Wang et al. Respond

Yoga, tai chi, and qigong (YTQ), which have been used as accessible and cost-effective mind–body practices in Eastern countries like China and India, are disproportionately practiced among White, well-educated, and high-income groups in the United States,¹ indicating that racial/ethnic and economic disparities exist in terms of the use of YTQ. This phenomenon reflects similar usage patterns in the United States among many, but not all, complementary and alternative therapies. We would answer “unfortunately, yes” to the question posed by Ibañez et al.: “Could integrative approaches such as YTQ be increasing health disparities rather than reducing them?” We would place much of the blame not on the complementary and alternative therapies themselves but on the health insurance industry, the culture of Western medicine, and medical education.

A major barrier to use of these holistic self-care practices, particularly among low-income populations, is the continuing lack of third-party reimbursement and thus out-of-pocket costs for most complementary and alternative therapies. The lag in insurance reimbursement and lack of integrative health care have continued despite the continually increasing evidence for efficacy and effectiveness of these therapies. What is needed most are explorations of integrative health care models and payment arrangements that can facilitate access to YTQ and other efficacious mind–body therapies for all patients within the US health care system. Thus, substantial interprofessional research and multilevel strategies that emphasize public health policy reform may be critical.^2,3

Currently, most US medical schools still do not require courses in complementary and alternative health care; thus, physicians generally have little knowledge about these therapies, their holistic philosophies, and their appropriate integration with conventional medical practice. As noted by Ibañez et al., our study found that two thirds of YTQ users chose not to tell their health care providers about their use of YTQ. Why would physicians who have not been taught the value of mind–body practices be inclined to ask about or promote their use? And why would patients relay information to their physicians that they perceive as outside the domain of their physician’s interest or expertise?

We therefore applaud Ibañez et al.’s recommendation for improving communication between YTQ users and their health care providers by including more information about mind–body practices and integrative approaches in US medical school curricula, as well as by increasing continuing education training on these topics for health care professionals and therefore increasing cultural competency for both patients and health care providers.^2,4