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National rules for the education in Complementary Medicine approved in Italy

On 7 February 2013, the State and the Regions and Autonomous Provinces Conference approved the national rules for the education in Complementary Medicine. The process which led to this important event started in 2007, when the Tuscan Regional Council approved the Regional Law of Tuscany n. 9/2007, which regulates education and practice of Complementary Medicine (CM) by medical doctors, dentists, pharmacists and veterinarians. The legislation stipulates that Regional Professional Associations are to draw up lists of professional experts in CM based on the requirements defined by the Regional Law and by the Regional Committee for CM education, and to issue a specific certification.

On 20 December 2012, a proposal of National Agreement among the State and the Regions and Autonomous Provinces on rules of CM education, that includes at the moment only medical doctors and dentists, was approved by all the Italian Regional Presidents and finally the Agreement was officially signed on 7 February 2013.

Now Italy is one of the few European countries with a national law stating the rules for education in Complementary Medicine.

The agreement defines the training and accreditation of complementary medicine professionals and education institutions and  provides for the establishment of lists of CM professionals who practice acupuncture, herbal medicine and homeopathy. Those wishing to register must have a certificate issued by accredited public and private training centres and must have completed a course of no less than 500 training hours, included 100 hours of clinical practice, after having passed a theoretical and practical exam and discussed a thesis. Courses for medical doctors cannot last less than 3 years.

Transitional provisions for professionals who initiated the practice of CM before the law were also set up.

In addition to the basic principles and clinical application of complementary medical techniques, courses must ensure the teaching of medical criteria based on evidence, the capacity to conduct clinical research, and the knowledge of legislation and regulations on rights to information and informed consent.

So far, the Italian rules on CM education can be a point of reference aiming at possibly defining European rules in all the Member States.

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Italian homeopathic doctors on their way to regulation

Last month the Conference of the Regions and Autonomous Provinces in Italy approved a document on the regulation of education and training in homeopathy, acupuncture and herbal medicine for medical doctors.

The document was produced in close cooperation with the Italian Medical Council FNOMCeO, along the lines of a previous similar agreement in Tuscany and proposed by the interregional Technical Group for Complementary Medicine. It was the main hurdle to pass on the way to a national regulation. Now it is up to the State-Regions Conference to approve the agreement, probably early this year.

The agreement stipulates that doctors specialised in one of these therapies should have taken a minimum of 500 hours of theoretical and practical training over 3 years, in addition to individual study and tutoring. Also learning objectives, teaching methods, teacher training and transition rules are part of the agreement.

The assessment of qualifications for admission to the registers will be entrusted to special committees of experts nominated by the Medical Council. The accreditation of teaching institutions (public or private) will be issued by the Regions.

There are more than 20,000 doctors in Italy practising homeopathy, acupuncture and herbal medicine, while around 20% of the population use these therapies.

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EU funded CAMbrella research project holds final conference

On 29 November CAMbrella, an EU-funded pan-European research network for CAM, presented the findings of their three years’ work at a conference held at the Bavarian Representation in Brussels close to the European Parliament. They confirm that CAM is a much neglected area of research and that knowledge, provision and handling of CAM differs greatly in the different countries of Europe. Europe lags behind North America, Asia and Australia in its approach to CAM and there is an urgent need for a centralized and coordinated effort to enhance the knowledge about this field. The researchers called for a coordinated European approach, presenting a ‘Roadmap for European CAM research’.

CAMbrella research team and advisory boardCAM is in high demand by the citizens of Europe: as many as half of all citizens in Europe use complementary and alternative medicine for their healthcare needs; speaking at the final conference in Brussels, project coordinator Dr Wolfgang Weidenhammer, centre for CAM research at the TU Munich said, “Citizens are the driver for the use of CAM. Their needs and views on CAM are a key priority and their interests must be investigated and addressed in future CAM research.”

There are more than 150,000 registered medical doctors with additional CAM certification in Europe and more than 180,000 registered and certified non-medical CAM practitioners, meaning up to 65 CAM providers per 100,000 inhabitants compared to the EU figures of 95 general medical practitioners per 100,000 inhabitants. However, regulation of and education in CAM is different in each of the 39 European countries. Speaking at the conference, Prof. Vinjar Fønnebø, director of the Norwegian Institute for CAM research at the University of Tromso said: “The current EU regulation and education chaos for CAM provision makes it impossible for health professionals to give safety and security to their patients and clients.”

Substantial lack of data about CAM
To date, there has been no thorough investigation of this field of health care in Europe. There is almost no knowledge about the prevalence of CAM use by European citizens and patients. In most European countries, there has been no research into the needs of citizens regarding CAM provision and nothing much is known about the providers’ concerns.

What is CAM and what do people use it for?
CAM is an umbrella term for popular treatment strategies mostly outside conventional medicine. Practices such as herbal medicine, homeopathy, manual therapy (massage, osteopathy and reflexology), acupuncture, anthroposophic medicine or naturopathy are applied in the care of chronic conditions, disease prevention and health management. Herbal medicine is the most frequently reported CAM practice, and musculoskeletal problems the most reported conditions for the use of CAM.

The CAMbrella “Roadmap for European CAM research”
The CAMbrella researchers call on the EU to support and implement CAM research that pays proper attention to the real world conditions of European healthcare. Professor Jarle Aaarbacke, rector of University of Tromsø explains, “CAM is not part of the medicine we teach and learn in European universities – but it is nevertheless used by large numbers of patients and providers across Europe, so better we understand more about it.”
“If CAM is to be employed as part of the solution to the health care challenges we face in 2020, it is vital to obtain reliable information on its cost, safety and effectiveness in real world settings. CAMbrella’s vision is for an evidence base which enables European citizens and policy makers to make informed decisions about CAM,” adds Prof. Dr. Benno Brinkhaus, who led the roadmap workpackage, at the conference today.

CAMbrella recommends the establishment of a European research centre for CAM, allowing researchers to develop a uniform and scientific approach to CAM research, and thereby to determine the prevalence of CAM in Europe, research the most promising CAM treatments for the most common health problems such as obesity, diabetes and cancer; review patient safety, and evaluate the integration of CAM into routine healthcare treatments. And Dr. Weidenhammer sums up: “The CAMbrella project thus plays a central role for CAM and healthcare in Europe, it alls depends now on taking up the proposals and put them in action.”

Comprehensive information on the CAMbrella project can be found here

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Unprecedented CAM conference in the European Parliament

Complementary and Alternative Medicine - Innovation and Added Value for European Healthcare - a conference held in Brussels at the European Parliament on 9 October 2012. It was organised by EUROCAM, a European stakeholder group of European umbrella organisations of patients, physicians and practitioners working in Complementary and Alternative Medicine which includes the European Committee for Homeopathy. The conference was funded by the European Commission and the Robert Bosch Stiftung.

Members of the European Parliament, health professionals, patients and policy makers gathered in the European Parliament to hear and debate presentations on the innovative added value of Complementary and Alternative Medicine (CAM) for European Healthcare. The potential that CAM has to maintain health, prevent ill-health, promote healthier lifestyles and contribute to the sustainability of health systems should not be disregarded by the European Union at a time when health funding is under so much pressure from economic and demographic pressures, the Conference forcefully concluded.

CAM conference Oct2012

The event was hosted by MEP Elena Oana Antonescu (EPP, Romania) and co-hosted by MEPs Sirpa Pietikäinen (EPP, Finland) and Alojz Peterle (EPP, Slovenia). It was moderated by Harald Walach, Professor of Research Methodology and Complementary Medicine, European University Viadrina, Frankfurt/Oder, Germany.

Across Europe at least 25% of the population use CAM, currently largely paying for it out of their own pocket. Despite clear citizen use and demand, CAM has not received a proper consideration by the European institutions, despite a call to do so from the European Parliament as far back as 1997.

"We are very grateful to the European Parliament for having hosted this landmark conference, and to the Commission for having part funded it. The EU faces a serious economic crisis that puts its Member States' healthcare systems at risk and requires them to fundamentally reform. The impact of increased life expectancy, the alarming rise in chronic diseases, growing health inequalities and shortages in health workforces s are overstraining health care services in a way unseen before. We believe that investing in a CAM Innovation Partnership will support reforming health systems to focus primarily on prevention and complement conventional care in a way that benefits healthcare systems and people across Europe", stressed Ms Enid Segall on behalf of EUROCAM, one of the organisers.

“The fact that more and more Europeans live longer requires the adaptation of entire healthcare systems. I believe that complementary and alternative medicine can help promote a healthier and more environmentally aware lifestyle, with significant benefits to personal and societal health. Complementary and Alternative Medicine has the capacity to change the medical treatment philosophy, by adopting a more holistic outlook on illness and its effects”, echoed Elena Oana Antonescu, Member of the European Parliament and co-host of the event.

"CAM is reality. Research has shown that millions of patients do use CAM when diagnosed with different diseases. On the other side, we see how different is legal status of it in the Member States which is considered by patients as a kind of discrimination to them. Not much has been done so far at the EU level. I plead for a higher level of attention in this regard and call on Commission action to start a new initiative, in cooperation with the stakeholders concerned, for the regulations on the licensing and use of CAM medicinal products in Europe and in particular to act upon the suggestions outlined in the Commission Communication 2008, notably that the suitability of a separate legal framework for products of certain traditions should be assessed. For me, this is a very important element of the closeness to our citizens", echoed Alojz Peterle, Member of the European Parliament and co-host of the event.

“There is a growing demand for CAM therapies in Europe. We as the European legislators need to facilitate safe accessibility to these therapies by providing a functioning, legal framework. The next EU Health Strategy needs to set a clear and enhanced role for CAM therapies with a view to European level regulation to be established in the future", stressed Sirpa Pietikainen, Member of the European Parliament and co-host of the event.

Across Europe there are in the order of 300,000 CAM practitioners and 150,000 medical doctors practising a range of modalities such as acupuncture, anthroposophic medicine, aromatherapy, ayurveda, herbal medicine, homeopathy, kinesiology, naturopathy, massage, reflexology, shiatsu, traditional Chinese medicine, etc. They offer a whole person approach to health with a focus on supporting the person’s health-maintaining capacities and within which illness is treated according to the distinct diagnostic and treatment methods of the modalities used. This can be on a stand-alone basis and/or in ways complementary to conventional medicine. Currently CAM is mostly provided privately but in a growing number of cases in some countries in collaboration with conventional medical practitioners.

"Up to 80% of citizens in the EU Member States have used complementary and Alternative Medicines in their health care. Their hopes are to get relief from concerns that the conventional medical services do not meet, and to improve general wellbeing. And yet, access to CAM with rare exceptions is limited to those who can afford to pay for it", said Helle Johannessen, Professor of Social Studies in Health and Medicine, Institute of Public Health, Faculty of Health Sciences, University of Southern Denmark, Denmark.

"Equitable access to healthcare, including CAM, and the sustainability of health services requires a shift towards health promotion and prevention of illness. CAM has the potential to support strategies to increase critical health literacy amongst EU citizens in collaboration with conventional medicine”, echoed Andrew Long, Professor of Health Systems Research, University of Leeds, United Kingdom.

The Conference concluded by outlining how CAM can fit into the Health for Growth Programme and the economic and innovation priorities of the European Union. "The growth potential of the sector, both in terms of GDP, savings on healthcare, healthier citizens, CAM workforce and innovative competitiveness is enormous. For this to happen, we need the EU to give it its due consideration and adequate resources, as well as a framework for professionals to operate in", concluded Harald Walach, Professor of Research Methodology and Complementary Medicine, European University Viadrina, Frankfurt/Oder, Germany.

At the end of the conference EUROCAM issued a call for action addressed to the European Commission, the European Parliament and the EU Member States. It is available here.

Conference programme
Speakers' biographies

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Large majority of patients with joint diseases use manual therapies, acupuncture or homeopathy

A research team in the Netherlands explored patients’ perspectives towards the use of Complementary and Alternative Medicine (CAM), its integration in primary care and the specific role of the GP therein.

The study included a survey on use, attitudes and disclosure of CAM, an e-panel consultation and focus group among patients with joint diseases. A total of 416 patients responded to the survey who suffered from osteoarthritis (51%), rheumatoid arthritis (29%) or fibromyalgia (24%).

The following four research questions were addressed: (1) What is the prevalence of CAM use among Dutch patients with joint diseases? (2) What are these patients’ attitudes toward CAM use? (3) Do these patients disclose CAM use to their GP? (4) How do these patients envision integration of CAM therapies in primary care?

The study demonstrated a high prevalence of CAM use among patients with joint diseases. A two-year prevalence of 86%, including the use of CAM home remedies, and 71% of patients visiting a CAM practitioner. Reasons for CAM use include a wide range of factors. The primary pull factors were an integrative approach to disease management, advice from a different angle and having received positive information about CAM practitioners. Push factors for CAM use were searching for an alternative to conventional medication and no further progress with conventional treatment. These results largely confirm earlier observations, that nowadays patients intentionally seek CAM because they want to be treated in an integrative or holistic way, rather than for reasons of negative experiences with conventional treatment.

Manual therapies, acupuncture and homeopathy were most frequently used. Currently, there seems to be a gigantic gap in conventional medicine between patients who would like to discuss CAM and physicians who do not talk about it with their patients. A minority (30%) actively communicated CAM use with their General Practitioner (GP). The majority (92%) preferred a GP who informed about CAM, 70% a GP who referred to CAM, and 42% wanted GPs to collaborate with CAM practitioners. Similar attitudes were found in the focus group and upon e-panel consultation.

Interestingly, almost one quarter of patients with joint diseases reported to use less conventional medication and to pay less visits to their GP upon CAM use. Since conventional medication, especially those for rheumatoid arthritis, is associated with high expenditure of healthcare costs, this observation may indicate possible cost-effectiveness upon CAM use.

The authors conclude that most patients in primary care want a GP who listens, inquires about CAM and if necessary refers to or collaborates with CAM practitioners.
To meet needs of patients, primary care disease management would benefit from an active involvement of GPs concerning CAM communication/referral. This study presents a model addressing the role of patients and GPs within such an integrative approach.

Jong MC, et al.(2012) Integration of complementary and alternative medicine in primary care: What do patients want? Patient Education and Counseling, [PubMed]

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