John WeeksSummary: The Summary Report from the Institute of Medicine on the February 2009 Summit on Integrative Medicine and the Health of the Public is an expansive and stimulating conversation for anyone close to the integrative practice movement. The more than 60 sections in 164 pages are inviting in length, style and substance. An appendix with bios let”s you know something about the sterling group of professionals who were invited to do the talking. Here are 10 short reflections including: integrative “medicine” versus “health”; Senator Harkin”s warning about opposing vested interests; Don Berwick”s 8 principles for integrative medicine, and his holy grail for integrators; Ed Wagner”s chronic care model and a 1989 definition of naturopathic medicine; notes on NCCAM”s priorities, as shared; an opportunities for accessing $75-million a year for evaluating models, such as the Penny George Institute-Allina initiative; apparent exclusion of multiple suggestions that licensed CAM providers might help meet primary care needs; and deep thanks to the Bravewell sponsors for providing the funding that made this happen. If you are at all wonkish about this field, buy the book. Gift yourself. It”s a great little reader.
On November 4, 2009, the Institute of Medicine (IOM) of the National Academies released its Integrative Medicine and the Health of the Public: A Summary of the February 2009 Summit. The book is adamantly a summary, rather than a compendium of sanctioned recommendations such as were made in the IOM”s 2005 volume Complementary and Alternative Medicine in the United States. Yet an over-all sense of endorsement for this direction for US healthcare pervades the text. I urge you to purchase or download the Summary Report. Here are some impressions.
1. Only a report on a meeting but it feels like an IOM endorsement
The IOM never planned to offer any recommendations based on this February 25-27, 2009 Summit. Yet when the Bravewell Collaborative of philanthropists for integrative medicine chose IOM as its strategic partner, then ante-ed up the $445,000 to fund the event, Bravewell knew that they had the chance to create a sort of recommendation through association. My guess is IOM knew what they were getting into. The power of the “large and diverse group” at the February Summit of 600 participants, with an overflow of interested parties who wanted to attend, created the intended effect. IOM president Harvey Fineberg, MD, PhD and Summit chair
Ralph Snyderman, MD both state that the Summit was “far bigger and
far more important than the organizers could have anticipated.” (p 163) So while there are no formal IOM recommendations, one does see myriad recommendations from top integrative medicine leaders, and healthcare leaders otherwise unconnected to this field who were assembled by the organizers and are looking in.
Comment: Despite disclaimers, one cannot read the volume without a sense that the
energy and vision of the attendees gained a powerful
endorsement from the IOM. Credit the strategy of Bravewell, the hard work of the planning committee, which Snyderman led, and the IOM”s quality staff. The vision for health care from this diverse group, and the investment priorities offered, makes one proud, even as we slog through the other health reform debate. Kudos to Bravewell and its president Christy Mack for the vision and wherewithal to make it happen.
2. “Integrative health” prevails over “integrative medicine”
The power of word choices in how the field or movement is described was a repeat theme at the February Summit. In Fineberg”s forward to the report, he begins the hop-scotch from one term to the other that continues throughout the book. Sentence 2: “Like a Rorschach blot, integrative medicine, or integrative health, means different things to different people.” (pages ix-x) In his ensuing 3 paragraphs, he uses the “medicine” form 3 times, the “health” form twice. However, in the concluding section, moderator Michael Johns, MD, chancellor at Emory University, describes the qualities of “integrative health” then lays down the gauntlet. He “suggested replacing integrative medicine with integrative health.” (page 156) A close reading of the IOM closing pages will show how much the “integrative health” phrase came to dominate.
Comment: The IOM trend-line was toward inclusiveness of the diversity many were somewhat shocked to see in the room at the Summit. It wasn”t a typical IOM gathering. Seeing this trend at the IOM meeting made me concerned about the NIH National Center for Complementary and Alternative Medicine perspective as presented in their white paper #1 on their strategic planning process. NCCAM”s people were present at the IOM meeting and the tension over the language choice was certainly not lost on them. Yet in two long paragraphs in their white paper, NCCAM uses the “integrative medicine” term 8 times, without reference to “integrative health” or the controversy or the inclusion issues surrounding it. This is unfortunate, especially in an agency charged, by its mandate, to evaluate a handful of licensed disciplines that offer “integrative health care” but do not typically feel included in the MD-centric medical term.
3. Briggs notes NCCAM”s focus on basic research but expanding interest in real effectiveness
Among the presenters on the science of integrative medicine was NIH NCCAM director Josephine Briggs, MD. The summary of her talk notes that basic sciences consumes roughly half of NCCAM”s budget, with resources and efficacy studies, including RCTs, using another 12%. Regarding the outcomes and health services areas for research which Congress prioritized in its mandate, the Summary reads: “Effectiveness research, which is an expanding area of activity for NCCAM, is particularly ripe for new study designs.” (pages 104-105) Briggs further noted that “improved methodologies will be needed to evaluate complex complementary and alternative interventions in real world settings.”
Comment: Briggs language about the “expanding area” is hopeful for those stakeholders – such as Bravewell”s own interests in models, below – who want real world outcomes so they can influence real world decisions. Briggs needs to brace for a huge expansion from the present 1% on effectiveness and cost if she wants to make any significant impact.
4. Pilot projects and models: How Bravewell”s key recommendation can access $75-million of research funds annually
Notably, the Summit”s funding sponsor, and behind-the-scenes influencer, Bravewell, promotes the real world focus for research. The organization asserts on their website description of the Summit that the “Summit provides models for healthcare reform.” (They did not assert that the Summit proves efficacy of natural products.) Then they call out: “Large demonstration projects are needed.” They state: “Because funding for research on the effectiveness of specific models of
care is difficult to obtain from standard grant channels, participants
voiced support for pursuing a demonstration project funded by the
government that would fully demonstrate the effectiveness of the
integrative approach to care.“
Comment: Note to Bravewell: If NCCAM did what Congress mandated and had examination of outcomes and cost prioritized as Congress does in Subsection (f) of the mandate, funding such as you request would not be difficult to obtain. Heck, if the sum total of all investment in Congress” priority areas #1 (outcomes) and #3 (health services) were at what #4 (basic research) and #5 (RCTs) now receive, we”d have $75-million plus each year to help you and the rest of us on demonstration projects. Interestingly enough, perhaps the best place in the nation for a demonstration project in combined outpatient-inpatient care is via the Penny George Institute at Abbott Northwestern Hospital in the Allina system. This ambitious, model program, with over 60,000 inpatient CAM visits in the last 4 years, has Bravewell”s past president Penny George and her spouse Bill George as lead funders. Creating this kind of research funding might be the very best fund-raising they can be doing for their project. If that initiative is to be a model for the nation, as they intend, we need the outcomes. Here”s hoping Bravewell and the Macks and Georges have weighed in with NCCAM on these priorities.
5. Chronic care model”s Wagner: distinctions between prevention and treatment are breaking down
A piece of the brilliance in the organization of the Summit was to bring into the integrative healthcare dialogue thoughtful opinion makers in other areas of health care, and let them both inform and be influenced by this compelling movement and its attractive energy. One comes across many outcomes of that strategy in this Summary. One is from chronic care model leader Ed Wagner, MD, PhD who is not known, in the Seattle area which is his base, for being very open to complementary healthcare practices and integration. Yet at the Summit Wagner notes that “the mindset and principles of primary care provide a foundation for integrative care.” He shares with his audience an emerging perspective in primary care that primary care needs to transform itself to be such a foundation. Why? We now know that “for the 40 to 50 percent of the population suffering from chronic conditions, the distinctions between prevention and treatment begin to break down since the interventions are much the same.” (pages 11 and 60)
Comment: In 1989, a re-emerging group of integratively-oriented physicians, based largely in the Northwest, were completing a two year process of establishing their own self-definition. They chose to say that what defined them was that they “treated disease by restoring health.” In short, Wagner”s vision is catching up to that work of the American Association of Naturopathic Physicians 20 years ago. Had Wagner known integrative practice
better, he might have stated that “the mindset and principles of
integrative practice provide a foundation for primary care.”When I shared Wagner”s pleasing connection between prevention and treatment with my spouse, who was training to become an ND in 1989, she recalled a parallel moment in the 1993 health reform debate. I had shared a nugget from a state report in Washington which included reference to the growing recognition in conventional medicine that acute and chronic diseases are often linked. Alas, the mindset and principles of
integrative (including naturopathic medical) practice (do indeed) provide a foundation for primary care. It”s hard to always hold back the reflexive “I told you so,” especially amidst patterns of exclusion which continue to exist (see #8, below).
6. Don Berwick”s list of “Principles for Integrative Care”
Since Integrator adviser Milt Hammerly, MD, introduced me to the work of Don Berwick, MD, MPP, FRCP and the Institute for Health Improvement, Berwick”s been a hero as he has been to many. His outspoken advocacy for true patient-centered care in last year”s Health Affairs deepened my respect. Brilliant to include Berwick in this Summit. And then how fine to see Berwick”s 8 principles on page 57:
Berwick”s Principles for Integrative Medicine
- Place the patient at the center.
- Individualize care.
- Welcome family and loved ones.
- Maximize healing influences within care.
- Maximize healing influences outside of care.
- Rely on sophisticated, disciplined evidence.
- Use all relevant capacities – waste nothing.
- Connect helping influences with each other.
Berwick is quoted as concluding this way: “The sources of suffering are in separateness and the remedy is in remembering that we are all in this together. Integration, if it is to thrive, is the name of a duty to contribute what we can to a troubled and suffering planet.”
Comment: Now if you were wondering to what I was referring at the top of this article when I spoke of the vision offered at the Summit making one proud, well, these comments should help justify it! This is clean, pure and wise as it gets. Is Berwick a Western Buddha, or what?
7. Cooper “upends” view that MDs will be key “integrative medicine” providers
Workforce specialist Richard Cooper, MD offers a startling view of the shortages ahead in medicine”s near future that will prompt MDs to withdraw into “ever more narrow scientific and technological spheres, while other disciplines evolve to fill important gaps.” Cooper is paraphrased as expecting these migrations of practices would “upend many of the expectations expressed by previous speakers at the Summit – implicit in many … prescriptions for change is that (MDs) will play a crucial role in integrative medicine.” Cooper thinks medical doctors will be “abandoning primary care and leaving it almost entirely to non-physician providers.”
Comment: Perhaps it”s time for the Bravewell to fund a Consortium of Nursing Schools for Integrative Health Care, and, for that matter, to back the Academic Consortium for Complementary and Alternative Health Care that already exists, rather than only supporting the consortium of integrative academics in conventional MD medicine. (Okay this is rank fund-raising for my work under my ACCAHC hat.) If Cooper is right, these disciplines may provide the lion”s share of integrative primary care in the future and the movement Bravewell is pushing may rest with them. (As a side note, many of these NDs and DCs are not non-physicians.)
8. IOM”s disappearing act regarding licensed CAM practitioners and primary care
When the IOM”s Fineberg, Snyderman and Bravewell president Mack announced the IOM Summit on the March 28, 2008 Charlie Rose Show, the question of the presence or visibility of “CAM” at the Summit and in the Summit”s planning quickly came to the fore. Mack made a point, for the national audience, of distinguishing “integrative medicine” from “CAM” and clarifying that the Summit was about the former rather than the latter. I had the opportunity to work with others to help make sure that licensed “CAM” integrative practitioners were included in the Summit planning. Happily, IOM responded favorably, as did the planning team. I consider this to be fulfilling on Berwick principle #7: “Use all relevant capacities – waste nothing.” Yet the question was of interest to me as I open the Summary Report: To what extent would non-MDs be specifically included in the text?
A key area of interest is whether licensed CAM practitioners such as acupuncture and Oriental medicine practitioners, naturopathic physicians, whole practice chiropractors, and even direct-entry midwives would be visible in the document as potentially valuable in helping meet the nation”s primary care needs. The answer is, basically, that their potential participation is not, directly, included. Take a look at how these licensed CAM professions are made invisible in the editing choices:
- A paraphrase of comments by Mary Jo Kreitzer, RN, PhD references a new model with “nurse practitioners, physicians assistants and others to provide primary care.” (italics added – page 120)
- Comment from Victor Sierpina, MD, an Integrator adviser, includes a recommendation to “expand the pool of primary care providers to include nurses, physicians assistants and other professional groups.” (italics added – page 44)
- Comments from workforce specialist Richard Cooper, MD, on non-MDs who will help meet the primary care need similarly refer to “nurses and others” and to “nurses and other non-physician health professionals” and “non-physician clinicians.” (italics added – page 124-125)
Enlighten me if I have missed something. In general, the Summary Report only very rarely refers at all to “complementary and alternative medicine” or to any of the distinctly-licensed CAM disciplines. A reader would not know that there are 350,000 of these licensed practitioners out there, 100,000 of whom are licensed chiropractors, naturopathic physicians and acupuncturists who could, potentially, be contributors in primary care.
Comment: I confess that I have not listened to each of these individual”s presentations to know for certain what each said. But I have seen Kreitzer, Sierpina and Cooper publicly present on the topic and each supports exploration of the roles of specific licensed “CAM” practitioners in meeting primary care needs. Cooper”s work has examined the growing size and potential of the DC, ND and LAc fields to meet primary care needs. Kreitzer told the US Senate 2 days before the Summit that “there are licensed complementary and alternative medicine (CAM) providers (naturopathic medicine, chiropractic and acupuncture/Chinese medicine) who can meet this definition (of primary care) as well.” Were these disciplines intentionally kept out of the text? Looks like it.
Funny, speakers repeatedly refer enthusiastically to the
great diversity of the audience. But here, as elsewhere in the book, it is left to the reader to
imagine the ingredients of that diversity.
9. US Senator Harkin warns about vested interests and summons us all to action
US Senator Tom Harkin keynoted the section on economics and policy. He pledges to do all he can to “place integrative health care at the heart of the 2009 health reform debate.” Then he is directly quoted in this note of caution:
“Just because integrative health care is the most commonsense, rational, health-effective and cost-effective approach to reform does not mean it is a done deal. Nothing in this town is done easily, and there are tremendous entrenched forces and vested interest that will defend the conventional allopathic medicine with all their power.” (page 136)
Comment: In fact, integrative healthcare has hardly flowed into the outermost veins of the health reform debate, much less the heart. Harkin, however, can be credited for helping put it at least on the map of the body politic. He calls on all of us to speak up for the movement. Credit the IOM report editors for highlighting this obstacle. Now, about the various vested interests in the room …
10. For wonks, IOM”s integrative medicine health care book is our bedside reader
Despite certain exclusions and oversights, this little book is a great and inviting reader in this field of which we are all part. The 222 pages include just 164 of core text. These are filled with some 60 different summaries of talks from extraordinary professionals who are either deeply embedded activists in integrative care or powerful presences in US healthcare who are stopping by the movement and looking in. An appendix shares brief biographies of each.
If you are even a little wonkish about this field – and you wouldn”t be this deep into this Integrator article if you weren”t – you can literally open this volume up anywhere and find something of interest, even if you don”t agree. I am making my way through, sections at a time. What I have shared are just a few of the gems I have found thus far. Give yourself a holiday treat and buy this book. It, and the Summit described, are truly watershed moments for the emergence of both the integrative health care movement and the integrative medicine field.
johnweeks@theintegratorblog.com
for inclusion in a future Your Comments Forum.
Dr. Judith Orloff MD
Barry Bittman MD
Dr Jacob Teitelbaum MD