedic Medicine, Acupuncture and Oriental Medicine, Naturopathic Medicine and Chiropractic. As an additional sign of respect, the editors use the term "Naturopathic Medicine," which reflects both the profession's use and legal standing, rather than the less assertive "naturopathy" that is typically favored in allopathic presentations.
Will the book take off?
Another useful strategy chosen by Jacobs and Grundling was to limit the presentation to key therapeutic arenas (Women's Health, Men's Health, Cancer, Coronary Heart Disease, etc.) rather than attempting to look at scores of individual diagnoses.
The success of the text may be a plebiscite on whether these internists believe it's
finally time to pay attention to CAM.
While conditions are often specifically noted by chapter authors, this set up is friendly, familiar and conducive to focusing on areas where use is highest and evidence more plentiful, rather than forcing a survey of the entire waterfront.
It will be interesting to see how this ACP book will be received and reviewed inside the discipline of internists. Potentially this is a huge audience. The success, dependent in part on how visible the ACP chooses to make it, may be an effective measure of whether or not the nation's internal medicine doctors believe it is time finally, to figure out what this complementary and alternative medicine hooplah is all about.
Send your comments to
for inclusion in a future Integrator article.
A useful characteristic of the book for busy clinicians is the inclusion of "Evidence Summary" tables with each of the roughly two dozen chapters. The areas in which readers are offered guidance for each therapeutic intervention reviewed are "Confidence of the Estimate on Effectiveness," "Magnitude of Effect," "Safety" and "Clinical Recommendation." Guidance is based on scales described in an introductory section.
