Summary: Duke Primary Care physician Richard Schneider, MD, a recent graduate of the Fellowship in Integrative Medicine at the University of Arizona Center for Integrative Medicine, found difficulties in developing an integrative medicine practice after he completed his program. He wondered if other graduates did. Schneider surveyed them. Just 23% were in integrative practices. His overall conclusion: “The results are quite encouraging, but not without caveats to the development of an IM practice.” Here are Schneider’s findings, plus a look at perceived barriers and areas for work to facilitate change.
Graduates of IM Fellowship surveyed on success in establishing practices
The signature educational program for integrative medical doctors, particularly those linked to academic medicine, is the Fellowship in Integrative Medicine at the University of Arizona Center for Integrative Medicine. Over 500 MDs and DOs have completed the 1000 hour, 2-year course of study. Their success in setting up practice as integrative medical doctors is one useful measure of the uptake of integrative medicine in the delivery system.
So how are these U Arizona Fellows in Integrative Medicine doing? What challenges are they facing?
Richard Schneider, MD is a recent Fellow. After finding “some difficulties” in establishing
an integrative medicine practice, Schneider wanted to learn if others were too. He informally surveyed 27 of his fellow graduates. Below is his report.
Schneider presently serves as medical director for Duke Primary Care’s Creedmoor Road Clinic. He is also co-founder and faculty at CoHvation, which he describes as “a think-tank for collaborative
healthcare innovations which seeks to assist and promote Integrative Medicine
practice in both the in and out patient setting.“
Integrative Medicine: The Spirit is Willing
Richard, Schneider, MD
Schneider: How are the other Fellows faring?
The concept of Integrative Medicine has taken its proper
place in the health care paradigm over the past few years. Unfortunately,
although the spirit of the IM provider is strong, so are the challenges in
developing a practice prioritized to the practice of Integrative Medicine.
As a recent graduate of the Fellowship in Integrative
Medicine from the University of Arizona, I too had the strong desire to
practice what I had come to develop a passion for: Primary Care Integrative
Medicine. My training was state of the art from mentors with a strong presence
for a well respected
academic medical centers which
invested significantly in Integrative Medicine,
I have not been able to
integrative medicine practice
to the degree I would like.”
Unfortunately, developing a practice has been somewhat challenging. Even
working (as a Medical Director for one of their Internal Medicine practices)
for a well respected and arguably one of the top 10 academic medical centers which
has invested significantly in Integrative Medicine, I have not been able to
advance my integrative medicine practice to the degree I would like.
Wondering whether I shared the difficulties in developing
an IM practice with others, I decided to run an informal survey of 27 recent
graduates of one of the premier Fellowship programs in IM both nationally and
internationally. The results are quite encouraging, but not without caveats to
the development of an IM practice.
For example, while over 90% want to practice integrative
medicine either exclusively or at least most of the time, only:
23% are currently in an IM practice.
For those asked if they are ready to develop
an Integrative Medicine practice:
50% are in the planning stages or actively pursuing
23% are thinking about it.
When it comes to some of the barriers limiting a
provider’s practice of integrative medicine, most indicated:
Next most identified
This was followed by:
current practice limitations
legal concerns regarding themselves (one indicated
that the FDA does not approve integrative medicine treatment) and their
referral sources as well as
Medical insurance coverage was mentioned as a
problem. Coding has been an issue with respect to reimbursement.
Most find themselves using traditional ICD-9 codes for [these typically treated conditions]:
When asked to rate the importance of certain areas to the
development of an IM practice, most again indicated reimbursement. Then came:
quality referral sources,
political advocacy and
seminars to enhance networking among providers.
One responder summed it up quite succinctly: “It’s great
to be altruistic, but it’s a realty that we’ve got to pay our bills to keep our
“A willing spirit has taken us far –
blood, sweat, tears
might take us home.”
Working within the outpatient integrative medicine
community, as well as on a committee recently bringing IM to the inpatient
setting, I quickly came to the realization that while there are a number of
quality programs teaching the fundamentals of IM, there was no one entity
focused primarily on the development and promotion of outpatient or inpatient
integrative medicine practices.
As practitioners and believers in the value of
integrative medicine we have vested much on this journey.
Now it’s time to recognize the reality of healthcare
delivery, the impact of reform and the place that integrative medicine takes in
A willing spirit has taken us far – blood, sweat, tears
and advocacy might take us home.
Duke Primary Care Creedmoor Rd.
Raleigh, North Carolina
Comment: Questions: What sort of integrative medicine are the 23% (6 of 27, presumably) practicing? In what environments are they practicing? Integrating what modalities or professionals? What stories might be told by the roughly 50% (13/14 of 27) who are actively pursuing establishing integrative practices but haven’t yet been successful? And how about that other quarter, the fallow Fellows, who paid their money, spent their time, but are not even thinking seriously about employing their new skills? And how about those who have been out longer? How are they doing?
I wonder if perhaps the sweet spot Schneider identified for practice building
is the relationship factor.
I am reminded of the survey data on practices of licensed acupuncturists. Do 47% of these LAcs truly prefer to work part-time? Here, some 75% of the Fellows are not yet making a living based on what they paid good money to learn. We have a problem of under-employment in both fields.
Noticeably, the challenges Schneider found that rank highest as barriers are those most tethering of coordinates: time and money, known here as “reimbursement” and “time constraints.” Tough to budge. Sobering.
I wonder if perhaps the sweet spot for building a practice identified by Schneider is the relationship factor, known here as “referral sources.” Are the spirits of these new integrative medicine fellows willing to relentlessly work to earn the hearts and minds of their health system colleagues? Are the Fellows equipped to persevere in building communities of support for the principles and practices for which they are emissaries? Focusing on this human-to-human work may produce the most significant rewards; including, potentially, opening new relationships to both time and money.