Healthy people, healthy planet

Integrator Blog – Integrator Forum: 20 Voices on Weil/Univ. Arizona and the American Board of Integrative Medicine

Summary: The Integrator Special Report on the decision of the Arizona Center for Integrative Medicine to promote a board specialty in integrative medicine has proved the most widely read Integrator piece in 2 years. Opinions are all over the map. Most are strongly held. None doubt the significance of the moment. Here are Bill Manahan, MD, Lou Sportelli, DC, Marc Micozzi, MD, PhD, Pamela Weeks, MA, Taylor Walsh, Jim Winterstein, DC, Kevin Wilson, ND, Richard “Buz” Cooper, MD, DSc, Bill Reddy, LAc, DiplAc, Chris Foley, MD, Nancy Gahles, DC, CCH, RSHom, Patrick Massey, MD, PhD, Andrew Rubman, ND, Stephen Marini, MS, PhD, DC, actuary Heather McLeod, plus an anonymous MD, anonymous chiropractor academic, anonymous journalist, anonymous integrative medicine academic; plus, links to a couple of the prominent anti-quackademic bloggers writing on the topic. I hope this exchange will be constructively utilized. Most of these comments beg this question: What are the optimal standards for this emerging guild of Board Certified Integrative Medical Doctors, especially relative to other health professionals and disciplines, if their interest is, in fact, the positive transformation of our system? I splice comments throughout..

The Integrator Special Report on the new effort to create a formal integrative medicine specialty that is recognized by organized medicine (“Strategic Change in Direction” as Weil’s Arizona Center Commits to Creation of American Board of Integrative Medicine) generated significant reader response. Some readers are excited and supportive. Others express deep concern and even fear that this step represents the ultimate take-over of “CAM” and related disciplines by medical doctors. Here is the Integrator Forum.

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Bill Manahan, MD

1. Bill Manahan, MD: “This is timely, appropriate and wonderful”

Integrator adviser Bill Manahan, MD was an early member of the American Holistic Medical Association. He was also a co-founder and president of the American Board of Integrative Holistic Medicine (ABIHM), the leaders of which are backing the new ABIM. Manahan has long served as faculty member in family medicine at the University of Minnesota and in a leadership program in integrative medicine sponsored by the American Medical Students Association.  

“Good reporting once again, John, regarding the
ABIM. I am delighted that the Arizona group has decided to go
forward with the American Board of Integrative Medicine.  I think
their idea of ‘both/and’ is excellent. Yes, every physician should
have available in his or her practice some of the tools of integrative
medicine, and that is something that will hopefully occur over the next
few decades. At the same time, some physicians will specialize
and have more skills in this most holistic of all medical fields that we
now call integrative medicine. 

 

“Those of us who were involved with the original testing for the ABIHM were
hopeful – and quite certain – that there would eventually be enough
training available in integrative holistic medicine so that
applicants would have to do more than just sit for the test.  Thanks
to the U of Arizona and Andrew Weil, that training is now occurring. 
Therefore, it is time to eliminate the old (the ABIHM) and merge it into
the new ABIM.  As one of the founders of the ABIHM, this is a transition
that is timely, appropriate, and wonderful.”


Comment: For one straddling Manahan’s twin interests, the move must be particularly healing. I will be curious to see if the 800 U Arizona fellows throughout the country will be part of the clinical training for the educational standards that emerge.

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Lou Sportelli, DC

2.  Lou Sportelli, DC: They condemn, then they investigate, then they take over 

Lou Sportelli, DC was one of the nation’s first chiropractors to be integrated into the mainstream delivery system via a series of roles in his community hospital. He is presently the president of the NCMIC Group. NCMIC is the most significant provider of malpractice insurance for the chiropractic and naturopathic medical professions. Sportelli is also a veteran of the Wilk trial that led to a successful federal lawsuit that convicted the American Medical Association of restrain of trade. In doing so, it ended the era of legal slander from organized medicine toward chiropractors and other non-conventional practices. NCMIC Group was the founding Integrator sponsor.

“I cannot believe that anyone would fall for Dr. Weil’s charade of attempting to
integrate anything. Look at his board (ALL MD’S). Even if he put in one DC, ND,
LAc or whatever else, they would still be token. To predict future behavior, look to past behavior.


“Dr. Weil’s past actions do not engender
confidence that his future behavior will be any more receptive or friendly
toward Chiropractic, or any of the other NON-MEDICAL flavors of care.  The
absurdity of having patients ask their medical doctor if they should go to an
ND, DC, LAc is supposing they know something about what folks are asking. They
know nothing!! Yet people are supposed to ask these folks who know
nothing about something that they are interested in. 


“Look at
the Medical board of this proposed group, I care not who they are, but what
they know. It will take a lot of convincing to get me to believe that this
is nothing more than the old medical model at work in three stages.


1. 
Condemn

2. 
Investigate

3. 
Take over

“The AMA
was notorious for doing this to any thing that was not allopathic. This is
their modus operandi and they had been successful with it until folks got wise.


“Dr.
Weil and his new idea are not so novel, but are highly suspect. Sounds
like a lot of hype and no substance.”

I asked Sportelli if I could print this. He wrote back: “Not a problem. But this is not to be passed off
lightly.  A movement like this could thwart your efforts and the efforts
of many others who have truly worked in Integration. Why, because the immediate
credibility and audience given to Weil has not been afforded to other groups
and thus his influence is immediate and welcomed because it is from a medical
source. This makes me angry.”


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Mark Micozzi, MD, PhD

3: Marc Micozzi, MD, PhD: Started as a reform movement, but like osteopathy …

Rockport, Massachusetts-based Mark Micozzi, MD, PhD is a medical anthropologist who was the editor of the first textbook on the field, the Fundamentals of Complementary and Alternative Medicine. Micozzi convened the first federally-sanctioned
explorations of CAM through a position he held in the early 1990s at the
National Library of Medicine.
He is a past executive director of the integrative medicine program at Thomas Jefferson University. Micozzi’s new book is expected out later this fall. 


“Should ‘integrative medicine’ be a movement to
transform all of medicine? Or should it be an effort to create a new medical
specialty?




“Very good question. Are you familiar with the work of
Paul Root Wolpe, PhD, at the Center for Bioethics at Penn during the 1990’s. He was selected as the bioethicist for NASA, following Nobel
Laueate from Penn, Dr Barry Blumberg, who was my own faculty advisor. Wolpe
published about CAM and orthodoxy in medicine. 

He wrote that CAM would be tolerated, brought into the
“fold”
– we now know as “integrative medicine” which
had it own issues. The final stage is
relegating CAM to just another medical sub-speciality in our overspecialized
healthcare system.


   
   “Should ‘integrative medicine’ be a
movement to
transform all of medicine?
Or should it be an effort to create

a new medical
specialty?
Very good question.”

“Like Osteopathy one hundred years ago, CAM was started as
a ‘reform movement.’ That field instead was tolerated for 50 years and then
brought completely into the fold by allowing DOs the same status and
specializations as MDs. This began during the Korean War by the military medical
corps (see M*A*S*H), then in California
during the 1960s because many state legislators had sons
who were DOs but not MDs. Then this spread everywhere.




“CAM arguably started as a reform movement also. (See the
Hillary Care symposia of the early 1990’s and the CAM White House
Commission of the late 1990’s.) By becoming a sub-specialty of medicine
it
has completely undergone what Wolpe wrote about: the orthodoxy
tolerating
unorthodoxy and then bringing it into the fold to control it. An analogy
is the Roman Catholic Church, ‘one, holy, catholic and apostolic.’ The
‘catholic’
literally means having different orders, ‘sects’, divisions under the
‘one’ church. As Wolpe writes this has enable the church to
predominate over 2000 years in a vastly changing society and culture.
If you reach Wolpe and get him to comment, it would be
informative.”


Comment: The scholars view and Sportelli’s street-level view appear to be aligned. Reference to the osteopaths is not auspicious. The osteopaths set a standard for selling its soul for recognition.


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Pamela Weeks, MA

4. Pamela Weeks, MA: “Big news”

Pamela Weeks, MA, is a therapist by profession and a valued friend and adviser to the present writer. She
typically takes a look at the Integrator when it comes out, mainly out
of love of her brother, though with some professional and personal interest
in the field. I rarely hear from her directly. This time she responded. I
thought her comment worth passing on, as an outsider’s perspective. She
wrote, simply:

“Wow –
This seems like BIG news!”

Yes Big Sister, I think so too. This is/was a big moment. Pam told me I could share her comment.

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Taylor Walsh

5.  Taylor Walsh: “How does this affect remuneration?”

Integrator columnist Taylor Walsh has offered acute commentary and reporting on numerous themes
of importance to the evolving integrative practice field. He is a writer
and consultant who has worked with such entities as The Institute for
Integrative Health
, founded by Brian Berman, MD and the Samueli
Institute
, founded by Wayne Jonas, MD. His own blog is Getting to Integrative Health and Wellness.


“I can’t tell if this is a major moment in the quickening
acceptance and adoption of integrative practice across the land, or
another incremental step within the field itself. My questions, that surely you are already creating answer for:




  • How will this
    affect the non-MD integrative practitioner?
  • How does this
    affect remuneration, if at all? And if
    it doesn’t, then what? Perhaps this is a major structural step in that direction.
  • How will this
    be viewed by the AMA?  Or other
    conventional medical entities?
  • Does this
    initiative require any political support – of the US Congress or [Health and Human Services-HHS] type?
  • Has the
    founding group had indicators from HHS or anyone else (Institute of Medicine?)that this step will advance the prospects of
    practitioners who comprise the field?


“I’ve always thought that given the state of US healthcare
the integrative community has had a chance to drive through the gates of the
healthcare enterprise and put down foundations for its own wing. Maybe this
is it. Although of course I hate to use
a metaphor of destruction! But then: does Schumpeter apply in health?).”


Comment: Austrian-American economist and political scientists Joseph Schumpeter, according to Wikipedia, “popularized the term ‘creative destruction.'” When I finished my interview with U Arizona executive director Victoria Maizes, MDs with “good luck,” I meant: Good luck in crafting an MD, BCIM
discipline that knows its part of its interest must be in destroy the inter-guild feuds that are partly responsible for producing the gawd-awful outcomes of US healthcare. Good luck, in short, in
creative destruction.


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Kevin Wilson, ND

6. Kevin Wilson, ND: “This is as far from integrated as possible”

I sent notice of the Special Report to Kevin Wilson, ND, a long-time leader of the
naturopathic medical profession in Oregon, and asked him to comment. Wilson has served in various
capacities including president of the Oregon Association of Naturopathic Physicians and chair of the state’s naturopathic licensing board. He maintains a busy practice of 30 years in Beaverton, Oregon.


“Well, this is an interesting development in that it oddly plays right into the
AMA’s strategy of impeding the licensing o,f and any increases in scope of
practice of, alternative practitioners. If you can’t beat them, you steal their
thunder.


“Andrew Weil has marketed himself very well. Claiming to be integrative
and
alternative, Weil, as many MD’s, simply started practicing similarly to
a
naturopathic physician without any discernible paper trail that I have
ever
seen. If he had been in another state or another era, he, like many
medical doctors, might have been disciplined by his licensing board for
practicing quackery for unapproved therapies. For years, naturopathic
doctors were ridiculed and impeded from practicing because they were
doing the very
modalities of which Dr. Weil now claims to be expert. Naturopathic
physicians
and other like-minded doctors fought for the incorporation and
implementation
of clinical nutrition and botanical medicine into general medical
practice for
decades before Dr. Weil saw the light, so to speak.

   
  Naturopathic
physicians
and other
like-minded doctors fought for the
incorporation and
implementation
of
clinical nutrition and botanical medicine
into general medical
practice for

decades before Dr. Weil saw
the light, so to speak.”

“Frankly, as a naturopathic
physician, licensed for nearly 30 years, I find that the wholesale
adoption of ‘holistic’ or integrative therapies by MD’s, DO’s or other
non-naturopathic
physicians offensive. Naturopathic medicine has been clearly defined
and licensed in some states for more than 100 years. If you look at the
principles
that Dr. Weil MD espouses,they are ours and always have been.


“Furthermore, the list of board members of the American Board of
Integrative Medicine is as far from integrated as is possible. It is all MD’s
coming from their MD schools doing MD things, unless they are really practicing
naturopathic medicine without a license.


“Many MD’s, some of whom I admire tremendously, have acknowledged the historical
validity and unique qualities of a real and rigorous naturopathic education.
They have chosen to do the right thing and to go to an accredited naturopathic
medical school
and get a naturopathic degree. These may be the truly
integrative practitioners, at least as far as our medicolegal system has
evolved.


“It has always been odd to me that Dr. Weil refuses to use the term naturopathic
medicine. This is especially odd in that he comes from a state with such a
vibrant naturopathic profession. Other doctors who espouse our medicine, such
as Dr. Oz, give us credit for adding a different, cogent and effective paradigm
to the practice of medicine in the US. If Dr. Weil wants to be truly
integrative, rather than usurping the ideas of those who came before him, he
would embrace naturopathic medicine and include us in his board and simply go
to a naturopathic medical school.”

Comment: The relationship between the naturopathic profession
and Weil and his program is tangled. Weil served on an advisory board to a group that successfully gained licensing for
naturopathic doctors in California. A visitor to the homepage of the New
York Association of Naturopathic Physicians
will see a button for a
video that asserts Naturopathic medicine: the time is now. Click on it and one sees Weil deliver a powerful testimonial for the
naturopathic profession. He even speaks to the value of NDs in developing the
University of Arizona program.

The program Weil founded has always been closest, among academic medicine offerings, to
naturopathic principles. What makes Weil a target is his visibility compared to the NDs relative obscurity, especially since the Arizona program does not touch a naturopathic
medical program in its intensity, duration, commitment or cost.
Adds fuel to the naturopaths’ ire is that the lesser-trained
integrative medicine specialists are already inside the payment and
delivery system. As such the MD BCIMs will, experts or not, be effectively accepted as
such.




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Patrick Massey, MD, PhD

7.  Patrick Massey, MD, PhD: “Certification is long-overdue”

Elk Grove Village, Illinois-based Patrick Massey, MD, PhD is the medical director for complementary and alternative  medicine for the Alexian Brothers Hospital Network. He also serves as president of the ALT-MED Medical and Physical Therapy Program.


“Certification is a topic
that is long overdue.




“Integrative medicine is
a complex area of medicine that incorporates many aspects of traditional and
nontraditional medicine: formal education is important. Considering how
many people are blending medicine on their own, it is important for them to
have qualified physicians to make sure they are not doing anything dangerous.



“It cannot be done by
primary care physicians. They are barely able to keep abreast of the recommendations
for diabetes, HTN and CAD. Integrative medicine is not remotely in their
sphere of expertise, nor the expertise of PAs and NPs, unless specifically
trained in integrative medicine.

Comment: Massey’s point is good. I would put the stress on the affirmative: It is important that people have qualified physicians to given the the optimal benefits of natural therapeutic approaches that do less harm and help them toward health.
 

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Richard Cooper, MD

8. Richard “Buz” Cooper, MD: “One more example of Weil’s entrepreneurial reach”

Richard “Buz” Cooper, MD is known as a workforce policy leader. In 1996, Cooper was among the first conventional academic to publish a view that licensed chiropractors, naturopathic physicians and acupuncturists should be included in the nation’s workforce planning. (See his Health Affairs article here.) Cooper is a former medical school dean with the University of Wisconsin who also taught medicine and policy at the University of Pennsylvania.


“This is just one more
of example of Weil’s entrepreneurial reach. It will enhance his 1,000 hour
costly and profitable training program. He is pursuing it through a rump group,
the American Board of PHYSICIAN Specialties [ABPS], which “certifies” a few
marginal specialties (e.g., urgent care), rather than through the American
Board of MEDICAL Specialties
[ABMS], the recognized authority, which certifies
legitimate specialties and which apparently has turned down the idea of
certifying Weil’s Integrative Medicine. Tainting the emerging discipline of
Integrative Medicine with ‘Weil’s Entrepreneurism’ will push it in
the wrong direction and be a disservice to generations of patients.”




I responded to Cooper with this note:
“I do [guess the Weil group] found some
prejudice when barking up the other tree.” Cooper responded:
“I have a lot of respect
for the ABMS. My guess is that they saw Weil’s $$$ behind the veil of
certification.”

Comment: Cooper and others personalize their commentary around the persona of University of Arizona Center for Integrative Medicine (ACIM) founder Andrew Weil, MD. This is not appropriate. There are now 800 graduates of the University of Arizona fellowship. In ACIM executive director Maizes’ reasonable telling, many of these were calling for this direction long before ACIM engaged it. Personalizing this as a move by Weil diminishes it. This is a classic step of an emerging discipline.

Cooper’s focus on how “lucrative” this is also strikes me as off target. Weil does not financially benefit from the Center. In fact, he donates roughly a quarter of a million a year to the program. He is investing in something that may swell the historic importance of his work. Big egos are often associated with good things. Who isn’t seeking to have more rather than less positive impact?


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Bill Reddy, LAc, DiplAc

9.  Bill Reddy, LAc: “Patients will benefit”


Virginia-based Bill Reddy, LAc, DiplAc
is a licensed acupuncturist with experience working in integrative
settings. He serves as the representative from the American Association
of Acupuncture and Oriental Medicine to the Integrated Healthcare Policy Consortium. His recent article on integrative medicine for the American Acupuncturist is here.

“Integrative
medicine is a complex, multi-dimensional issue. I firmly agree that using the title without any formal certification can
mislead the average patient entering an ‘integrative’ practice. A conscientious MD could possibly read a
myriad of books, take seminars on homeopathic medications and essential oil
therapy, be well-versed in Cranio-Sacral Therapy, Zero Balancing, BodyTalk,
EFT, TAT, etc. with no ‘formal’ certification and be a tremendous help to his
or her patients.

“In
the field of Acupuncture and Oriental Medicine (AOM), three specialties have
emerged in the past two decades:  Facial Rejuvenation,
Orthopedics and Infertility/Reproduction. 
Are these ‘certifications’ backed by the National Certification
Commission of Acupuncture and Oriental Medicine
(NCCAOM), our profession’s
certifying body? No. They are marketed by self-proclaimed experts
in that field of study. I’m not
suggesting that the practitioners teaching these specializations do not have
rigorous standards or are not respected in the field of AOM. They’re just not working through our
profession’s certifying agency. 

   
   Having a specialty of IM supported
by one or more of the Physician boards
 is a good start – a foot in the door
so to speak to get the ball rolling …

“In
a recent discussion with Dr. Kory Ward-Cook, Chief Executive Officer of the NCCAOM, regarding her interpretation of
the type of credential offered by the National Board of Acupuncture Orthopedics
(NBAO) and the American Board of Oriental Reproductive Medicine (ABORM) and she
stated: ‘These
qualifications are different than a nationally accredited certification
program. I can tell you that based on the National Commission
on Certifying Agencies (NCCA) and the American National Institute
Standards
(ANSI) national standards for accredited of certification programs
these two
credentials would not meet the standards for an accredited
 professional certification. They are more
closely aligned with assessment-based certificate programs (NBAO) or
qualification
programs (ABORM). Actually, both NCCA and ANSI offer separate
accreditation
for assessment-based certificate programs that have different standards
than those
for accreditation of certification programs” noted Dr. Ward-Cook.

“Obviously the MDs are also going through some growing pains of
their own. They actually have three
organizations involved with physician Board Certification:  The American Board of Physician
Specialties (ABPS), the American Board of Medical Specialties (ABMS), and the
American Osteopathic Association’s Bureau of Specialists (AOABOS), each with
their own standards and requirements. 

“Integrative medicine is the model of the future of healthcare in
America. I strongly agree with Dr.’s
Weil and Maize’s conceptual framework that IM should be taught in medical schools and
adopted by every practicing physician. Having a specialty of IM supported by one or more of the Physician boards
is a good start – a foot in the door so to speak to get the ball rolling, and
to limit the doctors who attended a weekend course in foot reflexology from
marketing themselves as integrative medicine practitioners. 

“In discussing the integrated medicine
specialty certification that is being created through the efforts of one of the
three national physician organizations, Dr. Ward-Cook stated that ‘it appears
that the physician groups developing the proposed IM certification are planning
for this credential to be another recognized national board specialty
certification that is supported by standards agreed upon by at least one of the
recognized physician national organizations. If their IM specialty certification is set up
like the other national medical specialty certifications, it will most likely
meet the standards of NCCA accreditation.’

“The bottom line is that patients
will benefit from this change in paradigm in healthcare delivery and the sooner
it happens, the better. The question for the complementary and alternative
healthcare organizations and practitioners would be “Is there a need for the
development of an integrated medicine credential for CAM practitioners?” noted
Ward-Cook.

Comment: Reddy showed good instinct to
check with Ward-Cook, an expert in this area. One note: The ABIM will not keep any medical doctor who studies natural health modalities on the weekend from
self-declaring as an integrative medical doctor. They just won’t be able to say they are ABIM.
Restricting the rights of others to the name would take state legislation.

Meantime, Ward-Cook and Reddy are right to highlight this question: Is there a value and/or need for an integrated medicine credential for licensed CAM practitioners?  Chiropractors, naturopathic doctors and licensed acupuncturists and others from the CAM fields may benefit in two ways. First, new knowledge skills and attitudes are needed to help these lead the movement toward integrative health care. Second, the tendency of medicine, and even integrative MDs, is to continuously reduce these practitioners and their disciplines to mere modality-objects. Like advanced
practice nursing, some kind of fellowship in integrative practice may be needed to assert a right to co-leadership.

Ward-Cook and her colleagues in the Academic Consortium for Complementary and Alternative Health Care, with whom I work, have been dancing in this direction through development of what they call Competencies for Optimal Practice in Integrated Environments.

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Jim Winterstein, DC

10. James Winterstein, DC: “Deep down, I fear it is more of the same …”


Jim Winterstein, DC is president of the multidisciplinary National University of Health Sciences. He was frequently contributed direct, useful commentary on Integrator themes. Like Sportelli, the span of his career includes memory of the Wilk vs. the AMA trial. His university and members of his leadership team have made significant, ongoing commitments to fostering more mutual respect and understanding between the healthcare professions.

“Thanks for this most
recent information. At this point, I don’t know anything about what the
educational process will be for those who choose to become certified by the
American Board of Integrative Medicine. The intention is for a 1,000 hour
fellowship. But in what? Is this going to be a fellowship in which allopaths teach
allopaths about subjects in which they are not expert? Will this lead to
another subset of patient care that somehow fails to consider the whole
patient, or will this ‘specialist’ be a person who actually practices ‘conservative primary care?’ Will these specialists actually care for
patients personally as chiropractic and naturopathic physicians do today, or as
acupuncturists and Oriental medicine practitioners do? Or will the intent be for
these allopathic specialists to ‘oversee’ the work of those who are
currently engaged in alternative medicine? For me, at least, the picture
remains pretty cloudy.”


Winterstein asked good questions. We don’t know. Other questions come to mind. To what extent will these individuals be clinically prepared to delivery alternative therapies? Will the University of Arizona change its course if it has such a board specialty in mind? Will they be offering significant clinical training via what is now a principally online program? I responded to Winterstein. He sent a further note:


“[This is] an interesting move on their part. Down deep, I fear it is more of the same –
dominance at all costs – in a circumstance over which they have had little
control (the interest by the public in alternative medicine). Now, they form a
specialty and take it [over]. I hate to say it, but I think that is a likely
probability. We have already seen them work toward usurping our ‘tools.’ I don’t like the sound of this, John.”


Comment: A concern that hit me with Winterstein’s comment is that the definition of integrative medicine used by the Arizona Center does not include specific reference to the importance of integrating the skills of other types of practitioners, such as the chiropractors, naturopathic doctors, massage therapists and acupuncture and Oriental medicine specialists. This is the U Arizona definition:

“The Center defines integrative medicine (IM) as healing-oriented
medicine that takes account of the whole person (body, mind, and
spirit), including all aspects of lifestyle. It emphasizes the
therapeutic relationship and makes use of all appropriate therapies,
both conventional and alternative.”

The Center’s principles also speak only to the integration of therapies. A chiropractor, of course, is not a “therapy.” By comparison, the definition of integrative medicine used here by the Consortium of Academic Health Centers for Integrative Medicine is more inclusive:

“Integrative
Medicine is the practice of medicine that reaffirms the importance of
the relationship between practitioner and patient, focuses on the whole
person, is informed by evidence, and makes use of all appropriate
therapeutic approaches, healthcare professionals and disciplines to
achieve optimal health and healing.”
(bold added)

One might assume from the ACIM definition that the importance of integrative teams and co-management is not embedded in the program. To the extent that this is so, there is reason for concern if one believes that part of transformation we seek is breaking the hegemony of the single party leadership that got us into this mess.
 

 

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Actuary Heather McLeod

11. Actuary Heather McLeod: Resonances with German issues with naturopaths a century ago

Actuary Heather McLeod is a complementary and alternative medicine researcher and organizer presently involved with the New Zealand Centre for Evidence-based Research into Complementary and Alternative Medicine. She sent a PDF file with this note.


“(This is a) paper on
the early history of Naturopathy and licensing in Germany. I found it
fascinating and have a sense to send it to you. It
resonates with the issues you raise in “Strategic Shift: Weil’s Arizona Center Leads
Push for MD Board Certification in Integrative Medicine”.

The paper, published February 2011 in Social History of Medicine, is Medicine from the Margins? Naturheilkunde from Medical Heterodoxy to the University of Berlin, 1889-1920.

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Steve Marini, MS, PhD, DC

12.  Stephen Marini, MS, PhD, DC: “The concept of an integrative medical specialty is inherently contradictory”

Stephen C. Marini, PhD, DC received an MS in microbiology and immunology in 1976 from Hahnemann Medical College in Philadelphia. He later earned his PhD in microbiology in
1989 from
Pacific
Western University with dissertation research on avian tumor viruses
accomplished at the Wistar Institute in Philadelphia. He subsequently earned his DC from the
Pennsylvania College of Chiropractic. Marini serves on the boards of the International Chiropractic
Pediatric Association
(ICPA), the Holistic Pediatric Association (HPA), and the
Integrated Healthcare Policy Consortium (IHPC).
In a note on his background he write: “As a vitalist trained in classical science and
conventional medicine, I appreciate the role of energy/information on
an individual’s health and healing processes.”


“The concept of a medical
specialty in integrative medicine is inherently contradictory. The paradigm of
conventional medicine is reductionistic, hierarchical, & mutually exclusive
to other paradigms of health and healing. So to ponder the concept of such a
medical doctor would require drastic changes on a medical, anthropologic,
sociologic, political levels etc…..




“What is needed within a
complementary system is a new species of health care provider that can
appropriately triage a patient with regard to Era 1, Era 2 & Era 3 health
care components.”

Marini then shared a figure entitled Health Care Eras. It included the following:


  • Era I Medicine: Allopathic Therapies. Paradigm: CHEMISTRY – STRUCTURE – FUNCTION

  • ERA II Medicine: Holistic/Holoenergetic Therapies
    . Paradigm:  ENERGY – CHEMISTRY –
    STRUCTURE – FUNCTION

  • ERA III Medicine:
    Intercessory Therapies
    . Paradigm: UNIFIED – ENERGY –
    CHEMISTRY – STRUCTURE – FUNCTION FIELDS



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Chris Foley, MD

13. Chris Foley, MD: “I think this is a mistake”


Chris Foley, MD is an integrative and functional medicine doctor who developed one of the earliest health system based integrative medicine programs in the mid-1990s. He presently practices out of his clinic Minnesota Natural Medicine. He was last seen in the Integrator in this July 2011 Readers Forum.

“So they will be competing with the (Institute for Functional Medicine) Inst Fcnl Med which has just
established boards. I think this is a mistake. (This will be): ‘I am more
integrative than you are because I went to Andy Weil’s fellowship
program.’ It would be better to establish integrative arms across
the medical sub specialties so we have more integrative orthos, cardiologists,
neurologists, etc.”


Comment: Interesting comment regarding the IFM which has indeed recently started its own certification program. The ongoing relationship between these entities will be interesting to watch. IFM has recently established beachheads in various academic medicine programs.


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Andy Rubman, ND

14. Andrew Rubman, ND: “Horizontally-integrated system needed”

Andrew Rubman, ND has practiced naturopathic medicine in Connecticut for three decades. He also teaches at the University of Bridgeport and has served as an adviser to the National Institutes of Health. He is a contributing editor for Bottom Line’s Daily Health News.

“The new Board Certification is welcomed
news. While encouraging MD/DO and DDS aspirants to establish a uniform higher
standard of practice for those claiming this area of practice, I strongly
encourage a statement regarding recognition of naturopathic physicians and
their place within the emerging paradigm.

“It is important to look forward
towards a horizontally integrated delivery system that includes all licensed
providers, works towards full scopes of practice for all licensed physicians,
and encourages providers to practice as formal education and clinical experience
dictates. If we are to transition from disease management to healthcare, all
emerging efforts need to be clear and transparent in adopting language and
practice which fosters an inclusive position. The time is certainly right for
all involved entities to embrace these goals if we are to indeed to reform our
systems in the US.”


Comment: I first came across the concept of “horizontal integration” via Anne Nedrow, MD, MBA a graduate of the U Arizona fellowship who is now the integrative medicine leader at Oregon Health & Sciences University. Nedrow co-founded the Oregon Collaborative for Integrative Medicine with nearby leaders of naturopathic, chiropractic and acupuncture programs as a way of institutionalizing this approach. The concept was also effectively embraced, at least between doctors and nurses, in the Institute of Medicine’s historic 2010 Future of Nursing report. Rubman is right: Unless integrative medicine doctors directly and overtly lead in an “inclusive” position of shared-power, co-management and horizontal respect, the possibility of all whole practice disciplines and stakeholders to pull together is likely nil. Unfortunately, at this point the oversights and non-inclusions can make one wonder. See, for example, Transformation and MD-Centrism in Dr. Weil’s Policy Book



16. Anti-CAM Bloggers: “Blatant effort of the MD wing of alternative medicine to push others aside” 

The leading anti-CAM bloggers hail from academic health centers. They are particularly opposed to their “quackademic” colleagues. They beleive the integrative medicine doctors are putting the entire history of Western medicine at risk by suggesting that massage and mind-body interventions may be useful to patients. (Given what the Institute of Medicine says about harmful waste amounting to roughly a half of what is done in medicine, key question here is: Can the corruption of a negative create a positive?) The subject of the Integrator Special Report caught their attention. Integrator advisers Glenn Sabin and Jan Schwartz alerted me to these two posts.

Comment: I was struck on reading the latter that the principal conclusion is squarely aligned with perspectives expressed in this Forum by licensed complementary and alternative healthcare leaders. The blogger, David Gorski, MD, begins his conclusion by citing this closing comment in the Integrator:


Quoting the Integrator: “This strategic decision
by ACIM has many dimensions. There are clear public health implications. The
ACIM-ABIHM alliance represents a significant new alignment. Grassroots access
to the ‘integrative medical doctor’ title or at least board
certification may disappear. There are guild dimensions here, ground claiming,
and not just for IM doctors. Many naturopathic doctors and acupuncturists and
chiropractors use the term. The brand ‘integrative medicine’ may
become even more closely associated with, and effectively owned by, medical
doctors. New clarities will emerge, new boundaries will be drawn, new
possibilities empowered.”

   
  One potential
result, if Weil and his merry

band of woo-meisters are successful, is
to
marginalize non-MD practitioners, which
might not be a bad thing from the point

of view of science-based medicine.

Gorski then concludes:

David Gorski, MD in Science-Based Medicine:
“Indeed. I rather suspect that this is a blatant effort of the “MD
wing” of the alternative medicine world to claim the specialty for itself
and push out all the “riff raff,” like naturopaths, homeopaths,
chiropractors, acupuncturists, and the like by preventing them from using the
term ‘integrative medicine’ to describe what they do. One potential
result, if Weil and his merry band of woo-meisters are successful, is to
marginalize non-MD practitioners, which might not be a bad thing from the point
of view of science-based medicine. What would be a bad thing is that it would
simultaneously allow MDs like Weil to lay claim to the woo inherent in IM in
order to give it the patina of legitimacy that, despite 20 years of the best
efforts of doctors like Weil, IM or CAM or whatever the pseudorespectable nom
du jour
is still doesn’t have and doesn’t deserve because much of it
consists either of Trojan horses or pseudoscience.”

I shared this with two colleagues from the licensed CAM field with this note: “When did you ever think you’d be eye to eye with these
fellows?” 

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Nancy Gahles, DC, CCH, RSHom

17.  Nancy Gahles, DC, CCH, RSHom: “This is co-opting integrative healthcare”

New Jersey-based clinician and homepathy leader Nancy Gahles, DC, CCH, RSHom has been the modern leader in pushing the field of homeopathy into the nation’s health policy dialogue. Gahles is president of the National Center for Homeopathy. She is on the board of the Integrated Healthcare Policy Consortium.


“Knee deep in integrative healthcare
policy stuff et al. That brings me to my comment on the Board Specialty for
Integrative MEDICAL DOCTORS.  What will happen to integrative HEALTHCARE?




“The stakeholders at the IOM summit on Integrative Medicine and the Health of the Public clearly called for
language change away from MEDICINE toward creating a culture of prevention and
wellness. Sen. Harkin even said that he would change the name of
NCCAM to National Center for Complementary and Alternative HEALTHCARE to
reflect the desires of the community and the new direction.




“Integrative care is inclusive of practitioners other than
medical doctors. The non-discrimination amendment in the [Affordable
Care Act] defines the new national HEALTHCARE workforce to
include ‘licensed CAM providers and INTEGRATIVE HEALTHCARE
practitioners.’ So, the Integrated Healthcare Policy Consortium is
planning Congressional briefings, for the first of which I am
working with others to write the template, to define who these players are
in the
workforce, etc. Clearly, our aim is to define the breadth of the
practice and
the breadth of providers. How confusing can we make this for them? ‘Oh,
yes, and now there will also be Board Certified Integrative Medical
Doctors.’ You KNOW [the MDs] will get
the juice because they are the REAL doctors. The ones you can trust.
What do
they even study to make them ‘integrative’? Homeopathy? NO. Functional
medicine…betcha! Little nutraceutical is now the new Big Pharma.
Please tell
me I am dead off base here, please!



“My comment is that this looks like a duck, walks like a duck
and acts like a duck: co-opting integrative healthcare, calling it integrative
MEDICINE and creating a Board Specialty will identify integrative healthcare
with medical doctors and they will own it, be reimbursed for it and thereby drive
consumers to use them only as they will get insurance for it.



“As it stands now, I recently returned from Sen. Hatch’s
office discussing his amendment to the [Health Savings Act] bill. I will send you a copy of
that. Basically, it calls nutritional supplements MEDICAL care and restricts
payment for nutritional supplements, herbs, homeopathic remedies etc to be paid
for only by primary care physicians, nurse practitioners and physicians
assistants. Oh, yes and you have to go to your primary care doc, pay your
co-pay, pay the AMA their fee for the CPT code, to get a prescription if you
want to deduct your homeopathic remedy or herbs or any over the counter drug
from your HSA.



“Can you say MONOPOLY???? No, Virginia, I’m afraid there is no Santa Claus. All blessings for change you can believe in…one day.”


I asked Gahles for some clarity on the reference to the IOM summit. Gahles responded:


“So, at the IOM Summit, the stakeholders were loud and
clear on the fact that our current system of medicine is broken. They called
for an integrative system that reflected the person at the center and the
individualizing of case taking. They asked for the ability to work with other
disciplines outside of conventional medicine and to share records
electronically. Sen. Harkin spoke about his support for integrative healthcare
and the need to move from a disease-oriented system to one of prevention and
wellness. One woman came to the microphone and suggested that we change the
wording of integrative medicine to integrative healthcare to more clearly
define the inclusive nature and to move past “medicine” as the only
form of treatment. Sen. Harkin agreed heartily and said that he would change
the name of NCCAM to National Center for Complementary and Alternative
HEALTHCARE.”

Comment: The IOM report certainly
affirmed Gahles’ perspective that the momentum of the meeting and of the report itself, as I noted in my analysis here, was
toward use of health care, and away from “integrative medicine.” However, Senator Harkin sang a different tune on October 4, 2011 at the 10th anniversary celebration for the Samueli Institute. Gahles, who sent her comment prior to that function, was in the crowd when Harkin stated that he wished he’d had the
foresight to name NCCAM the National Center for Integrative Medicine.



18. Anonymous MD: “Likely MD centric since they are all MDs”

I sent the news of the U Arizona move to a leading integrative medical doctor and long-time reader who is not involved with certification but is skilled in offering various integrative services. Had he read the piece?


“Yes. I saw it. Likely MD centric since they are all MDs.

“Whence cometh patient-centered care?

“Sigh.”

Comment: Such medical doctors need to speak up and help shape this new field.


19. Anonymous chiropractor in academic medicine: “There will be unintended consequences”

A chiropractic doctor who works at a high level in the education of chiropractic doctors saw the article and sent off a quick note:


“Just what we need – another medical specialty that justifies a
higher cost for its services plus another way to ‘medically’ own the concept of ‘integrative.’ Don’t get me wrong, I understand their motivations and I’m all
for standards, but there will be unintended consequences. Will it get to the
point that an integrative medicine specialist only takes patients on referral
from a primary care provider? Would that sound like an advance in health care?


“Sorry, but I’m in a cynical kind of mood today.”

I asked if he would go on the record. He wrote back: “To
be fair, I would need to be a little more thoughtful and justify my whining.” Here’s hoping history does not prove his whining to be justified.

20.  Anonymous academic integrative medical doctor

I had a similar exchange with a leader in the education of medical doctors at a significant academic health center that is part of the Consortium of Academic Health Centers for Integrative Medicine. The individual, a medical doctor, volunteered this note upon reading the report.

“Nice job John, well done.”

I shared with this person two of the stronger comments of mistrust from licensed CAM practitioners opposing the action, together with my own sadness that the rift between these fields remains so pronounced. I asked the provider to consider commenting based on what I sent.  The response: “Wow.  I think I will stay back from this one.” Then: “It would be good to reassure people a little that this is not
about ‘taking over.'”

Comment: That reassurance would be good through not merely words but some form of action of inclusion. Otherwise I fear the words will sound like the adolescent drama: Trust me, I am not like all the others.


21. Healthcare journalist: “Wow!”

I reader who is a healthcare journalist and has covered CAM and integrative practices for many years sent this immediate, one-word response:

“WOW!!!“



Overall Comment
:
I would hope that as this emerging MD, BCIM discipline engages the process of formalizing its standards and requirements, Weil, Maizes and the other leaders will view “integrative” as a requirement to re-frame the relationship these medical doctors have with all other disciplines. Why not break the mold and include practitioners from other fields in standard setting?

One reason may be that convincing more conservative medical colleagues will be easier if the new Board follows past patterns and involves only MDs. The more the ABIM looks like a part of the club, the easier to gain acceptance. Yet if this new guild is dedicated to transforming medicine, proactively fashioning a new relationship to other professions is not only called for but, well, integrative.

That said, what is urged of the goose must be urged of the gander. Are the educational standards and practices in the licensed CAM fields embracing the need for interprofessional education? Are they engendering mutual respect such as is being asked of the ABIM? Are the standard-setting practices of chiropractic and naturopathic boards integrated? Transformation of the system will come through, and require, change within all parties.
 

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John Weeks Written by John Weeks