Forum #2 on the American Board of Integrative Medicine: Quinn, Redwood, Gmeiner, Anderson, and Manahan

Summary: The discussion of the origins, intentions and ramifications of the move to create a formal integrative medicine specialty through the American Board of Integrative Medicine (ABIM) produced 5 additional, especially thoughtful responses. These had a chance to first read the forum of 20 voices. These five are: former Integrated Healthcare Policy Consortium chair Sheila Quinn; Daniel Redwood, DC, Cleveland College of Chiropractic faculty member and writer on policy issues; past American Holistic Medical Association (AHMA) board member Kjersten Gmeiner, MD; AHMA founder and past American Board of Integrative Holistic Medicine (ABIHM) executive director Robert Anderson, MD; and ABIHM co-founder Bill Manahan, MD. These provide balanced, watchful, mainly supportive comments and advice to the founding ABIM board members. Can the ABIM demonstrate that they are not like all the others?

Other articles in this series:



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. A first set was published as

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

Additional thoughtful perspective is published here from Sheila Quinn, formerly with the Institute
for Functional Medicine, Bastyr University and Integrated Healthcare
Policy Consortium; Cleveland College of Chiropractic educator and policy
writer Daniel Redwood, DC; former American Holistic Medical Association (AHMA)
board member Kjersten Gmeiner, MD; AHMA founder and past ABIHM executive director Robert Anderson, MD; and, responding again,
ABIHM American Board of Integrative Holistic Medicine co-founder and past president Bill Manahan, MD.
 

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Sheila Quinn

1.  Sheila Quinn: “The only valid reason for the Board is to help patients”

Sheila Quinn has held a series of significant leadership positions in the integrative practice movement. She co-founded
Bastyr University, served as executive director of the American
Association of Naturopathic Physicians, was a senior editor for the
Institute for Functional Medicine and chair of the Integrated Healthcare Policy Consortium. Quinn, an Integrator editorial adviser, presently works as a freelance writer from her Gig Harbor, Washington residence and is available here:

sheilaquinn@medwriter.comcastbiz.net

“Just getting around to reading the submissions on the
development of the ABIM. A few thoughts came to mind:


  •    

     “Just because a good reason exists
    to develop a
    new board doesn’t mean

    that a whole host of other problems
    and/or benefits
    can’t hitch a ride

    on the moving train.”


     

    I love the irony of creating a medical specialty
    for an essentially non-specialized approach to care. One could say the same thing
    about family practice, which is essentially a specialty for generalists.

  • IMHO, the best (and perhaps only valid)
    reason for developing a new board is to help patients make (better) informed
    decisions about their clinicians and their health. It CAN be useful for
    patients to identify practitioners who have met some standards in integrative
    medicine; otherwise (just as in unlicensed states with NDs), knowing which
    practitioners really have what you want is difficult.


  • Just because a good reason exists to develop a
    new board doesn’t mean that a whole host of other problems and/or benefits
    can’t hitch a ride on the moving train. However, unless the problems seriously
    outweigh the benefits to the public, I would come down on the “pro”
    side.


  • IFM [Institute for Functional Medicine], uniquely, offers their training and

    certification (not through a specialty board) to a very broad range of
    practitioners-those who (1) graduated from an accredited medical, osteopathic,
    chiropractic, physician assistant, nursing, naturopathic medicine, dietetics,
    acupuncture, pharmacy, dentistry, or nutrition program in the United States,
    Canada, or equivalent programs from other countries, (2) hold a current license
    to practice by the appropriate authority in the applicant’s location, and (3)
    are in active clinical practice. So, there already IS something available for
    those folks who, by virtue of not having an MD or DO, are not eligible for
    ABIM. Of course, they do have to learn functional medicine.


  • Acknowledging my own bias as a former staff
    member and now consultant for IFM, I also feel that the value of functional
    medicine is inherently far greater than that of integrative medicine because
    (a) it facilitates integration among practitioners and disciplines, not just
    therapies, and (b) it offers a sophisticated understanding of the causes of
    disease and presents an innovative set of tools and concepts for
    individualizing assessment, therapy, and prevention.

  •    
      “If conventional medicine does indeed
    coopt what
    we now think of as integrative
    medicine, the public will still find its way
     to
    the disciplines it wants.”

     

    If conventional medicine does indeed coopt what
    we now think of as integrative medicine, the public will still find its way to
    the disciplines it wants. If integrative physicians offer primarily
    conventional care plus a few add-ons in nutrition and botanicals, the
    discipline will not sustain a long life as a real alternative for those who
    want one. If, however, the development of a board creates greater respect for
    alternatives in medicine, fueling more research, integrating formal teaching in
    academic medicine, expanding reimbursement, and advancing integration of
    practitioners and professions in clinical settings, then I think that’s a good
    thing, even if it blurs the lines between certain professions.”




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Daniel Redwood, DC

2.  Daniel Redwood, DC: “This is a fundamentally positive step”

Daniel Redwood, DC  is a writer and educator who frequently publishes on policy-related issues. His last comment in the Integrator were on the comments opposing Donald Berwick, MD’s appointment to run the Center for Medicare and Medicaid Services. Redwood is a professor at Cleveland Chiropractic College and editor-in-chief of Health Insights Today. After receiving a short note from Redwood, I requested that he expand his thoughts.

“I initially refrained from offering comments
about the American Board of Integrative Medicine (ABIM) out of a desire to
think it through more deeply and listen to others’ responses. Along those
lines, I found your ‘
20 Voices‘ article quite perspective-inducing. As a
long-time chiropractic practitioner who has in various eras identified as
holistic, alternative, CAM and integrative, and as a chiropractic educator for
the last five years, I feel a stakeholder’s sense of connection with the continuing
evolution of integrative health care.




“Several thoughts:

   
  “The medical doctors are working
to improve the medical and osteopathic
 professions. I
think this is a
fundamentally positive step.”

“1. ABIM is organized as a board certification program for MD/DO
practitioners, not non-MD/DOs. While many of the people involved in its
creation enjoy warm collegial relations with practitioners of various non-MD/DO
CAM disciplines, they purposely chose not to set up an interprofessional board.
Instead, they are working to improve the medical and osteopathic professions. I
think this is a fundamentally positive step.




“2. It should be quite clear that expanding the ABIM certification
process to include DCs, NDs, etc., would greatly complicate, if not outright
destroy, the chances for ABIM to become an officially recognized medical or
physician specialty.

   
“It is certainly possible that [the MDs]
might use ABIM in an effort to control
rather than collaborate with[non-MDs].
If so, we can respond as needed. 
At
present …Turning
our friends into

enemies gains us nothing.”

 

 

“3. Chiropractic, naturopathic, AOM and massage therapy practitioners
need not respond with fear or pessimism to this effort by our holistic MD/DO
colleagues to more solidly establish their position within the medical and
osteopathic professions. It is certainly possible that in the short or long
run, they might use ABIM in an effort to control rather than collaborate with
us. If so, we can respond as needed.  At
present, however, it is an unforced tactical error to assume the worst. Turning
our friends into enemies gains us nothing.




“4. In the unfolding health reform process, ‘integrative’ or ‘integrated’
care has not yet been well-defined and its definition is likely to remain in flux
for at least the next few years. The kind of CAM-friendly definition that ABIM
will be advocating is far superior to models of ‘integrated’ care that involve,
for example, integrating conventional rheumatologists, orthopedists, primary
care physicians and radiologists, while marginalizing or ignoring
chiropractors, naturopaths, acupuncturists and massage therapists for the
treatment and/or management of pain. We would be well advised to see the
relative pluses in efforts like the fledgling ABIM, rather than preemptively
rejecting approaches that fail to meet all of our wishes, hopes and dreams.



“5. Regarding the notion of ‘ownership’ of holistic /integrative/CAM
principles and practices, and concerns expressed by some of the ’20 Voices’ that
the ABIM and its members may be, in effect, stealing something that is not
rightfully theirs, now is as good a time as any to state forthrightly that this
attitude represents a profoundly flawed approach to integration, holism,
healing, health and health care. Whether it’s a DC claiming that chiropractors should
own spinal manipulation, an ND excoriating integrative MDs for muscling in on what
he perceives to be naturopathic ownership of various holistic/integrative
principles, or an MD asserting a monopoly on integrative care, such claims are
rightly seen by those outside the immediate battlefield as doctor-centered turf
protection rather than the kind of patient-centered collaborative model whose
green shoots we should all seek to nurture wherever they break through into the
light of day.


   
  “I suggest we give ABIM the chance
to show its desire
for mutuality and

broad collaboration in its relations
with other CAM
disciplines.”

 

“6. Therefore, I suggest we give ABIM the chance to show its desire
for mutuality and broad collaboration in its relations with other CAM
disciplines. This does not require that they make us members of their medical
specialty group. It does require that they demonstrate, now and in the future,
in word and deed, a sincere and openly acknowledged respect for what we all
have to offer. This, along with the recognition that no profession has all the
answers, that our patients need us to cooperate on a basis of equality rather
than hierarchy or hegemony, and that true integration requires us all to
stretch beyond our comfort zones on a regular basis.”


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Kjersten Gmeiner, MD

3. Kjersten Gmeiner, MD: “The ABIM should state an intention to work with CAM practitioners”
 
Kjersten Gmeiner, MD is a former member of the board of the American
Holistic Medical Association. She last commented in the Integrator in


8 Voices: Stakeholders on Report of Employer Cost Savings from Whole Practice Naturopathic Care
. She was formerly with Group Health Cooperative where she led their group-focused medical services, written up here:

Interview: Holistic Leader Kjersten Gmeiner, MD on the Fit of “Group Visits” with Holistic Medicine

.

“The ’20 Voices’ is a terrific piece of reporting– a great read.

“Of
course, I notice the loss of ‘holistic’. And the absence of an
AHMA member on the new Board. And I do not see any of the Functional Medicine
leaders. One of the key issues on the table is who will determine who can say
they practice ‘integrative medicine’, and so far the Board is missing
some key people.  

   
“As formulated
currently, there is no
reason at all to trust that this will be
good for
non-MD’s, or for an integrated
and mutually respectful community of
diverse
practitioners which has

always been my ideal/goal.”

  

 

“I
also notice the absence of any non-MD’s on the Board.  As formulated
currently, there is no reason at all to trust that this will be good for
non-MD’s, or for an integrated and mutually respectful community of diverse
practitioners which has always been my ideal/goal. 




“And
I believe it is a realistic fear that empowering an MD integrated medicine specialty
will result in decreasing the power of the CAM practitioners, analogous with
the waning of the art of Osteopathic manipulation. I would like to see
a stated intention for members of this new specialty to spend a significant
amount of time, energy, and money empowering and supporting the people who have
held and teach these CAM modalities to MD’s.
[Bolding in orifginal.]

“I
will continue to support and promote those that are outside MD-dom (nice word,
huh?!). The healing that matters to me these days happens almost exclusively
outside/despite Western/orthodox medicine. I
have always known I am not one to work inside the system.” 


Comment: I am personally in alignment with Gmeiner inasmuch as I
believe that this emerging discipline will be stronger if it declares
its respect for collaborating with the licensed “CAM” disciplines and
“holistic medical” movement out of which “integrative medicine” was
born. Otherwise, the movement tends toward the disappearance of roots
that, as Gmeiner said, has been the destiny of osteopathy.”

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Robert Anderson, MD

4.  Robert Anderson, MD: “Will they subscribe to the 10 principles of holistic medicine?”

Bob Anderson, MD, one of holistic medicine’s stalwarts, was in touch this past week relative to his new book, Stories of Healing: A Family Doctor’s Journal. Anderson is a founder of the AHMA, past executive director of the American
Board of Integrative Holistic Medicine (ABIHM) and sparkplug of an effort to create a holistic doctor research network. I asked him for his perspective on the new ABIM.

“Re: 
ABIHM and the “new” board. I haven’t been in the loop on the
negotiations. One of the issues raised at our last ABIHM board meeting was
this:  Do the constituent bodies who would be covered under the new
umbrella subscribe to the principles of holistic medical practice which we
elaborated early in our existence? I’m sure you’ve seen them, but if not, I’ll
attach a copy. [See them at this link.]

“Some of us old-timers raised that issue, which raises the
question: Are we substituting a new model (as we initially conceived) or
instead addressing a variant of the old model? My Bastyr students call the
latter ‘green allopathy,’ with the implication that the model hasn’t
really changed, and that we’ve only substituted neutraceuticals and botanicals
for




Image

Bill Manahan, MD

4.  Bill Manahan, MD: “Thanks for this series of comments”
 

Comments from Integrator adviser Bill Manahan,
MD were included in the original 20 Voices.
This co-founder and past president of the American Board of Integrative Holistic Medicine

(ABIHM) sent an additional note after than column was published.


“Thanks
so much for this really interesting series of comments, John.  I loved
your comments and especially this one when you stated, ‘This is not
appropriate,’ and ‘lucrative is off target’ and ‘big egos
are often associated with good things.’ Way to say it like it
is.


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?


   
   “My
dream is that within ten years
there will be thousands of small clinics
with
about 5 caregivers from different
disciplines working together to
help patients
heal.”

 

“Anyway, there is lots of room for a good discussion about this topic.  My
dream is that within ten years there will be thousands of small clinics with
about 5 caregivers from different disciplines working together to help patients
heal.  The caregivers will be an MD/DO, an ND, some type of bodyworker, an
energy worker, and and body/mind psychology type of practitioner. Then
there could also be Ayurvedic or Chinese Medicine practitioners as
part of the group. They will meet weekly to discuss patient cases and to
learn from each other.

“We already have a few of these practices in
Minnesota and I know that other states also have them.  The practitioners
are happy and the patients are really pleased about them.  Working
out payment systems and the crazy insurance system is now the biggest problem,
but time and patient unrest will hopefully help heal that mess.”



Overall Comment
: I was pleased to see this second-round thoughtfulness. I bounce between, on one hand, strong support for the move as necessary maturation of the field of MD integrative medicine, to significant concern on the other. History gives us little reason to believe anything other than that the dominant players will take the money and run. So it has (almost) always been with the colonizers and the colonized. The parallel with first-world/third-world relations is strong. Come in, extract, export, leave. Trust me, I am not like all the others seems as naive for CAM practitioners as it ever was for the objects of exploitation in 100 teen relationships and movies.

   
Historically there is no reason to believe
anything other than that the dominant
players will take the money and
run.

So it has always been with the
colonizers and the colonized.

 

What the integrative MDs need to do is develop a contrary evidence base that they are not, in fact, like all the others. This means doing something like what Gmeiner says: “I would like to see
a stated intention for members of this new specialty to spend a significant
amount of time, energy, and money empowering and supporting the people who have
held and teach these CAM modalities to MD’s.” 


Redwood is right: This is a board by and for MDs and t
rying to include DCs, NDs [and even DOs] would kill ABIM’s chance to be a recognized medical specialty. Yet the integrative MDs could commit to defining a new ground. Mightn’t a field that declares itself “integrative” and “transformative” guarantee a required level of training in the values and practices of other disciplines? Mightn’t it consider bringing these disciplines into the process of developing that curriculum and advising on test questions? Such behavior would demonstrate that the emerging guild of integrative medical doctors is not, in fact, like the others, and is a new and transformative player in health care.   

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