Summary: Running into a buzz saw. That may be the best description of what happened to the MD-led integrative medicine educators when they told some CAM educators that they were about to publish an articles in Academic Medicine on competencies in integrative medicine. The CAM educators, organized now as the Academic Consortium for Complementary and Alternative Health Care, decided to conduct a formal, researched response which was published this fall in Journal of Alternative and Complementary Medicine. Here is a short report on a complex exchange between these educators, plus a response from Ben Kligler, MD, lead author of the Academic Medicine article.
So, who do you think should be charged with the responsibility for establishing the “competencies” in integrative medicine?
One answer to this question might be the Consortium of Academic Health Centers for Integrative Medicine (the Consortium), the organization which now has 39 medical school members. In fact, they provided an answer in the, to them, prestigious pages of Academic Medicine. This is the journal published by the Association of American Medical Colleges. The paper, led by Ben Kligler, MD, MPH and Victoria Maizes, MD, MPH, was entitled “Core Competencies in Integrative Medicine for Medical School Curricula: A proposal.”(1) The paper had particular heft as it was endorsed by the Consortium.
The publication represented a breakthrough in recognition for the integrative medicine MDs who were sticking their necks out in asserting the value of integrative medicine. If not exactly tablets of stone, here were, effectively, The 10 Competencies, plus, handed down from the extant authority, into the very best crowd from the perspective of the integrative MDs. This was the group to influence.
I recall when I first heard of these MD-created competencies. I was in a hotel room immediately following the original Bravewell Collaborative dinner in November of 2003. I was sitting with a mixed group of good friends and colleagues which included Adi Haramati, PhD, then vice-chair of the Consortium. Also present were 6 or 7 others. Among them were professionals licensed as naturopathic physicians, one as an acupuncture and Oriental medicine practitioner, and a direct-entry homebirth midwife. As I recall, the roof-lifting response was fueled by shock and disbelief. I paraphrase:
What, you people are setting competencies without even talking to us? We are the ones who have been in these fields and practiced for decades. What do you people know of competencies?
Something like that. One of those classic, relationship-testing moments. Because in fact the conventional academics had set their competencies without connecting to those who had been building educational programs around over-lapping competencies for at least the past couple of decades. Yes, the fear seemed to be coming true: The MDs are stealing the family jewels without reference to us who have been in the trenches, creating professions, establishing standards of practice, promoting licensing, delivering care to hundreds of thousands …
Once passions settled, the whole group of us in the room got practical. We thought: How can we bring together educators from the diverse disciplines to explore some of these issues together? That hot-house dialogue birthed both the National Education Dialogue to Advance Integrated Health Care: Creating Common Ground (NED) and the Academic Consortium for Complmentary anbd Alternative Health Care (ACCAHC).(2)
Response from the CAM Educators
As part of its work in preparation for the June 2005 NED conference, ACCAHC took on the project of formally examining the (other) Consortium’s views of competencies. The ACCAHC team – which includes representatives of all the licensed CAM disciplines – linked with a multi-disciplinary group in Portland, Oregon called the Oregon Collaborative for Complementary and Integrative Medicine. Under the leadership of Patricia Benjamin, PhD, that group engaged a modified Delphi survey on key issues in the Academic Medicine article. Last fall their work was published as “Response to a Proposal for an Integrative Medicine Curriculum” in Journal of Alternative & Complementary Medicine.(3)
The 18 member team – in which I played a bit part – noted various areas of concern. Among these were:
- Shortcoming in the definition of integrative medicine The original Consortium definition of referred only to therapies and did not acknowledge the importance of integrating health professionals and disciplines. The authors note that the Consortium did change the definition, based on a subsequent request from ACCAHC. (See: “‘Integrative Medicine’ Definition Changed by Conventional Academics at Request of CAM Academics,” November 25, 2006.)
- Not enough time if the competency is to practice Concern that the competencies paper was focusing on training “about” CAM or training an MD to practice CAM. If the latter, the ACCAHC-OCCIM team felt it was not doable given time constraints of the curriculum. The ACCAHC-OCCIM team generally felt that the Consortium’s competencies didn’t adequately reflect the “time it takes to gain competency in CAM knowledge and skills.”
- Not enough respect for distinct, whole systems The ACCAHC-OCCIM team thought that “modality” or “therapy” were used in ways that sometimes demeaned the whole system of care that the distinctly licensed practitioners represent.
- Failure to train to refer to CAM practitioners The ACCAHC-OCCIM team “identified an important omission. The proposed competencies had nothing about how to appropriately refer to a CAM practitioner.
- More on partnership and collaboration with CAM practices The team saw a number of areas where education toward collaborative care was understated or omitted.
The overall recommendation from the group was a “desire for closer collaboration between conventional medical schools and CAM academic institutions in developing IM curricula.” One model proposed is a “lateral collaboration versus a vertical collaboration,” giving representatives from diverse disciplines an opportunity for an equal voice at the table.
(1) Kligler B, Maizes V, Schachter S, et al. Academic Med 2004;79:521-531.
(2) Both were created by the Integrated Healthcare Policy Consortium
(www.ihpc.info); ACCAHC has since, with IHPC blessing,become a
(3) Benjamin P, Phillps R, Warren D, et al.JACM Volume 3, Number 9, 2007, pp.1021-1033.
Comment from Ben Kligler, MD, MPH, lead author on the Academic Medicine article: I saw Kligler, the lead author of the Academic Medicine piece, at the recent Integrative Healthcare Symposium and asked him what he thought. Here is his response:
“This exchange has certainly been a great learning experience
for those of us on the ‘conventional medicine’ side of the equation.
Hopefully our colleagues in the CAM institutions have also learned from us
about some of the challenges and constraints we face in trying to open the
doors to a more whole-person, collaborative approach to health care within the
very conservative institutions of academic medicine. I think all of us can look
forward to continuing to learn together, both personally and on an
organizational level, how to build health care teams that will be most
effective for our patients.”
Kligler’s sentiment is broadly echoed, in both camps. The Consortium’s incoming chair, Victor Sierpina, MD, strongly supported Kligler’s views when I shared them with him. Sierpina is pursuing strengthened links between his organization and ACCAHC. Meantime, ACCAHC’s leaders have structured their organization to facilitate exchange with the conventional Consortium and have planned their 2009 conference to co-locate with the conventional Consortium’s research meeting in Minnesota.
Disclosure: I was involved with both NED and ACCAHC when this action took place and remain in ACCAHC’s leadership.
for inclusion in a future Your Comments Forum.