HACKENSACK, N.J. - When Sherran Rapp was wheeled into the operating room in August, she wasn't thinking about the 10 hours of cancer surgery about to begin. Instead, she pictured her two toddlers listening to stories at bedtime and imagined the joyous melody of a Puccini aria.

She had been trained by the hospital to focus on the positive instead of her fear.

Rapp is one of a growing number of patients who receive everything from massage to aromatherapy at their local hospitals. Before her double mastectomy, Rapp took a class on imagery and music, a technique doctors say can help reduce time spent in hospitals.

The 47-year-old Mendham, N.J., resident was so calm going into surgery that she even exchanged smiles with the surgeon before the anesthesia took effect. She left the hospital in four days and stopped pain medication in six. Now, she is doing fine and is busy with her advertising firm and family.

Hospitals cautious

With the caution of a stiff person trying yoga for the first time, hospitals are embracing some decidedly nontraditional approaches to healing. Alternative medicine is going mainstream.

At Saint Barnabas Health Care System, where Rapp underwent her operation, open-heart patients can receive a full-body massage before surgery, and foot reflexology treatments during recovery. An herbalist will mix teas to soothe nausea and nerves. Patients are encouraged to take a class about the power of imagery and are allowed to wear headphones during surgery, a practice doctors say reduces the need for pain medication.

At Pascack Valley Hospital in Westwood, N.J., acupuncturists treat the chronic pain of arthritis and migraines, and patients can get massages and biofeedback sessions at a new Center for Complementary Medicine.

A former nursing school at Englewood Hospital and Medical Center houses yoga classes for new and expectant mothers such as Rie Crawford. "It definitely helped with the delivery," said Crawford, 34, a first-time mother from West New York. She returned to the "graduate" class - for new mothers and babies - just a month after delivering her son.

At Passaic Beth Israel Hospital, Carmen Johnson, 81, joins her older sister and other seniors for weekly classes in tai chi. Hit by a car as she walked in Passaic six years ago, Johnson's fast pace and spirited repartee attest to the miraculousness of her recovery. "You have to get up off your rusty-dusty and move," she said, as she began the smooth, weight-shifting movements of the Chinese martial art to the music of Frank Sinatra.

Louis R. Ycre Jr., the president of Pascack Valley Hospital, says hospitals like his are responding to the public's demand for these services. "It's no longer right for the medical profession to ignore this," he said, noting the effectiveness of some of these approaches to pain relief.

Hospitals have a role to play in distinguishing beneficial from harmful treatments, he said. "Isn't it better to have them controlled and in the hospital?"

Getting into the business requires little investment. Massage tables and yoga mats are cheap compared with new MRIs and operating room suites. Even though no hospital in the state has made money from these ventures, the programs are a good way to attract patients for more traditional procedures.

Although the public seems eager for these offerings, reaction from physicians ranges from scorn to enthusiasm, mixed with a large dose of caution. Skeptics say much of what is called complementary medicine is old-fashioned comfort care, relabeled with fancy names and billed by the hour. Little so-called alternative treatment has passed the rigors of scientific research, they say.

"Quackery has been renamed," said Dr. Stephen Barrett, a retired Pennsylvania psychiatrist and founder of Quackwatch Inc. "What it boils down to is the [hospitals] offer a little massage, some exercise, maybe some Chinese exercise to give it some mystique, and market it as complementary and alternative medicine. All they are is relaxation techniques. They have the value of relaxation techniques, which is not very high."

Hospital executives find it less controversial to add an exercise class for the healthy to their community offerings, for example, than to win physician acceptance for a herbalist to prepare brews from a cupboard of botanical remedies.

Yet no hospital can ignore the growing popularity of these treatments. In 1997, Americans paid more out of pocket for such care - $12.2 billion - than they did for hospital stays. The number of visits to alternative medicine practitioners, such as chiropractors, massage therapists and acupuncturists, exceeded those to primary-care physicians, according to a seminal study by Daniel Eisenberg published in the Journal of the American Medical Association.

Women, people age 35 to 49, and those with higher incomes and education were most likely to seek complementary care - exactly the kind of people for whom hospitals compete.

The Valley Hospital in Ridgewood discovered in its 1999 survey that more than one-third of the households in northwestern Bergen and parts of Passaic and Morris counties had used some kind of complementary medicine in the previous year. In 1998, the University of Medicine and Dentistry of New Jersey found that one-third of its Newark faculty used herbal medicines.

A last resort

For some doctors, these services represent something to try when all else has failed.

At the Siegler Center for Integrative Medicine at St. Barnabas, "We aren't parsley on the plate," said Joanne Campbell, a holistic and critical-care nurse who is its administrative director. "We don't settle for that. We're part of the main course."

Every heart-surgery patient at St. Barnabas is offered a consultation with a holistic nurse, who asks about habits and issues that affect health, and discusses anxiety about surgery. The nurse refers patients to practitioners who can help guide lifestyle changes in exercise, diet, smoking, or stress management, and makes a follow-up call after they are discharged.

More than 90 patients have been seen so far, including a critical care patient who was recently treated with foot reflexology, a form of massage based on a system of points in the feet that are believed to correspond with the rest of the body. "He was anxious, restless and thrashing about," said Patti Panfile, the coordinator of the program. "The nurse called to ask if I could give him a healing treatment. I did reflexology on him, massaging him, stimulating the flow of energy through the feet. It causes a profound, deep relaxation. He was dozing on and off, about 10 minutes into it."

Such work, she said, is "like East meets West in terms of healing in the acute-care setting. "We're using the most advanced medical and surgical technology," she said, "and then we offer them healing therapies."

The work also showcases the jobs of holistic nurses, who have their own certification program. They look at patients as spiritual, emotional, social and physical persons, said Panfile, whose title at St. Barnabas sums it up: she is the Heart Hospital of New Jersey's "mind-body-spirit specialist."

View of skeptics

To skeptics in the medical community, the new-found institutional interest in complementary medicine is about one thing: dollars and cents. "The patient wants to feel good, and they'll pay money to do it," said Saul Green, a research biochemist formerly with the Sloan-Kettering Institute, who edits the Scientific Review of Alternative Medicine.

None of the services actually cures disease, he said. Whether it's massage, meditation, or aromatherapy, "it doesn't make a damn bit of difference with respect to the clinical condition of the patient," he said. "They are services which provide purely psychological support."

The public harm from these programs, said Barrett, the Quackwatch founder, "comes not necessarily from the people who go there. It's just the general notion that's been spread that alternative and complementary methods have value."

For hospitals, the embrace of nontraditional medicine can be tricky.

Their marketing materials are loaded with buzzwords such as "scientific," "certified," and "credentialed" - terms intended to banish any hint of faddishness. Patients depend upon physicians and their hospitals for sound medical advice, and to damage that trust by an unproven recommendation or a potentially harmful treatment would harm the entire institution.

"If patients can't turn to their physician, or health-care system, for reliable information, then where can they turn?" asked Dr. Adam Perlman, medical director of the Siegler Center.

At Hackensack University Medical Center, "I take a very strong view that in order for it to succeed, it has to be scientifically based," said Dr. Louis Teichholz, director of the Center for Complementary Medicine. The center doesn't offer homeopathy, megavitamins, magnetic therapy, or other treatments considered untested or controversial.

To gain acceptance of the staff, many hospitals have put highly respected physicians at the helms of these centers.

Hackensack turned to Teichholz, a cardiologist with a professional interest in the role of adrenaline and the "relaxation response" in heart disease, and an interest in Native American cultures, to head its center as well as cardiology services.

And when the Valley Hospital in Ridgewood decided it was time to get into the business, it partnered with the late Dr. William Fair, a urologist at Memorial Sloan-Kettering Cancer Center and founder of a chic center in Soho. He used yoga, meditation and vitamins along with conventional therapies when his colon cancer recurred. His stature with physicians was key to winning acceptance for his program, said Gail Callandrillo, Valley's vice president.

Hospitals take risk

Another hurdle for hospitals is that the credentials of non-traditional practitioners - such as yoga teachers, massage therapists, and herbalists - are tough to check. New Jersey, for example, licenses acupuncturists, but not massage therapists.

That makes it difficult for a hospital, whose reputation and liability are on the line. "We have an obligation that we take very seriously to guarantee that the people who are working here are really top quality," said Teichholz, of Hackensack, N.J.

Finally, of course, there's the money issue. The usual sources of hospital payments - government programs and insurance companies - run mostly dry. Medicare, the federal program for older Americans, doesn't cover acupuncture or other complementary treatments. Hospitals that entered the field hoping to cash in on the billions spent by consumers have learned that most of that money goes elsewhere. The hospital-based centers in North Jersey don't break even.

Pascack Valley's center doesn't deal with insurance - it expects patients to pay out-of-pocket. Fees for acupuncture are $70 to $95, depending on whether a doctor does it. The fee for a massage is $70.

"Unfortunately, most insurance companies are not yet paying," said Teichholz. Saint Barnabas does a bit better with insurance, reporting that about half of its patient visits to its integrative medicine program are covered by health insurance Even so, the center could not exist without the support of its founding donors, Carol and Morton Siegler. Those financial realities may limit the growth of such hospital-based programs.

But for some physicians, complementary medicine is part of the complete care a hospital should offer patients.

Dr. Elissa Santoro, a surgical oncologist for 32 years and the one who operated on Sherran Rapp in August, refers many of the women she treats for breast cancer for various unconventional therapies, including massage to relax, exercise to boost immunity, and herbal and nutrition advice to boost natural defenses and support the body through chemotherapy.

Her patients feel "empowered," she said. "We see excellent wound healing and personality adjustment. It's like a light bulb goes on, and they see hope - true hope. That's the greatest medicine we have."