chapter 2
PHYSICIANS, NURSES, DENTISTS, AND OTHER HEALTH CARE PRACTITIONERS

The art of medicine consists of amusing the patient while nature cures the disease.

—Voltaire (1694–1778)

One of the first duties of the physician is to educate the masses not to take medicine.

—William Osler (1849–1919)

PHYSICIANS

Physicians routinely perform medical examinations, provide preventive medicine services, diagnose illness, treat patients suffering from injury or disease, and offer counsel about how to achieve and maintain good health. There are two types of physicians trained in traditional Western medicine: the MD (Doctor of Medicine) is schooled in allopathic medicine and the DO (Doctor of Osteopathy) learns osteopathy. Allopathy is the philosophy and system of curing disease by producing conditions that are incompatible with disease, such as prescribing antibiotics to combat bacterial infection. The philosophy of osteopathy is different; it is based on recognition of the body's capacity for self-healing and it emphasizes structural and manipulative therapies such as postural education, manual treatment of the musculoskeletal system (osteopathic physicians are trained in hands-on diagnosis and treatment), and preventive medicine. Osteopathy is also considered a "holistic" practice because it considers the whole person, rather than simply the diseased organ or system.

In modern medical practice, the philosophical differences may not be obvious to most health care consumers since MDs and DOs use many comparable methods of treatment, including prescribing medication and performing surgery. In fact, the American Osteopathic Association (AOA), the national medical professional society that represents about fifty-two thousand DOs, admits that many people who seek care from osteopathic physicians may be entirely unaware of their physicians' training, which emphasizes holistic interventions or special skills such as manipulative techniques. Like MDs, DOs complete four years of medical school and postgraduate residency training; may specialize in areas such as surgery, psychiatry, or obstetrics; and must pass state licensing examinations in order to practice.

Medical School, Postgraduate Training, and Qualifications

Modern medicine requires considerable skill and extensive training. The road to gaining admission to medical school and becoming a physician is long, difficult, and intensely competitive. Applicants to medical school must earn excellent college grades while acquiring their undergraduate degrees, achieve high scores on entrance exams, and demonstrate emotional maturity and motivation to be admitted to medical school. Once admitted to medical school, students spend the first two years primarily in laboratories and classrooms learning basic medical sciences such as anatomy (detailed understanding of body structure), physiology (biological processes and vital functions), and biochemistry. They also learn how to take medical histories, perform complete physical examinations, and recognize symptoms of diseases. During their third and fourth years, the medical students work under supervision at teaching hospitals and clinics where they learn acute, chronic, preventive, and rehabilitative patient care. By completing "clerkships"—spending time in different specialties such as internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery—they acquire the necessary skills and gain experience to diagnose and treat a wide variety of illnesses.

Following medical school, new physicians must complete a year of internship, also referred to as "postgraduate year 1 (PGY1)" emphasizing either general medical practice or one of the specialties and providing clinical experience in various hospital services—inpatient care, outpatient clinics, emergency rooms, and operating rooms. In the past, many physicians entered practice after this first year of postgraduate training. In the present era of specialization, most physicians choose to continue in residency training, which lasts an additional three to six years, depending on the specialty. Those who choose a subspecialty such as cardiology, infectious diseases, oncology, or plastic surgery must spend additional years in residency and may then choose to complete fellowship training. Immediately after residency, they are eligible to take an examination to earn board certification in their chosen specialty. Fellowship training involves a year or two of laboratory and clinical research work as well as opportunities to gain additional clinical and patient care expertise.

Conventional and Newer Medical Specialties

Rapid advances in science and medicine along with changing needs have resulted in a variety of new medical and surgical specialties, subspecialties, and concentrations. For example, geriatrics, the medical subspecialty concerned with the prevention and treatment of diseases in the elderly, has developed in response to the growing population of older adults in need of medical care. In 1909 Dr. Ignatz L. Nascher coined the term geriatrics from the Greek "geras" (old age) and "iatrikos" (physician). Geriatricians are physicians trained in internal medicine or family practice who obtain additional training and certification in the diagnosis and treatment of older adults. According to the American Geriatrics Society, the United States currently needs at least 20,000 geriatricians to care for its 36 million older adults. In 2004 board-certified geriatricians numbered only 9,500—still less than half of the estimated need.

Another relatively new medical specialty has resulted in physician "intensivists." Intensivists, as the name indicates, are trained to staff hospital intensive care units (ICUs, sometimes known as critical care units or CCUs), where the most critically ill patients are cared for using a comprehensive array of state-of-the-art technology and equipment. This specialty arose in response to both the increasing complexity of care provided in ICUs and the demonstrated benefits of immediate availability of highly trained physicians to care for critically ill patients.

More traditional medical specialties include:

• Anesthesiologist—administers anesthesia (partial or complete loss of sensation) and monitors patients in surgery
• Cardiologist—diagnoses and treats diseases of the heart and blood vessels
• Dermatologist—trained to diagnose and treat diseases of the skin, hair, and nails
• Family Practitioner—delivers primary care to persons of all ages and, when necessary, refers patients to other physician specialists
• Gastroenterologist—specializes in digestive system disorders
• Internist—provides diagnosis and nonsurgical treatment of a broad array of illnesses affecting adults
• Neurologist—specializes in the nervous system—diagnosis and treatment of brain, spinal cord, and nerve disorders
• Obstetrician-gynecologist—provides health care for women and their reproductive systems, as well as care for mother and baby before, during, and immediately following delivery
• Oncologist—dedicated to the diagnosis and treatment of cancer
• Otolaryngologist—skilled in the medical and surgical treatment of ear, nose, and throat disorders and related structures of the face, head, and neck
• Pathologist—uses skills in microscopic chemical analysis and diagnostics to direct detection of disease in the laboratory
• Psychiatrist—specializes in the prevention, diagnosis, and treatment of mental health and emotional disorders
• Pulmonologist—specializes in diseases of the lungs and respiratory system
• Urologist—provides diagnosis as well as medical and surgical treatment of the urinary tract in both men and women as well as male reproductive health services

High Costs, Long Hours, and Low Wages

According to the Association of American Medical Colleges (AAMC), in the 2003–04 school year median medical school costs were $14,544 for in-state residents at public schools and $32,028 for private school tuition and fees. (See Table 2.1.) Still, tuition and fees do not even completely cover the cost of educating prospective physicians—tuition is subsidized by other university teaching hospital activities as well as grants and endowments. According to other AAMC data, public medical school students graduating in 2003 had incurred a median debt comparable to a home mortgage—about $100,000—and private medical school students incurred a median debt of $135,000. More than one-fifth of students (21.4%) incurred a debt of more than $150,000. Medical school debt has increased more than 60% since 1993, when students owed an average of $60,000 at graduation. Although physicians' earning power is considerable, and many students are able to repay their debts during their first years of practice, some observers believe that the extent of their indebtedness may unduly influence medical students' career choices. They may train for higher paying specialties and subspecialties rather than following their natural interests or opting to practice in underrepresented specialties or underserved geographic areas. The high cost of

TABLE 2.1

medical education also is believed to limit the number of minority applicants to medical school.

Historically, medical training has been difficult and involved long hours. Residents typically worked twenty-four- to thirty-six-hour shifts and more than eighty hours a week. Lack of sleep and low wages are a way of life for most medical students and residents, although the thirty-six-hour shift has come under criticism as an unnecessary, and possibly dangerous, practice. In 1995 the state of New York limited most residents to twenty-four-hour shifts and eighty-hour weeks. The regulations were the first of their kind in the country. New York has almost 150 teaching hospitals and trains 16% of the nation's doctors.

In 2001 the Committee of Interns and Residents and the American Medical Student Association, which represents more than 30,000 physicians-in-training, were two of several groups to petition the U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) to limit the number of hours medical residents must work. The petition observed that sleep deprivation among physicians in training, who may work as many as 130 hours a week with only one day off, increases their risk of automobile accidents, depression, and other ailments and poses risks to the patients they treat. The petition sought a limit of eighty hours per week, with a maximum of twenty-four hours in one shift and with ten hours between shifts. For emergency medicine residents, the maximum allowable hours of work per day would be twelve.

By 2002, several states and many professional associations including the AOA approved an eighty-hour work-week for all interns and residents. The AOA ruled that interns and residents may not work more than twenty-four consecutive hours. To reduce the possibility of diagnostic and treatment errors, residents are forbidden to assume responsibility for new patients after they have worked twenty-four hours. The AOA mandated that its training programs comply with this measure by November 1, 2002, in order to retain their accreditation. On July 20, 2002, in a published statement, Dr. James E. Zini, the 2001–02 president of the AOA, said: "Patient safety is our number one priority, and that is the main reason the osteopathic profession will implement these changes this fall."

In July 2003 the Accreditation Council for Graduate Medical Education, which oversees more than seventy-eight hundred residency programs, adopted guidelines that limited duty hours to eighty hours a week (surgical programs were permitted to have residents work eighty-eight hours per week) for the nation's one hundred thousand physicians-in-training. By July 2004, a study performed by the accreditation council found that most medical residency programs were adhering to the new guidelines. The council's review of 2,019 medical residency

TABLE 2.2

training programs found that just 5% of programs did not comply with the new standards ("New Doctors Work Less but Problems Persist," Associated Press, CNN.com, July 28, 2004).

Applying to Medical School

The average premedical student applies to twelve medical schools. There is an average of 2.6 applicants for every available opening. The ratio, however, jumps as high as seventy to one for small, selective schools such as the Mayo Medical School in Rochester, Minnesota, or the Yale College of Medicine in New Haven, Connecticut. After a six-year decline, the number of applicants to U.S. medical schools is on the rise, according to a survey by the Association of American Medical Colleges published in 2003. There were nearly thirty-five thousand applicants in the 2003–04 school year, a 3.4% increase over the prior year's applicant pool of 33,625. The increase was driven by the number of women applicants—17,672—an almost 7% rise over the prior year's total. For the first time ever, women made up the majority of medical school applicants. Despite this increase the number of applicants was still well below the all-time high of 46,965 in 1996. (See Table 2.2.) These applicants were vying for 16,500 available places.

There are several explanations for the six-year (1996–2002) decline in medical school applications. With the exponential growth in the cost of medical school, some prospective students may no longer be willing or able to incur such significant debt. Another factor may be physician concern about the growing health care system bureaucracy and unavoidable paperwork, including requirements to seek approval from insurers for many diagnostic tests, surgical procedures, and admission of patients to hospitals. Intrusion into medical practice from government and private payers, fear of malpractice suits, and increasing consumer demand for greater equality in physician-patient relationships may have combined to diminish some of the professional satisfaction and prestige associated with the medical practice.

Still, despite mounting costs for medical education and growing constraints on physicians' practices, a medical degree still offers continuing employment, economic security, and a measurable way to help people. Many potential physicians consider medicine a rewarding and relatively "recession-proof" way to earn a living.

applicants and students becoming older and more diverse. Data from the AAMC also indicate that classes

TABLE 2.3

in American medical schools more closely resemble the American population in gender and ethnic background than they did two decades ago. However, minority enrollment has declined in recent years from its peak in the early and mid- 1990s. For the 2003–04 school year, the number of African-American applicants rose almost 5% to 2,736 (1,904 of the 2,736 were African-American female applicants), but the number of African-Americans who entered medical school declined by 6% to 1,056 from the prior year. Hispanic applicants increased by less than 2% to 2,483, while the number who entered medical school declined by almost 4% to 1,089.

Medical students are also older than they used to be. In the past, almost all students entered medical school directly from undergraduate college. While the majority of students in the late 1990s were still fresh from college, in recent years older applicants have gained admission, and many medical schools have come to value the maturity and experience of older students.

Number of Physicians in Practice Is Increasing

In 2001 an estimated 713,375 physicians practiced medicine in the United States, about 23% more than the 547,310 practicing in 1990. (See Table 2.3.) The proportion of physicians in patient care (as opposed to researchers, educators, or retired) has increased dramatically—from 13.5 per ten thousand civilian population in 1975, to 21.3 in 1995, to 22.6 in 2001. (See Table 2.4.)

Table 2.4 reveals that in 2001, New England and the Middle Atlantic states had the highest ratio (31.2 and 29.4 per ten thousand respectively) of physicians practicing in patient care to civilian population. Idaho and Oklahoma were the states with the fewest physicians active in patient care (14.8 and 15 per ten thousand) and the Mountain region—including Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, and Nevada—was the region with the fewest practicing physicians (18.4 per ten thousand).

Many Are Specialists

Most doctors are specialists rather than primary care generalists. Primary care physicians are the "frontline" of the health care system—the first health professionals most people see for medical problems or routine care. Family practitioners, internists, pediatricians, and general practitioners are considered to be primary care practitioners. Primary care physicians tend to see the same patients regularly and develop relationships with patients over time as they offer preventive services, scheduled visits, follow-up, and urgent medical care. When necessary, they refer patients for consultation with, and care from, physician specialists. In 2001, 34.6% of active physicians were primary care generalists. Of this group, 12.4% were in general and family practice, 14.8% were in internal medicine, and 7.4% were in pediatrics. (See Table 2.3.)

Working Conditions

Many physicians work long, irregular hours. The U.S. Department of Labor Bureau of Labor Statistics (BLS) reported that in 2002 about one-third of physicians worked sixty hours or more a week in 2002, performing patient care and administrative duties such as office management.

TABLE 2.4

The BLS reported that physicians and surgeons held about 583,000 jobs in 2002, and one out of six was self-employed. Physicians in salaried positions, such as those employed by health maintenance organizations (HMOs), usually have shorter and more regular hours and enjoy more flexible work schedules than those in private practice. Instead of working as solo practitioners, growing numbers of physicians work in clinics, or are partners in group practices or other integrated health care systems. Medical group practices allow physicians to have more flexible schedules, realize purchasing economies of scale, pool their money to finance expensive medical equipment, and be better able to adapt to changes in the health care environment.

Data from the 2001 National Ambulatory Medical Care Survey (NAMCS) revealed that about one-third of office-based

physicians were in solo practice, 40.8% were in a single-specialty group practice, and 25.9% were in multispecialty group practices. During 2001 the typical physician in an office-based practice saw about eighty patients in the office, provided sixteen telephone and 0.5 e-mail consultations, and made thirteen hospital visits and 0.9 house calls each week. Naturally, physicians'hours and the settings in which they provided care varied somewhat depending on their specialties. General and family practitioners and pediatricians spent far more time conducting office visits, while surgeons, obstetricians, and gynecologists spent more time at the hospital performing procedures. About 17.8% of physicians made house calls during a typical week, and primary care physicians were much more likely to make house calls than physician specialists. According to the American Academy of Family Physicians, in 2003 the average family physician saw about ninety patients per week in the office, 10.5 patients in the hospital, and supervised the care of 10.5 nursing home patients, 5.7 patients receiving home health care, and 1.5 hospice patients.

The number of office visits per week varied by geographic location. Rural family physicians saw more patients in their offices (93.9) per week than their urban counterpart (89.1). Family physicians in the West South Central region reported the highest number of office visits per week—104.5—while family physicians in New England had the fewest office visits per week—75.1 (American Academy of Family Physicians, Practice Profile Survey, May 2003).

Physicians' Earnings and Opportunities

Physicians' earnings are among the highest of any profession. According to the Medical Group Management Association (MGMA) publication Physician Compensation and Production Report, 2003, the median total compensation for physicians in 2002 varied by specialty. The range of salaries varies widely and is often based on a

FIGURE 2.1

physician's specialty, the number of years in practice, hours worked, and geographic location. Anesthesiologists and general surgeons were among the top earners with median earnings of $306,964 and $255,438, respectively, while pediatricians and family practitioners earned the least, $152,690 and $150,267 a year, respectively.

Although the costs of running a medical practice have increased as a result of additional administrative requirements such as complicated billing and reimbursement formulas,

FIGURE 2.2

the prospects for physicians' employment and earnings continue to be excellent. Demand for physicians' services keeps pace with the growing and aging U.S. population, and rapidly evolving biotechnological advances promise to enable physicians to do more, and for more people. According to the U.S. Bureau of Labor Statistics, future opportunities for physicians will be plentiful, especially in rural and low-income communities.

Physician Visits

In 2001 Americans made about 3.1 physician office visits per person for a total of more than 880 million office visits to physicians, and half of these visits were to primary care physicians. (See Figure 2.1.) Women visited physicians more often than men, and, as expected, persons over seventy-five years of age saw doctors more than twice as often as most younger persons. African-Americans of all ages made fewer physician office visits than whites, about 1.9 times per year compared with 3.4 visits per year. (See Figure 2.2.)

According to the National Center for Health Statistics' Health, United States, 2003, people also visited physicians in other settings including hospital emergency departments and home visits, making the total of all ambulatory care visits to physician offices, hospital outpatient, and emergency departments more than one billion for the second consecutive year in 2001.

Understandably, older adults made more ambulatory care visits, with men over age seventy-five making the most frequent visits to physicians' offices and hospital outpatient and emergency departments. In 2001 African-American older adults (aged seventy-five and older) made more than twice as many hospital outpatient visits (sixty-seven visits per one hundred persons) as white older adults (thirty-six visits per one hundred persons). Similarly African-American older adults were seen much more frequently by physicians in hospital emergency departments (ninety-one visits per one hundred persons) than white older adults (fifty-eight visits per one hundred persons), according to the National Center for Health Statistics.

Physician Satisfaction

Changes in the health care delivery system, particularly the shift from traditional fee-for-service practice to managed care, with its efforts to standardize medical practice—which reduces physicians' ability to manage their time, schedules, and professional relationships—have been named as factors contributing to physicians' dissatisfaction with their choice of career. Other changes, including decreasing reimbursement and an ever-increasing emphasis on documentation to satisfy government and private payers as well as administrative requirements that infringe on time physicians would rather spend caring for patients, have also fanned the flames of physician dissatisfaction.

Research conducted by Bruce Landon and his colleagues at Harvard Medical School and the Center for Studying Health System Change (HSC) found that while the majority of physicians were satisfied with their careers, there was significant geographic variation in physician satisfaction

TABLE 2.5

("Changes in Career Satisfaction among Primary Care and Specialist Physicians, 1997–2001," Journal of the American Medical Association, vol. 289, no. 4, January 22/29, 2003).

The researchers surveyed more than twelve thousand primary care and specialist physicians who spent at least twenty hours per week in patient care in 1997, 1999, and 2001. Each survey found that approximately 80% of primary care and specialist physicians were somewhat or very satisfied with their careers, and about 18% were somewhat or very dissatisfied with their careers. The study also examined physician career satisfaction in twelve market regions in an effort to identify some of the underlying reasons for satisfaction and dissatisfaction.

Although new state regulations and health plan mergers, as well as changes in hospital competition and practice ownership, may have contributed to the geographic variation physician dissatisfaction, the researchers found that physician independence—the freedom to make clinical decisions in the best interest of patients, being able to spend adequate time with patients, and maintaining ongoing relationships with patients—was more important than income in predicting changes in physician satisfaction. Physicians who felt they had the greatest degree of autonomy appear to be the most satisfied with their career choices.

REGISTERED NURSES

Registered nurses (RNs) are licensed by the state to care for the sick and to promote health. RNs supervise hospital care, administer medication and treatment as prescribed by physicians, monitor the progress of patients, and provide health education. Nurses work in a variety of settings, including hospitals, nursing homes, physicians'offices, clinics, and schools.

Education for Nurses

There are three types of education for registered nurses. These include associate degrees (two-year community college programs), baccalaureate programs (four years of college), and postgraduate (master's degree and doctorate) programs. The baccalaureate degree provides more knowledge of community health services, as well as the psychological and social aspects of caring for patients, than does the associate degree. Those who complete the four-year baccalaureate degree and the other advanced degrees are generally better prepared to eventually attain administrative or management positions and may have greater opportunities for upward mobility in related disciplines such as research, teaching, and public health.

Between 1980 and 1999, the number of registered nurses grew from 1.3 million to 2.3 million. Over the same period, the proportion of nurses per one hundred thousand population rose from 560 per one hundred thousand to 832.9 per one hundred thousand. (See Table 2.5.) The largest percentage increases occurred among those holding baccalaureate, master's, and doctorate degrees.

need for nurses exceeds supply. Although the number of registered nurses holding baccalaureate degrees increased sharply during the 1990s, there is still a shortage of nurses that is predicted to persist until 2020. Some health care experts believe that the shortage is intensifying because more lucrative fields are now open to women, the traditional nursing population. Nursing school enrollment has declined. In an article in the Journal of Nursing Administration (vol. 32, no. 2, February 2002), Marilyn Kettering Murray, MN, RN, reported that the nursing shortage has already sharply compromised hospital operations. Researchers have confirmed that since 2002 the nursing shortage has caused more than 25% of hospitals to redirect patients to alternative facilities for emergency treatment, reduce their available number of beds, and cancel scheduled surgeries.

Industry observers feel the shortage results from a combination of factors including an aging population, a sicker population of hospitalized patients requiring more labor-intensive care, and public perception that nursing is a thankless, unglamorous job involving grueling physical labor, long hours, and low pay. A 2002–03 survey found that nursing was rated the 143rd most desirable job out of 250 professions, down from 137th in 2001. Observers also note that the public, particularly high school students considering careers in health care, are unaware of the many new opportunities in nursing such as advance practice nursing, which offers additional independence and increased earning potential, and the technology-driven field of applied informatics (computer management of information).

ADVANCE PRACTICE NURSES AND PHYSICIAN ASSISTANTS

Much of the preventive medical care and treatment usually delivered by physicians may also be provided by mid-level practitioners—health professionals with less formal education and training than physicians. Advance practice nurses, a group that includes certified nurse midwives (CNMs), nurse practitioners (NPs), and clinical nurse specialists (CNS—registered nurses with advanced nursing degrees who specialize in areas such as mental health, gerontology, cardiac or cancer care, and community or neonatal health). Physician assistants (PAs) are mid-level practitioners who work under the auspices, supervision, or direction of physicians. They perform physical examinations, order and interpret laboratory and radiological studies, and prescribe medication. They even do procedures—flexible sigmoidoscopy, biopsy, suturing, casting, and administering anesthesia—once performed exclusively by physicians.

The origins of each profession are key to understanding the differences between them. Nursing has the longer history, and nurses are recognized members of the health care team. For this reason, NPs—registered nurses with advanced academic and clinical experience—initially were easily integrated into many practice settings.

Physician assistant is the newer of the two disciplines. PAs have been practicing in the United States since the early 1970s. The career originated as civilian employment for returning Vietnam War veterans who had worked as medics. The veterans needed immediate employment and few had the educational prerequisites, time, or resources to pursue the training necessary to become physicians. At the same time, the United States was projecting a dire shortage of primary care physicians, especially in rural and inner city practices. The use of PAs and NPs was seen as an ideal rapid response to the demand for additional medical services. They could be deployed quickly to serve remote communities or underserved populations for a fraction of the costs associated with physicians.

The numbers of physician assistants and nurse practitioners have increased dramatically since the beginning of the 1990s. In 2004 there were nearly 140,000 advanced practice nurses (48,237 nurse practitioners, seventy-four hundred certified nurse midwives, 58,185 clinical nurse specialists, and 25,238 certified registered nurse anesthetists) and more than fifty thousand practicing physician assistants in the United States. Together, mid-level practitioners are expected to outnumber primary care physicians in 2005. According to the American Academy of Physician Assistants (AAPA), at the start of the 2004 school year there were about ten thousand students enrolled in PA programs.

Training, Certification, and Practice

Advance practice nurses usually have considerable clinical nursing experience before completing certificate or master's degree nurse practitioner programs. Key components of NP programs are instruction in nursing theory and practice as well as a period of direct supervision by a physician or nurse practitioner. The American College of Nurse Practitioners states that NPs are prepared to practice "either independently or as part of a health care team," but NP scope of practice varies by state.

PA training programs are accredited by the Commission on Accreditation of Allied Health Education Programs. According to the AAPA, most students have an undergraduate degree and about 45 months of health care experience before they enter a two-year PA training program. Graduates sit for a national certifying examination and, once certified, must earn one hundred hours of continuing medical education every two years and pass a recertification exam every six years.

PA practice is always delegated by the physician and conducted with physician supervision. The extent and nature of physician supervision varies from state to state. For example, Connecticut permits a physician to supervise up to six PAs while California limits a supervising physician to two. Although PAs work interdependently with MDs, supervision is not necessarily direct and onsite; some PAs working in remote communities are supervised primarily by telephone.

patients are satisfied with care from mid-level practitioners. Health care consumers bonded with NPs almost overnight. Their presence in neonatal and well-baby clinics, physicians' offices, school health, and busy pediatrics practices immediately improved access to, and availability of, primary health care services. Their focus on patient education, counseling, and preventive medicine generated measurable improvements in patient satisfaction.

During 2000, studies published in the Journal of the American Medical Association (JAMA) and British Medical Journal (BMJ) reported that patient satisfaction with NPs and clinical outcomes (the results of the care delivered) were indistinguishable from those achieved under physician care. Mary Mundinger, DrPH, RN, FAAN, and her colleagues conducted the first large-scale, randomized clinical trial of NPs and MDs in similar New York City practices. They found that physicians and NPs used comparable hospital and other services, and their patients, largely non-English speaking and medically underserved, fared equally well in terms of health outcomes.

Consumers seem receptive to care from advance practice nurses in a variety of settings. In other studies reported by JAMA and BMJ in 2000, researchers measured patient satisfaction with emergency services delivered by a family nurse practitioner in a rural hospital. They found "patients' perceptions of care provided by the NP were favorable." Physician response was equally approving—the physician group managing emergency services was so impressed with the competence of the first NP, they hired additional NPs to staff the department.

An editorial in the same issue of JAMA, written by a physician, was critical of Dr. Mundinger's research methods and conclusions. Harold Sox, MD, felt that the one-year follow-up was not long enough to assess outcomes or practitioner competence accurately. Dr. Sox argued that Dr. Mundinger's claim of comparable care was "far from convincing."

The BMJ study speculated that increased patient satisfaction with care from mid-level practitioners might be attributable to greater accessibility to NPs, such as the relative ease in obtaining same-day appointments and the extra time—in this study, an average of two additional minutes per visit—NPs spent with patients.

DENTISTS

Dentists diagnose and treat problems of the teeth, gums, and mouth, take X-rays, apply protective plastic sealant to children's teeth, fill cavities, straighten teeth, and treat gum disease. In 2003 there were about 152,000 professionally active (as opposed to retired or employed in other fields) dentists in the United States, almost twice as many as were practicing thirty years earlier.

Fluoridation of community water supplies and improved dental hygiene have dramatically improved the dental health of Americans. Dental caries (cavities) among all age groups have declined significantly. As a result, many dental services are shifting focus from young people to adults. Many adults today are choosing to have orthodontic services, such as straightening their teeth. In addition, the older adult population generally requires more complex dental procedures, such as endodontic (root canal) services, bridges, and dentures.

Most Dentists Have Their Own Practices

The overwhelming majority of dentists own solo dental practices, where only one dentist operates in each office. According to the American Dental Association (ADA), about two-thirds (66%) of the nation's private dentists work in solo practices and 33% work in group dental practices. Dentists work an average of 37.3 hours per week, supervise two full-time and two part-time staffers, such as dental technicians and hygienists, and schedule about eighty-four office visits per week. (Some of these patients are only seen by the hygienist.) According to the U.S. Bureau of Labor Statistics, self-employed dentists in general practice had an average net income (after taxes and expenses) of $158,080, and dental specialists netted about $240,580. In 2002 salaried dentists' median earnings were $123,210.

Dental Specialists

About 20% of all dentists practiced in one of the eight specialty areas recognized by the ADA. Orthodontists, who straighten teeth, make up the largest group of specialists. The next largest group, oral and maxillofacial surgeons, operate on the mouth and jaws. The rest of the specialists concentrate in pediatric dentistry (dentistry for children), periodontics (treating the gums), prosthodontics (making dentures and artificial teeth), endodontics (root canals), public health dentistry (community dental health), and oral pathology (diseases of the mouth). Cosmetic dentistry, including tooth whitening and restoration, is one of the newest and fastest-growing specialties.

As of 2004, seventeen states licensed or certified dentists who practice in a specialty area. Requirements vary by state and specialty and may include two to four years of postgraduate education and a passing score on a state-administered examination. Dentists who teach or conduct research generally spend an additional two to five years in advanced dental training in programs operated by dental schools or university-affiliated hospitals.

Training to Become a Dentist

Entry into dental schools requires two to four years of college-level pre-dental education—most dental students have earned excellent grades and have at least a bachelor's degree when they enter dental school. Dentists should have good visual memory, excellent judgment about space and shape, a high degree of manual dexterity, and scientific ability. Development and maintenance of a successful private practice requires business acumen, the ability to manage and organize people and materials, and strong interpersonal skills.

Dental schools require applicants to take the Dental Admissions Test (DAT). During the admission process, schools consider scores earned on the DAT, applicants' grade-point averages, and information gleaned from recommendations and interviews. Dental school usually lasts four academic years. A student begins by studying the basic sciences, including anatomy, microbiology, biochemistry, and physiology. During the last two years, students receive practical experience by treating patients, usually in dental clinics supervised by licensed dentists.

In 2003, 4,443 students graduated from the nation's fifty-six dental schools. Men outnumbered women graduates by almost two to one. Of the graduates, more than two-thirds were white and 5.4% were African-American, 5.9% were Hispanic, and 0.4% were Native American/Alaska Native (2002/2003 Survey of Advanced Dental Education, American Dental Association).

Visiting the Dentist

In 2001 more than two-thirds (65.6%) of Americans over two years of age had visited their dentists at least once in the past year. (See Table 2.6.) Children ages two to seventeen (73.3%) were more likely to have visited the dentist than any other age group, and women of all ages were somewhat more likely to see the dentist than men. Among adults aged eighteen to sixty-four, the proportion of non-Hispanic whites visiting dentists (66.6%) was considerably higher than the proportions of non-Hispanic African-Americans (55.8%) and Hispanics (49.2%). As anticipated, Table 2.6 shows that persons who were poor or near poor were much less likely to visit the dentist annually than those who were not poor.

severe shortages of dentists in some areas. The United States boasts the highest concentration of dentists of any country in the world. Nonetheless, health care planners caution that dentists' ranks will begin to decline during the coming decade as the number of dental school graduates, now about four thousand annually, falls below the number of dentists retiring from the work force. Even before this decline, residents of many states do not have adequate access to dental care, especially persons in rural communities and poor urban neighborhoods, where, arguably, the need is greatest.

The U.S. Department of Health and Human Services (HHS) reported that thirty-one million people live in shortage areas, with certain regions such as the Great Plains, southern Texas, much of Nevada, and northern Maine disproportionately affected. Health care planners estimate that 4,650 dentists are needed to restore access to dental care and deliver the appropriate level of service.

A September 20, 2003, CBS News report, "Where Have All the Dentists Gone?," described the plight of residents of Berlin, New Hampshire, one of 1,480 areas in the United States designated by federal authorities as suffering from a dentist shortage. Berlin has about 10,600 residents and just two dentists. In Berlin, even patients with private dental insurance often must wait months for an appointment, or travel long distances to visit a dentist. Uninsured and low-income families have even more difficulty gaining access to already overbooked dentists.

Dr. William Kassler, New Hampshire's state medical director, said nearly 20% of the state's 1.2 million residents live in communities with too few dentists. The dental problems resulting from the shortage are compounded by the fact that many towns, including Berlin, have unfluoridated water, causing higher cavity rates among local children who then lack ready access to treatment.

TABLE 2.6

Since New Hampshire is one of sixteen states with no dental school, it must actively recruit recent graduates or young dentists to serve needy towns or replace the many dentists now nearing retirement. Like many others states, New Hampshire is trying to attract dentists by offering to repay their student loans. Another state initiative pays the malpractice insurance and license fees of retired dentists willing to donate at least one hundred hours a year to treat underserved patients.

ALLIED HEALTH CARE PROVIDERS

Many health care services are provided by an interdisciplinary team of health professionals. The complete health care team may include physicians, nurses, mid-level practitioners, and dentists; physical and occupational therapists; audiologists and speech-language pathologists; licensed practical nurses, nurses' aides, and home health aides; and pharmacists, optometrists, podiatrists, dental hygienists, social workers, registered dieticians, and others. Table 2.7 describes some of these allied heath professions. Specific health care teams are assembled to meet the varying needs of patients. For example, the team involved in stroke rehabilitation might include a physician, nurse, physical and occupational therapists, a speech-language pathologist, and a social worker.

Physical and Occupational Therapists

Physical therapists (PTs) are licensed practitioners who work with patients to preserve and restore function, improve capabilities and mobility, and regain independence following illness or injury. They also aim to prevent or limit disability and slow the progress of debilitating diseases. Treatment involves exercise to improve range of motion, balance, coordination, flexibility, strength, and endurance. PTs may also use electrical stimulation to promote healing, hot and cold packs to relieve pain and inflammation (swelling), and therapeutic massage.

According to the U.S. Bureau of Labor Statistics, PTs worked at 137,000 jobs in 2002, but one in four were part-time jobs and some PTs held two or more jobs at the same time. Two-thirds of practicing PTs worked in hospitals and the remaining PTs were employed in physicians'offices, outpatient rehabilitation clinics, nursing homes, and home health agencies. Though most work in rehabilitation, PTs may specialize in areas such as sports medicine, pediatrics, or neurology. PTs often work as members of a health care team and may supervise physical therapy assistants or aides. Physical therapists'median annual earnings were $57,330 in 2002.

Occupational therapists (OTs) focus on helping people relearn and improve their abilities to perform the "activities of daily living," the tasks they perform during the course of their work and home lives. Examples of activities of daily living that OTs help patients to regain are dressing, bathing themselves, and meal preparation. For persons with long-term or permanent disabilities, OTs may assist them to find new ways to accomplish their responsibilities on the job, sometimes using adaptive equipment or by asking employers to accommodate workers with special needs such as persons in wheelchairs. OTs use computer programs and simulations to help patients restore fine motor skills and practice reasoning, decision making, and problem solving.

The U.S. Bureau of Labor Statistics reported that OTs filled eighty-two thousand jobs in 2002 with one in six holding more than one job at a time. The demand for OTs and PTs is expected to exceed the available supply through 2010. In addition to hospital and rehabilitation center jobs, it is anticipated that PTs and OTs will increasingly be involved in school program efforts to meet the needs of disabled and special education students.

Today, a bachelor's degree in occupational therapy is the minimum educational requirement; beginning in 2007, however, a master's degree or higher will be required. Median annual earnings of occupational therapists were $51,990 in 2002.

Pharmacists Provide Valuable Patient Care Services

Today pharmacists are involved in many more aspects of patient care than simply compounding and dispensing medication from behind the drugstore counter. According to the American Pharmaceutical Association (APhA), its more than 50,000 members (including practicing pharmacists, pharmaceutical scientists, students, and technicians) provide pharmaceutical care that not only improves patient adherence to prescribed drug treatment but also reduces

TABLE 2.7

the frequency of drug therapy mishaps, which can have serious and even life-threatening consequences.

Studies citing the value of pharmacists in patient care describe pharmacists improving rates of immunization against disease (pharmacists can provide immunization in twenty-seven states), assisting patients to better control chronic diseases such as asthma and diabetes, reducing the frequency and severity of drug interactions and adverse reactions, and helping patients effectively manage pain and symptoms of disease, especially at the end of life. Pharmacists also offer public health education programs about prescription medication safety, prevention of poisoning, appropriate use of nonprescription (over-the-counter) drugs, and medical self-care.

The U.S. Bureau of Labor Statistics reported that pharmacists held about 230,000 jobs in 2002. More than 60% worked in community pharmacies—either independently owned or part of a drugstore chain, grocery store, department store, or mass merchandiser. Most full-time salaried pharmacists worked about forty hours a week; however, about 19% worked part time in 2002, and many self-employed pharmacists worked more than fifty hours a week. The median annual wage and salary earnings of pharmacists in 2002 was $77,050.

INCREASE IN HEALTH CARE EMPLOYMENT

In 2002 almost thirteen million persons worked in the health care services, about three times the number employed in health services in 1970, when 4.2 million worked in the health field. (See Table 2.8.) Workers in health care professions accounted for 8.8% of all employed Americans (excluding military personnel). In 1970 only 5.5% of employed civilians worked in health care services.

Since 1970, the proportion of health care workers employed in hospitals has dropped dramatically. More than six in ten (63.4%) of health services personnel worked in hospitals in 1970. By 1990 that number had dropped to 49.6% employed in hospitals, and by 2002 that number fell again, to 42.2%. While hospitals still employ a larger proportion of health workers than any other service locations, more patients are now able to receive treatment in physicians' offices, clinics, and other outpatient settings. In addition, insurers are less willing to pay for lengthy hospitalizations than they were in the past.

Why Is Health Care Booming?

Three major factors appear to have influenced the escalation in health care employment: advances in technology, the increasing amounts of money spent on health care, and the aging of the U.S. population. In other sectors of the economy, technology often replaces humans in the labor force. But health care technology has increased the demand for highly trained specialists to operate the sophisticated equipment. Because of technological advances, patients are likely to undergo more tests and diagnostic procedures, take more drugs, see more specialists, and be subjected to more aggressive treatments than ever before.

The second factor in the increase in health care employment involves the amount of money the nation spends on keeping its citizens in good health. Americans spent more than $1.6 trillion on health care in 2004 and the Centers for Medicare & Medicaid Services project that national health expenditures will reach $3.4 trillion in 2013. For each year that the amount of money spent on health care continues to grow, employment in the field grows as well. Some health care industry observers believe

TABLE 2.8

that government and private financing for the health care industry, unlike most other fields, is virtually unlimited.

The third factor contributing to the rise in the number of health care workers is the aging of the nation's population. There are greater numbers of older adults in the United States than ever before, and they are living longer. According to the U.S. Bureau of the Census estimates, in 2005, 4.9 million Americans will be age eighty-five or older; and by 2030, 18.2 million people will be over the age of eighty-five.

The increase in the number of older people is expected to boost the demand for home health care services, assisted living, and nursing home care. Many nursing homes now offer special care for stroke patients, persons with Alzheimer's disease (progressive cognitive impairment), and persons who need a respirator to breathe. To care for such patients, nursing homes need more physical therapists, nurses' aides, and respiratory therapists—three of the fastest-growing occupations. The U.S. Bureau of Labor Statistics estimated that from 1996 to 2006 the number of physical therapists would increase 70.8%, to 196,000, and the number of respiratory therapists would grow 45.8%, to 119,000.

COMPLEMENTARY AND ALTERNATIVE MEDICINE

The National Center for Complementary and Alternative Medicine (NCCAM), an institute of the National Institutes of Health (NIH), defines alternative medicine as "a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine." Though there is some overlap between them, the NCCAM further distinguishes between "complementary," "alternative," and "integrative" medicine in the following manner:

• Alternative medicine is therapy or treatment that is used instead of conventional medical treatment.
• Complementary medicine is nonstandard therapy or treatment that is used along with conventional medicine, not in place of it. Complementary medicine appears to offer health benefits but there is generally no scientific evidence to support its utility.
• Integrative medicine is the combination of conventional medical treatment and complementary and alternative medicine (CAM) therapies that have been scientifically researched and have demonstrated evidence that they are both safe and effective.

In general terms, alternative therapies are untested and unproven, while complementary and integrative practices that are used in conjunction with mainstream medicine often have substantial scientific basis of demonstrated safety and efficacy.

Growing Popularity of Complementary and Alternative Medicine

In the United States, there is increasing enthusiasm for and use of complementary and alternative medicine (CAM) approaches and practices. Surveys conducted in 1991 and 1997 by Harvard Medical School researcher Dr. David Eisenberg and his colleagues about the use of alternative medicine in the United States found that more than four in ten Americans had used at least one alternative therapy (including the services of nutritionists, Pilates and tai' chi instructors, and chiropractors, among others). The earlier survey published in the New England Journal of Medicine in 1993 found that:

• In 1990 about one third of Americans regularly used alternative medicine therapies and treatment.
• Americans made more office visits to alternative medical practitioners than to traditional primary care physicians.
• About $14 billion per year was spent on alternative medicine.

The November 1998 Journal of the American Medical Association survey revealed that:

• Americans' use of alternative medicine had skyrocketed since the prior survey, from 34% to 42%.
• Total visits to alternative medicine practitioners rose by 47%.
• About $27 billion was spent out-of-pocket (not paid by insurance) for alternative medicine, nearly twice as much as was spent in seven years earlier and about as much as Americans paid out-of-pocket for conventional treatments from physicians in the same year.
• The highest rates of CAM use were among college graduates living in the western United States, ages thirty-five to forty-nine, with incomes greater than $50,000 per year.

A telephone survey of thirty-one thousand adults conducted in 2002 by several government agencies including the NIH, NCCAM, and the Centers for Disease Control and Prevention (CDC), confirmed the findings of previous surveys—that a significant proportion of Americans, as high as 62%, were using CAM therapies and products ("Complementary and Alternative Medicine Use among Adults: United States 2002," http://altmed.od.nih.gov/news/report.pdf, May 24, 2004).

ALTERNATIVE MEDICINE SYSTEMS AND PRACTITIONERS

This section considers two alternative medicine systems that originated in Western culture—homeopathy and naturopathic medicine—and two alternative medicine systems that developed in non-Western cultures—acupuncture and traditional Chinese medicine. It also describes some of the CAM practitioners who are providing care for Americans.

Homeopathic Medicine

Homeopathic medicine (also called homeopathy) is based on the belief that "like cures like" and uses very diluted amounts of natural substances to encourage the body's own self-healing mechanisms. Homeopathy was developed by a German physician, Dr. Samuel Hahnemann, in the 1790s. Dr. Hahnemann found that he could produce symptoms of particular diseases by injecting small doses of various herbal substances. This discovery inspired him to administer to sick people extremely diluted formulations of substances that would produce the same symptoms they suffered from in an effort to stimulate natural recovery and regeneration.

According to Dr. Kenneth Pelletier, a clinical professor of medicine at Stanford University School of Medicine and director of the NIH-funded Complementary and Alternative Medicine Program at Stanford, homeopathy has demonstrated effectiveness for a variety of ailments. In his book The Best of Alternative Medicine: What Works? What Does Not? (New York, NY: Simon & Schuster, 2000), Dr. Pelletier reports that clinical trials of homeopathy found it effective for the treatment of disorders such as seasonal allergies, asthma, childhood diarrhea, fibromyalgia, influenza, and rheumatoid arthritis.

Naturopathic Medicine

As its name suggests, naturopathic medicine (also called naturopathy) uses naturally occurring substances to prevent, diagnose, and treat disease. Although it is now considered an alternative medicine system, it is one of the oldest medicine systems and has its origins in Native American culture and also draws from Greek, Chinese, and East Indian ideas about health and illness.

The guiding principles of modern naturopathic medicine are "first, do no harm" and "nature has the power to heal." Naturopathy seeks to treat the whole person, since disease is seen as arising from many causes rather than a single cause. Naturopathic physicians are taught that "prevention is as important as cure" and to view creating and maintaining health as equally important as curing disease. They are instructed to identify and treat the causes of diseases rather than acting only to relieve symptoms.

Naturopathic treatment methods include nutritional counseling. Methods also include the use of dietary supplements, herbs, and vitamins; hydrotherapy (water-based therapies, usually involving whirlpool or other baths); exercise; manipulation; massage; heat therapy; and electrical stimulation. Since naturopathy draws on Chinese and Indian medical techniques, naturopathic physicians often use Chinese herbs, acupuncture, and East Indian medicines to treat disease.

Dr. Pelletier's research found studies demonstrating that naturopathy was effective for conditions such as asthma, atherosclerosis, back pain, some cancers, depression, diabetes, eczema (a skin condition), middle ear infections, migraine headaches, natural childbirth, and osteoarthritis. Further, Dr. Pelletier asserted that licensed naturopathic physicians are among the best trained CAM practitioners and he predicted that research would continue to confirm the benefits and efficacy of the safe, inexpensive, and lowrisk therapies they can provide.

Traditional Chinese Medicine

Traditional Chinese medicine (TCM) uses nutrition, acupuncture, massage, herbal medicine, and Qi Gong (exercises to improve the flow of vital energy through the body) to help people achieve balance and unity of their minds, bodies, and spirits. Practiced for more than three thousand years by about one quarter of the world's population, TCM has been adopted by naturopathic physicians, chiropractors, and other CAM practitioners in the United States.

TCM views balancing qi (pronounced "chee"), the vital life force that flows over the surface of the body and through internal organs, as central to health, wellness, disease prevention, and treatment. This vital force or energy is thought to flow through the human body in meridians, or channels. The Chinese believe that pain and disease develop when there is any sort of disturbance in the natural flow. TCM also seeks to balance the feminine and masculine qualities of yin and yang using other techniques such as moxibustion, which is the stimulation of acupuncture points with heat, and cupping, in which the practitioner increases circulation by putting a heated jar on the skin of a body part.

Herbal medicine is the most commonly prescribed treatment, and herbal preparations may be consumed as teas made from boiled fresh herbs or dried powders, or in combined formulations known as patent medicines. More than two hundred herbal preparations are used in TCM, and several (such as ginseng, ma huang, and ginger) have become popular in the United States. Ginseng is supposed to improve immunity and prevent illness; ma huang is a stimulant used to promote weight loss and relieve lung congestion; and ginger is prescribed to aid digestion, relieve nausea, reduce arthritic knee pain, and improve circulation. Many modern pharmaceutical drugs are derived from TCM herbal medicines. For example, ma huang components are used to make ephedrine and pseudoephedrine; GBE made from ginkgo biloba is used to treat cerebral insufficiency (lack of blood flow to the brain); and researchers have reported some encouraging findings about the use of ginkgo biloba to improve memory and slow the progression of dementia in some patients (Edward Ernst, "The Risk-Benefit Profile of Commonly Used Herbal Therapies: Ginkgo, St. John's Wort, Ginseng, Echinacea, Saw Palmetto, and Kava," Annals of Internal Medicine, vol. 136, no. 1, January 2002).

Acupuncture

Acupuncture is a Chinese practice that dates back more than 5,000 years. Chinese medicine describes acupuncture—the insertion of extremely thin, sterile needles to any of 360 specific points on the body—as a way to balance qi. After a diagnosis of an imbalance in the flow of energy, the acupuncturist inserts needles at specific points along the meridians (pathways of energy flow throughout the body). Each point controls a different part of the body. Once the needles are in place, they are rotated gently or are briefly charged with a small electric current.

Traditional Western medicine explains the acknowledged effectiveness of acupuncture as the result of triggering the release of pain-relieving substances called endorphins that occur naturally in the body, as well as neurotransmitters and neuropeptides that influence brain chemistry. In addition to providing lasting pain relief, acupuncture has demonstrated success in helping people with substance abuse problems, relieving nausea, heightening immunity by increasing total white blood cells and T-cell production, and assisting patients to recover from stroke and other neurological impairments. Imaging techniques have confirmed that acupuncture acts to alter brain chemistry and function.

Chiropractic Physicians

Doctors of chiropractic (also known as chiropractors or DCs) treat patients whose health problems are associated mainly with the body's structural and neurological systems, especially the spine. These practitioners believe that interference with these systems can impair normal functions and lower resistance to disease. Chiropractic medicine asserts that misalignment or compression of the spinal nerves, for example, can alter many important body functions. According to the American Chiropractic Association (ACA), they "consider man as an integrated being and give special attention to the physiological and biochemical aspects including structural, spinal, musculoskeletal, neurological, vascular, nutritional, emotional, and environmental relationships." Doctors of chiropractic medicine do not use or prescribe pharmaceutical drugs or perform surgery. Instead, they rely on adjustment and manipulation of the musculoskeletal system, particularly the spinal column.

Many chiropractors use nutritional therapy and prescribe dietary supplements; some employ a technique known as applied kinesiology to diagnose and treat disease. Applied kinesiology is based on the belief that every organ problem is associated with weakness of a specific muscle. Chiropractors who use this technique claim they can accurately identify organ system dysfunction without any laboratory or other diagnostic tests.

In addition to manipulation, chiropractors also use a variety of other therapies to support healing and relax muscles before they make manual adjustments. These treatments include:

• heat and cold therapy to relieve pain, speed healing, and reduce swelling
• hydrotherapy to relax muscles and stimulate blood circulation
• immobilization such as casts, wraps, traction, and splints to protect injured areas
• electrotherapy to deliver deep tissue massage and boost circulation
• ultrasound to relieve muscle spasms and reduce swelling.

According to the ACA, chiropractic is the third-largest group of health care professionals after medicine and dentistry. The ACA predicts that there will be nearly twice as many practicing doctors of chiropractic by 2010 as there were in 1999 when approximately 50 million patients sought care from slightly more than seventy thousand chiropractors. Visits to chiropractors are most often for treatment of lower back pain, neck pain, and headaches.

Critics of chiropractic are concerned about injuries resulting from powerful manual adjustments, and some physicians question chiropractors' abilities to establish medical diagnoses. Others worry that persons seeking chiropractic care instead of traditional allopathic medical care may be forgoing lifesaving diagnoses and treatment.

Alternative Medicine Is More Than a Fad

Researchers from the Harvard Medical School looked at long-term trends in the use of CAM therapies in the United States and published their findings in the August 21, 2001, issue of the Annals of Internal Medicine. The researchers conducted more than two thousand surveys and traced patterns of CAM utilization since the 1960s. They questioned survey respondents about twenty different CAM practices such as acupuncture, aromatherapy, biofeedback, energy healing, massage, and yoga.

The study found that over the past forty years nearly all of the twenty CAM therapies had increased in popularity, though interest surged during the 1960s and 1970s. The researchers observed that specific CAM therapies gained acceptance during each decade. In the 1960s Americans discovered diet programs, vitamins, and self-help support groups, and in the 1970s they turned to herbal medicine, biofeedback, and energy healing. The 1980s saw growing popularity of massage and naturopathy, and during the 1990s the appeal of massage increased along with interest in aromatherapy, energy healing, herbal medicine, and yoga.

Unlike the earlier studies that found CAM users to be mostly educated adults living in Western states, the Harvard researchers found the use of alternative therapies was unrelated to education, gender, or ethnicity. They observed that the increases in acceptance and use of CAM during the past fifty years suggest that demand for CAM therapies will continue in the future.

More recent research reveals that Americans' interest in and enthusiasm for CAM practices continues to grow. CDC researchers report that nearly two-thirds (62.1%) of American adults used some form of complementary or alternative medicine in the past year. (See Table 2.9.) The 2002 survey of thirty-one thousand U.S. adults asked about twenty-seven types of therapies such as acupuncture and chiropractic, the use of herbs or botanical products, yoga, meditation, special diets, and megavitamin therapy.

About 36% of survey respondents had used at least one form of complementary and alternative medicine. When prayer specifically for health reasons was included on the list of alternative approaches, the number of U.S. adults using some form of CAM in the past year rose to 62%. Researchers found that people most likely to use CAM therapies were women; those with higher education; and those who had been hospitalized within the past year. (See Table 2.10.) Former smokers were also more likely than current smokers or those who had never smoked to use CAM therapies. The survey also found that African-Americans were more likely than whites or Asians to use CAM when megavitamin therapy and prayer were included in the definition. (See Table 2.10.)

In "Complementary and Alternative Medicine Use among Adults: United States, 2002," the CDC reported that alternative approaches were most often used to treat back pain or problems (16.8%), colds (9.5%), neck pain or problems (6.6%), joint pain or stiffness (4.9%), and anxiety or depression (4.5%). When asked the reason they had sought or used CAM treatments, more than half (55%) of the survey respondents said they were most likely to use CAM because they believed that it would help them when combined with conventional medical treatments. Half of the respondents thought CAM would be interesting to try, 26% used CAM because a conventional medical professional suggested they try it, and 13% used CAM because they felt that conventional medicine was too expensive.

The CDC survey also found that within the past twelve months, 43% of adults reported that they had prayed for their own health, 24% prayed for someone

TABLE 2.9

else, 19% used products such as herbs, 12% practiced deep breathing, and 8% had meditated. Just about 12% of adults sought care from a licensed CAM practitioner—8% seek care from a chiropractor, 5% use massage therapeutically, and 4% use diet-based therapies for health.

critics say alternative medicine is a waste of time and money. Although complementary and alternative medicine practices are gaining in popularity throughout the United States and Europe, many allopathic physicians and scientists regard them with skepticism because they have not been rigorously tested or proven to be effective. In the May 15, 2002, issue of Time magazine, columnist Leon Jaroff asserted that the NCCAM budget of about $105 million per year is being misspent and that NCCAM is staffed with CAM practitioners and professionals who are biased in favor of CAM practices and unable to assess objectively their value to the American people.

Jaroff also contended that NCCAM monies are repeatedly given to the same alternative practitioners and researchers and that few of the results of NCCAM studies have been published. The Time columnist stated that NCCAM is always positive about CAM practices, and that he would like to see NCCAM publish at least one report that is critical or refutes the claims of CAM practitioners. Jaroff asserted that scientific repudiation of many CAM treatments would convince Americans that they are spending increasing sums of money on essentially worthless remedies and therapies.

Although detractors criticize the absence of scientific verification of the efficacy of CAM treatments, they also question whether some CAM approaches, which are generally not covered by health insurance and are paid for by the patient, exploit persons who are desperate, gullible, or otherwise vulnerable. Finally, critics of alternative medicine are concerned that CAM practices and practitioners are not adequately regulated. They point to variability of practitioners' training and expertise as well as the largely unregulated nature of the herbal and other remedies CAM practitioners may prescribe.

TABLE 2.10